Transarterial embolization of acute external carotid blowout syndrome with profuse oronasal bleeding by N-butyl-cyanoacrylate

Topographic Evaluation of Superior Thyroid Artery-A Terrain to be Well Versed for Surgeon's Knife

Observing the origin, varied branching configurations of superior thyroid artery (STA) and evaluating morphometric details with its surrounding relations was aimed at in this cadaveric neck dissection study to avoid surgical mishaps and its repercussions. This observational study was conducted on 40 fresh frozen embalmed and colored latex infused cadavers in the Department of Otorhinolaryngology and Head and Neck Surgery in collaboration with Department of Anatomy of our institute, which involved systematic evaluative dissection of both sides of neck especially focusing on superior thyroid artery, its branching variations and morphometric details with its surrounding relations. Details were measured using digital caliper. The collected data was statistically analyzed by applying chi-square test and significance was set at 5% level (p < 0.05). The analysis revealed the location of the origin of the superior thyroid artery of cadavers from carotid bifurcation and above it in 40% and from above the level of superior border of thyroid cartilage in 40% of cases. The distribution patterns of the superior thyroid artery were classified into three types depending on the branching pattern typical and variant glandular branching patterns were observed in 85% and 15% of the specimens respectively. A sound knowledge of the regional anatomy and its possible variations helps the surgeon in isolating and preserving the vital structures and avoid iatrogenic complications.

Transcatheter arterial embolization for traumatic injury to the pharyngeal branch of the ascending pharyngeal artery: Two case reports

BACKGROUND

The ascending pharyngeal artery (APhA) comprises the pharyngeal trunk (PT) and neuromeningeal trunk. The PT feeds the nasopharynx and adjacent tissue, which potentially connects with the sphenopalatine artery (SPA), branched from the internal maxillary artery (IMA). Due to its location deep inside the body, the PT is rarely injured by trauma. Here, we present two cases that underwent transcatheter arterial embolization (TAE) of the PT of the APhA due to trauma and iatrogenic procedure.

CASE SUMMARY

Case 1 is a 49-year-old Japanese woman who underwent transoral endoscopy under sedation for a medical check-up. The nasal airway was inserted as glossoptosis occurred during sedation. Bleeding from the nasopharynx was observed during the endoscopic procedure. As the bleeding continued, the patient was referred to our hospital for further treatment. Contrast-enhanced computed tomography (CT) demonstrated extravasation in the nasopharynx originating from the right Rosenmuller fossa. TAE was performed and the extravasation disappeared after embolization. Case 2 is a 28-year-old Japanese woman who fell from the sixth floor of a building and was transported to our hospital. Contrast-enhanced CT demonstrated a complex facial fracture accompanying extravasation in the left pterygopalatine fossa to the nasopharynx. Angiography demonstrated an irregular third portion of the IMA. As angiography after TAE of the IMA demonstrated extravasation from the PT of the APhA, additional TAE to the artery was performed. The bleeding stopped after the procedure.

CONCLUSION

Radiologists should be aware that the PT of the APhA can be a bleeding source, which has a potential connection with the SPA.

Carotid Blowout Syndrome in the Emergency Department: A Case Report and Review of the Literature

BACKGROUND

Carotid blowout syndrome (CBS) is an infrequent but dangerous oncologic emergency that must be recognized due to a mortality rate that approaches 40% and neurologic morbidity that approaches 60%. Patients present with a variety of symptoms ranging from asymptomatic to frank hemorrhage, and appropriate recognition and management may improve their outcomes.

CASE REPORT

A man in his late 60s with squamous cell carcinoma of the oropharynx presented to the emergency department (ED) with hemoptysis and several episodes of post-tussive emesis with large clots. He had been cancer free for multiple years after treatment with chemotherapy and radiation to the neck. Evaluation revealed a necrotic tumor on the posterior pharynx on bedside laryngoscopy and an external carotid pseudoaneurysm that was stented by interventional radiology. The patient experienced recurrent hemorrhage several months later and opted for palliative measures and expired of massive hemorrhage in the ED on a subsequent visit. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: CBS can be fatal, and early suspicion and recognition are key to ensure that a threatened or impending carotid blowout are appropriately managed. Once carotid blowout is suspected, early resuscitation and consultation with interventional radiology and vascular surgery is warranted.

Is percutaneous glue injection one of the treatments for arteriovenous malformation pinna?

Arteriovenous malformation (AVM) of the head and neck is a rare phenomenon, more so when it is an extracranial AVM like the auricle. AVMs are caused by genetic mutations. Most are probably present in the subclinical form at birth and then evolve; some may arise postnatally or during adolescence or get aggravated by precipitating factors like trauma, infection or hormonal influence like puberty or pregnancy. Once diagnosed, the feeding vessels have to be identified using radiological investigations. They are then embolised via means of percutaneous embolisation and surgical resection.

