Carotid Blowout Syndrome: Endovascular Management of Acute Hemorrhage with Tapering Overlapped Covered Stents

Heparin-bonded stent graft placement for treatment of massive epistaxis from ruptured radiation-induced internal carotid artery pseudoaneurysm: A case report

Rupture of an internal carotid artery (ICA) pseudoaneurysm is a rare but life-threatening complication of irradiation therapy for a nasopharyngeal carcinoma (NPC). A 36-year-old man had a history of NPC treated with radiotherapy 8 years previously. He was admitted to the hospital because of severe repetitive epistaxis with hemodynamically instablility. An emergent angiography showed the left ICA pseudoaneurysm at the petrous portion (C2 segment). The patient was successfully treated by a new-generation heparin-bonded stent graft without any complication. Emergent stent graft placement is effective in stopping hemorrhage and is therefore a life-saving intervention. Long-term follow-up is necessary to look out for delayed post-treatment complications.

Management of Cutaneously Exposed Carotid Stents in Recurrent and Unresectable Head and Neck Cancer

Objective Carotid blowout syndrome (CBS) is a rare but potentially life-threatening complication of head and neck cancer (HNC) treatment. Patients with CBS are managed with covered stents, limited published information exists regarding the management of delayed complications, specifically cutaneous exposure of stents. Here, we present our experience managing cutaneously exposed carotid artery stents (CAS) in patients with recurrent and unresectable HNC.

Methods A single-institution retrospective analysis was performed to identify recurrent HNC patients who underwent CAS placement for CBS and complicated with cutaneous exposure of the stent between 2014 and 2016. Medical records were reviewed with attention to treatment history, pre-, intra-, and postoperative courses, anticoagulation needs, and durability of the reconstruction.

Results We identified three patients who presented with a right CAS fully exposed in a large, ulcerative wound. All patients underwent a right pectoralis major myocutaneous flap (PMMF) to cover the exposed stent within 30 days of presentation to our institution. Two of three patients attained adequate coverage of the stent for more than 30 days, while one experienced partial flap dehiscence within 12 days. Two patients developed postoperative chest hematomas, which were managed conservatively. Two of three patients were able to undergo further palliative adjuvant treatments within 60 days of the initial surgical procedure.

Conclusion In this small series, durable coverage of an exposed carotid artery with PMMF was successful in two of three patients with extensive disease burden and complex prior treatment history. No mortalities occurred within 30 days postoperatively.

Endovascular Treatment of Peripheral Vascular Blowout Syndrome in End-Stage Malignancies

BACKGROUND

Vascular blowout syndrome (VBOS) is a life-threatening condition secondary to direct tumor encasement or invasion in advanced stage malignancies. Endovascular management can be used as an alternative to surgical treatment in this fragile patient population, providing a minimally invasive measure both acutely and prophylactically.

METHODS

Three patients with peripheral VBOS secondary to advanced stage malignancies underwent successful endovascular treatment. Technical success was obtained in all patients with nonsignificant perioperative complications.

RESULTS

Endovascular management controlled immediate life-threatening hemorrhage and enabled these high-risk patients to undergo other adjunctive therapeutic modalities.

CONCLUSIONS

Endovascular treatment can offer a safe and effective palliative measure of peripheral VBOS secondary to neoplastic erosion in patients with advanced stage malignancies.

Stent Graft-in-Stent Graft as a Rescue Technique for Endovascular Treatment of Giant Extracranial Internal Carotid Aneurysm

Endovascular treatment of a giant extracranial internal carotid aneurysm by a stent graft implantation was unsuccessful due to a high flow leak directly through the stent graft's coating. The problem was solved deploying a second stent graft inside the previously implanted one resulting in complete exclusion of the aneurysmal sac and patent carotid lumen preservation. The review of the literature did not provide a case using this endovascular strategy. Follow-up for more than 12 months, using CT angiography, showed confirmed aneurysmal exclusion and carotid patency and no clinical complications have been detected.

Carotid blowout syndrome after nasopharyngeal carcinoma radiotherapy: successful treatment by internal carotid artery occlusion after stent implantation failure

Introduction

Carotid blowout syndrome (CBS) secondary to radiation therapy is life-threatening and requires emergency treatment. More recently, endovascular treatment has provided an effective way to control CBS-related bleeding.

Case description

We present a case of CBS with a rupture of the internal carotid artery (ICA) pseudo-aneurysm after Gamma Knife radiation therapy for nasopharyngeal carcinoma (NPC). The patient was a 55-year-old man who was transferred to our hospital with severe repetitive epistaxis. He had a history of NPC and had been treated with Gamma Knife radiation therapy 7 months prior, with a central dose of 32 Gy and marginal dose of 16 Gy. As CBS was confirmed by angiography, and the affected part of the ICA lumen exhibited moderate stenosis, the patient was successfully treated by ICA occlusion after stent implantation failure. The patient died 40 months after this operation from tumor recurrence, but without epistaxis during follow up.

Discussion and Evaluation

Quick selection of an appropriate treatment method is very important for an acute CBS patient.

Conclusion

ICA occlusion can be directly considered for an acute CBS patient, if the affected ICA exhibits stenosis that is moderate or above.