Management of a Vascular Occlusion Associated with Cosmetic Injections


A vascular occlusion can result from arterial occlusion by direct injection into an artery or embolization of product, typically presenting immediately with acute pain and blanching. It can also result from venous occlusion from external compression of a vessel by soft tissue filler or subsequent edema and compression, more often with hyaluronic acid fillers. Venous occlusion usually presents later with a less severe, dull pain, or no pain at all, and dark discoloration of the skin.13,14

In some cases, it might be possible to resolve the occlusion with conservative measures, such as massage, tapping, and/or heat applied to the area. However, if conservative methods fail, hyaluronidase should be administered without delay when a hyaluronic acid dermal filler has been used.

Immediately stop treatment. As soon as the practitioner suspects the blood supply has been compromised, typically due to pain and blanching in the injected area, the most important step is to immediately discontinue injecting any more product, and if possible, aspirate any product when withdrawing the needle or cannula.23 Inform the patient of the problem. If the practitioner is not confident or is inexperienced in the management of a vascular occlusion, they should quickly seek the immediate advice of a more experienced practitioner. A vascular occlusion needs prompt management, as the risk of tissue damage and skin necrosis increases over time.7,8,10,11,13,14,17,18

Assess capillary refill time (CRT). The capillary refill time should be assessed on the affected and unaffected sides. Capillary refill time (CRT) is defined as the time needed by a distal body region, such as the fingertip, to regain the original color after having been compressed. Sansone et al24 considers a normal physiological capillary refill time to be two and three seconds, for men and women under 65 years of age, respectively, and four seconds for elderly patients of both sexes. CRT greater than three seconds can be indicative of a vascular compromise. A fast capillary refill time on a background of a bluish skin discoloration can indicate venous insufficiency.15 It is prudent to observe and assess skin color and capillary refill prior to treatment as a benchmark for posttreatment assessment.

To test capillary refill time, moderate pressure with either a finger or small, firm, flat object should be applied to the area being assessed for five seconds and then released. The time for the skin to return to its normal color should be observed and recorded. The test should be conducted over the entire area and on both the affected and unaffected sides for comparison. If capillary refill time is sluggish, but not less than three seconds, an initial attempt using conservative measures, such as massage, tapping, and heat should be used. If capillary refill time is not improved by conservative measures or CRT is greater than three seconds, practitioners should employ the ACE Group high-dose pulsed hyaluronidase protocol.25

Firmly massage the area. Firm and prolonged massage can encourage blood flow and remove any obstruction caused by a foreign body occluding a vessel. Massage might be required for several minutes.7,8,10,11,13,14,17,26

Apply heat. Heat will encourage vasodilatation and increase blood flow to the ar ea.7,8,10,11,13,14,17,18,19,23,26

Tap the area. Tapping over an area can dislodge intra-arterial emboli located at the site or further up in the vessel.14,19

Inject with hyaluronidase.1,7,10,11,13,14,18,19,23,26 Where hyaluronic acid fillers are the culprit, injecting with hyaluronidase can relieve the problem before complications even occur.25 Practitioners must remember that this is a time-critical event, and that test patching is not required if hyaluronidase is used for a vascular occlusion, as the risk of tissue damage is generally greater than the risk of anaphylaxis. As with any aesthetic treatments, it is important to have appropriate resuscitation equipment available to deal with any potential complications.15 There is some evidence to suggest that using hyaluronidase when a non-hyaluronic acid soft tissue filler has been injected can lessen the subsequent tissue damage, due to dissolving native hyaluronic acid and decreasing pressure on the blood supply.11,23

Practitioners should employ the ACE Group High-dose, Pulsed Hyaluronidase Protocol.25 Despite the simplicity of the intervention, it has prevented necrosis in virtually all cases since it has been implemented, even up to 48 hours after the initial treatment. The protocol involves repeated administration of relatively high doses of hyaluronidase into the whole area of compromised tissue, not just where the filler was injected,14 repeated hourly until clinical resolution is observed, denoted by improvements in capillary refill, skin color and pain. This technique has also led to successful and complete recovery without the need for any adjunctive treatment.2

There is contradictory evidence to suggest that hyaluronidase diffuses into the lumen of blood vessels even when injected externally to it. However, when treating a vascular occlusion, it is not necessarily essential to inject directly into the vessel, but the surrounding area is also likely to result in dissolution of the product. Indeed, the injection of hyaluronidase into the subcutaneous plane, rather than attempting intra-arterial injection, has shown more favorable outcomes.27

Aspirin.1,15 Following the evidence for the use of aspirin in cardiovascular disease, in order to limit platelet aggregation, clot formation, and further vascular compromise, a stat dose of 300mg should be given immediately, followed by 75mg a day until the vascular occlusion has resolved where there are no contraindications.28 Concomitant use of gastric protection medication might be recommended in some patients. If treatment of a vascular occlusion has failed, necrosis might ensue. The patient should be monitored regularly, and if tissue breakdown occurs, a referral for specialist management and care might be appropriate (Refer to ACE Guidelines on Necrosis).

Antibiotics.1,10,13,23 Necrosis consists of dead cells and tissue and is prone to secondary opportunistic infection. Depending on the extent of necrosis, topical and/or oral antibiotics might be required to promote healing and to prevent further complications. Antiherpetic medication might be necessary if necrosis occurs in a susceptible patient in a perioral distribution.1,11 In the case of a treated vascular occlusion without any signs of skin damage, antibiotics should not be given for prophylaxis.

Superficial debridement. Referral to a plastic surgeon might be required for removal of dead tissue to promote healing.7,10,13,17,18

Wound care management. Apply appropriate dressings and wound care to encourage healing.1,10,17

Pain management. Pain management needs to be considered in cases of necrosis; although over-the-counter medication might be all that is required, necrosis can cause severe pain requiring opioid analgesia.

Refer. It is always sensible to involve other practitioners experienced in the management of vascular occlusion for further advice and/or treatment.

Speak to your medical defense organization. A vascular event can be a distressing ordeal for both patient and practitioner. Whether or not it is managed well and resolved, a claim may ensue.

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