Verification of bleeding points in carotid blowout syndrome using guidewire manipulation

PURPOSE

Carotid blowout syndrome (CBS) is a catastrophic complication of aggressive treatment of head and neck cancer. Early detection of bleeding points with embolization is a life-saving procedure; however, some bleeding points may be difficult to identify. Our aim was to determine whether guidewire manipulation (GWM) could be used to verify bleeding point locations in patients with CBS.

METHODS

Of the 92 patients with CBS referred for embolization in a 5-year period, 14 men and one woman (mean age 58 years) had bleeding points at locations that could not be definitely determined. We used GWM to verify the presence of these bleeding points. We assessed the anatomy of the ruptured arteries, technical details of GWM, and the angiographic and clinical outcomes.

RESULTS

Bleeding points were difficult to detect because of the presence of small arterial pouches (n = 6) or multiple small arterial pouches (n = 9) in the unilateral or bilateral carotid arteries. Bleeding point locations were accurately identified using GWM in the internal carotid artery (n = 7), carotid bulb (n = 4), or common carotid artery (n = 4). Balloon-assisted GWM was applied in one patient. Fiber coils (n = 15) and/or liquid adhesives (n = 2) were used to occlude the affected artery. Endovascular management was technically successful in all patients and resulted in immediate cessation of hemorrhage without recurrence in a mean 22-month clinical follow-up.

CONCLUSION

GWM is a simple and effective method for verifying bleeding points in ruptured arteries and preventing erroneous occlusion by embolization.

Endovascular treatment of carotid blowout syndrome

BACKGROUND

Carotid blowout syndrome (CBS) is a life-threatening complication of head and neck cancer and radiation therapy. Endovascular techniques have emerged as preferable alternatives to surgical ligation for treatment of CBS. We performed a systematic review and meta-analysis to study periprocedural complications and outcomes of CBS patients treated with coil embolization and covered stents.

METHODS

A comprehensive literature search identified studies that reported outcomes of endovascular treatment of CBS published from 2000 to April 2016. Outcomes included technical success, postoperative rebleeding, survival time, and perioperative complications. Meta-analyses were performed using a random-effects model.

RESULTS

Twenty-five noncomparative studies with 559 patients were included in the meta-analysis. Technical success rate was 100% in both coiling and covered stenting groups. Median survival time was 3 months (range, 0-96 months) for all CBS patients. Overall perioperative mortality was 11% (95% confidence interval [CI], 5%-17%). Postoperative rebleeding rate was 27% (95% CI, 19%-367%). Perioperative stroke and infection rates were 3% (95% CI, 1%-6%) and 1% (95% CI, 0%-5%), respectively. At last follow-up, 39% of patients were alive (95% CI, 29%-48%).

CONCLUSIONS

Coil embolization and stent grafts may both be safe treatment options for CBS with few perioperative complications and high rates of technical success, but prognosis after treatment remains poor. In general, noncomparative studies do not demonstrate differences between the two techniques with respect to periprocedural complications and patient outcomes.

Sphenopalatine arteriovenous fistula complicating transsphenoidal pituitary surgery: A rare cause of delayed epistaxis treatable by endovascular embolization

Background:

Vascular injuries in transsphenoidal surgery for pituitary adenomas are uncommon but can result in serious disability or death.

Case Description:

A 46-year-old man, who underwent resection of a pituitary adenoma with suprasellar extension via a transsphenoidal approach, presented with massive epistaxis five days postoperatively. Angiography revealed an arteriovenous fistula (AVF) between the right sphenopalatine artery and a deep vein draining to the right internal jugular vein, as well as contrast agent extravasation at the fistula point. The AVF was catheterized and successfully occluded with N-butyl-2-cyanoacrylate.

Conclusions:

Transsphenoidal pituitary surgery can be complicated by massive epistaxis from a lesion of a small branch of the external carotid artery. Airway protection through intubation and investigation with conventional digital subtraction angiography is recommended. The treatment of choice is endovascular embolization because it can be done immediately at the angiography suite.

Transcatheter arterial embolization with N-butyl cyanoacrylate for arterial esophageal bleeding in esophageal cancer patients

Background

The aim of this study is to evaluate the clinical efficacy and safety of transcatheter arterial embolization (TAE) with N-butyl cyanoacrylate (NBCA) for the treatment of arterial esophageal bleeding in esophageal cancer patients.

