Ultrasound-Guided Hyaluronidase Injections for the Management of Filler-Induced Arterial Ischemia: A Pictorial Case Series and Systematic Review of Literature

Abstract The use of fillers for cosmetic purposes has increased in recent years. Although generally considered safe, fillers are not exempt from complications, including ischemic events. Arterial ischemia is a rare but potentially serious complication that requires prompt recognition and management. Ultrasound-guided hyaluronidase injection is emerging as a precise and effective treatment approach. The authors present a pictorial case series of filler-induced arterial ischemia managed with ultrasound-guided hyaluronidase injections, and systematically review the literature on ultrasound findings, enzyme dosage, time to resolution, and overall effectiveness of this approach. They present 3 cases of filler-induced arterial ischemia in the frontal, nasal, and temporal regions with visible intravascular thrombosis managed with ultrasound-guided intravascular hyaluronidase injections. Additionally, the authors systematically reviewed literature from PubMed/Medline, Scopus, Embase, and Web of Science up to August 2024 to evaluate the effectiveness, dosage, and ultrasound techniques utilized in the ultrasound-guided treatment of vascular complications from hyaluronic acid fillers. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we screened 88 studies, finally including 9 studies after full-text evaluation. Data from these studies, alongside our 3 cases (totaling 83 cases), showed rapid resolution of symptoms and ultrasound abnormalities following ultrasound-guided hyaluronidase injections. Delayed hyaluronidase administration was associated with slower or incomplete recovery, highlighting the importance of early intervention. Ultrasound-guided hyaluronidase injections effectively resolve arterial ischemia caused by filler injections, with early intervention significantly enhancing outcomes. Prompt diagnosis and timely ultrasound-guided intervention should be emphasized in clinical practice. Further large-scale randomized studies are necessary to establish standardized treatment protocols for dosage and timing. Level of Evidence: 3 (Therapeutic)