Methods

Between November 2008 and December 2014, five esophageal cancer patients underwent TAE with NBCA for the treatment of arterial esophageal bleeding. We retrospectively evaluated the technical and clinical success, recurrent bleeding, and procedure-related complications.

Results

All of the patients had bleeding from the esophageal artery and were in shock at the beginning of TAE. Four patients had a coagulopathy at the time of TAE; however, the TAE could successfully arrest bleeding in all five patients. After TAE, they immediately recovered from the shock state. Two patients were discharged without event, one patient is currently hospitalized for another complication, and the other two patients died due to multiorgan failure. In addition, no procedure-related complications such as esophageal infarction and recurrence of arterial esophageal bleeding were observed during this study.

Conclusions

TAE with NBCA can arrest bleeding in esophageal cancer patients with active arterial esophageal bleeding, even in those with a pre-existing coagulopathy.

Guidelines for the use of NBCA in vascular embolization devised by the Committee of Practice Guidelines of the Japanese Society of Interventional Radiology (CGJSIR), 2012 edition

Cyanoacrylates are a group of fast-acting adhesives. They form low viscosity liquids in the monomer state and instantly polymerize to become adhesive upon contact with ionic substances. Since the 1950s, they have been used around the world for industrial and household purposes. N-butyl cyanoacrylate (NBCA) is a cyanoacrylate that is commonly used for medical care, and the closure of skin wounds with NBCA has been found to promote hemostasis. However, in Japan, the intravascular injection of NBCA is considered to be off-label use, except during the treatment of gastric varices under endoscopy. The use of NBCA in embolotherapy is considered when the target vessels cannot be cannulated superselectively, for vascular diseases that require long segments of the target vessel to be embolized, or for patients in a hypocoagulable state. NBCA-based embolotherapy can be used to treat vascular malformations, acute hemorrhaging, tumors, and venous disease. The complications associated with NBCA-based embolotherapy include tissue ischemia, hemorrhaging, systemic or local reactions, and catheter adhesion to blood vessels. NBCA is mixed with Lipiodol to make it radiopaque and to adjust its polymerization time. Since there are various technical aspects to performing NBCA-based embolotherapy safely, it should be carried out by, or with the assistance of, proficient interventional radiologists.

Transarterial embolization of intractable nasal and oropharyngeal hemorrhage using liquid embolic agents

INTRODUCTION

Intractable hemorrhage of the nasal or oropharyngeal cavities can be life threatening, and endovascular embolization is one of the few effective treatments for severe recurrent bleeds. Traditionally, embolic particles have been used for transarterial embolization.

OBJECTIVE

To investigate the safety and efficacy of a less commonly performed treatment-namely, feeding artery occlusion with liquid embolic agents.

METHODS

We retrospectively reviewed our neurointerventional database for patients who had undergone transarterial embolization for intractable nasal and oropharyngeal hemorrhage with Onyx, N-butyl-2 cyanoacrylate (n-BCA) glue, or both, at our institution over a 5-year period from 2008 to 2013.

RESULTS

Forty-six patients who underwent a total of 51 procedures met the inclusion criteria. Causes of hemorrhage included neoplasm n=35 (68.6%), trauma n=12 (23.5%), and idiopathic n=4 (7.9%). The bleeding was oropharyngeal in 66.7%, nasal in 29.4%, and 3.9% originated from both sites. Embolic agents used were n-BCA in 26 cases (51.0%), Onyx in 22 cases (43.1%), and both agents in three cases (5.9%). Mean total procedural time was 93.1 min (range 34-323 min), and mean fluoroscopy time was 39.1 min (10- 121 min). Mean follow-up time was 7.4 months (0.25-36 months). Five of the 46 patients (10.9%) required re-embolization and one (2.0%) rebled during the same hospital stay. One periprocedural cardiovascular adverse event occurred that was unrelated to the embolic agent used, but no other complications were seen.

CONCLUSIONS

Transarterial embolization with n-BCA or Onyx is a safe and effective treatment for patients with intractable nasal and oropharyngeal hemorrhage. Further prospective studies are warranted to confirm these findings.

Predisposing factors, management, and prognostic evaluation of acute carotid blowout syndrome

BACKGROUND

Massive hemorrhages occur in 6%-10% of patients with advanced cancer. Acute carotid blowout syndrome is the most severe massive hemorrhagic complication in head and neck cancer patients.

METHODS

This was a single institute, retrospective, case control study. A total of 45 patients were enrolled in this study. The predisposing factors, management, and prognosis of acute carotid blowout syndrome were evaluated.

RESULTS

Among the baseline characteristics, the site of the primary tumor (P = .003), origin of bleeding (P = .048), method of intervention (P = .005), and time to intervention (P = .006) were significantly different factors between survivor and nonsurvivor patients. After 24 hours of onset, a Glasgow Coma Scale score (P = .000), the use of inotropic agents (P = .007), and neutrophil-to-lymphocyte ratio (P = .019) were significantly predicting factors for outcome. Multivariate logistic regression analyses revealed bleeding from common carotid artery was an independent factor for long-term survival (odds ratio, 25.951; 95% confidence interval [CI], 1.373-490.441; P < .030). The median overall survival of survivors and nonsurvivors were 12.1 (range, 3.7-118.7; 95% CI, 4.33-54.87) and 11.9 (range, 0.7-53.5; 95% CI, 5.78-25.69) months, respectively (P = .092).

CONCLUSIONS

Early and aggressive intervention is important for the successful management of acute carotid blowout syndrome. The Glasgow Coma Scale score, the use of inotropic agents, and neutrophil-to-lymphocyte ratio 24 hours after the onset were predictive factors for patients' outcomes. Bleeding from common carotid artery is an independent prognostic factor in multivariate analysis. Long-term survival can be achieved after successful management.

Management of hemorrhagic pseudoaneurysmal arteriovenous fistula of the sphenopalatine artery

n-Butyl cyanoacrylate (n-BCA) embolization of a hemorrhagic pseudoaneurysmal arteriovenous fistula of the sphenopalatine artery in a patient with paranasal sinus squamous cell carcinoma treated with regional surgery and radiation has, to our knowledge, not been previously reported.

The role of embolisation in ENT: an update

OBJECTIVE

To provide an update on the ever-increasing role that embolisation plays in the practice of otolaryngology.

METHOD

A literature search was performed during November 2008. The Medline, Embase, PubMed and Cochrane databases were searched. This resulted in 285 papers relevant for review.

CONCLUSION

The role of embolisation has expanded greatly to include the management of refractory epistaxis, pre-operative preparation of vascular tumours, vascular injuries and as an adjunct in skull base surgery.

Endovascular management of carotid blowout

OBJECTIVE

To highlight pertinent aspects of emergent endovascular management of carotid rupture, or carotid blowout syndrome (CBS), an emergent, life-threatening complication of head and neck cancer and its treatments.

METHODS

A retrospective chart review was conducted of all patients with carotid blowouts at the authors' institution from 2008-2010. A systematic literature review was also performed.

RESULTS

Eight patients (three women and five men) with an average age of 61 years (range 47-78 years) were reviewed. Seven patients had a positive history for squamous cell carcinoma of the neck, and five patients had active malignant disease. Carotid arterial deconstruction using liquid embolic material, coil embolization, or both achieved immediate hemostasis in every case (100%). No patients died as a result of their initial hemorrhage, but one patient had lethal hemorrhage at 1 day postoperatively. Two patients experienced nonlethal postoperative complications. At an average follow-up of 3 months (range<1-8 months), three patients were alive, three had died as a result of their underlying disease, and two had died of other causes.

CONCLUSIONS

The treatment of patients with terminal malignant disease and CBS should provide maximum relief and minimize the risks of repeat surgery, morbidity, and mortality. Endovascular management of CBS with deconstructive techniques achieves immediate hemostasis and definitive treatment. The risks of intraoperative mortality and recurrent hemorrhage are low.

Endovascular management of neurovascular arterial injuries in the face and neck

The diagnosis and treatment of traumatic vascular injuries continues to improve as new tools and techniques are developed. In addition to locoregional hemorrhagic complications, injuries to blood vessels in the neck and face can result in ischemic injuries to the brain and cervical spinal cord. Surgical access to these lesions may be difficult, and endovascular techniques, including stenting and embolization, now serve as definitive treatments in many instances. This article reviews the endovascular management of patients with arterial injuries in the neck and face.

Endovascular treatment of epistaxis

Epistaxis is a common condition that can be managed conservatively in most cases. When these measures, including anterior and posterior packing of the nasal cavity, are unsuccessful at controlling the bleeding, interruption of the blood supply to the sinonasal area can be performed, either by surgical ligation or by transarterial embolization. Embolization should be preceded by thorough diagnostic angiography. Aside from aiding with subsequent selective catheterization and embolization, such angiography may reveal significant anatomic anomalies, anastomoses, or an unsuspected cause of epistaxis. Taking these findings into account, the interventionalist may decide to refrain from embolization or adjust the technique to minimize the risk of adverse events, which are mostly related to inadvertent embolization of the internal carotid artery or ophthalmic artery. We present a review of the various causes of epistaxis and the treatment options, with emphasis on endovascular embolization. We also describe the protocol of our institution for endovascular management of this condition.