Endovascular treatment paradigm of carotid blowout syndrome: review of 8-years experience

Endovascular Management of Post-Irradiated Carotid Blowout Syndrome in Patients with Lower Neck Cancers

OBJECTIVE

Lower neck cancers (LNCs) include specific tumour types and have some different vascular supply or collaterals from other head and neck cancers. This prospective study evaluated the outcome of endovascular management of post-irradiated carotid blowout syndrome (PCBS) in patients with LNC by comparing reconstructive management (RE) and deconstructive management (DE).

METHODS

This was a single centre, prospective cohort study. Patients with LNC complicated by PCBS between 2015 and 2021 were enrolled for RE or DE. RE was performed by stent graft placement covering the pathological lesion and preventive external carotid artery (ECA) embolisation without balloon test occlusion (BTO). DE was performed after successful BTO by permanent coil or adhesive agent embolisation of the internal carotid artery (ICA) and ECA to common carotid artery, or ICA occlusion alone if the pathological lesion was ICA only. Cross occlusion included the proximal and distal ends of the pathological lesion in all patients. Re-bleeding events, haemostatic period, and neurological complications were evaluated.

RESULTS

Fifty-nine patients (mean age 58.5 years; 56 male) were enrolled, including 28 patients undergoing RE and 31 patients undergoing DE. Three patients originally grouped to DE were transferred to RE owing to failed BTO. The results of RE vs. DE were as follows: rebleeding events, 13/28 (46%) vs. 10/31 (32%) (p = .27); haemostatic period, 9.4 ± 14.0 months vs. 14.2 ± 27.8 months (p = .59); neurological complication, 4/28 (14%) vs. 5/31 (16%) (p = .84); and survival time, 11.8 ± 14.6 months vs. 15.1 ± 27.5 months (p = .61).

CONCLUSION

No difference in rebleeding risk or neurological complications was observed between the DE and RE groups. RE could be used as a potential routine treatment for PCBS in patients with LNC.

Endovascular embolisation of external carotid artery system haemorrhage in radiated nasopharyngeal carcinoma

PURPOSE

To review the effectiveness and safety of embolisation in managing haemorrhage from the external carotid artery (ECA) system in radiated nasopharyngeal carcinoma (NPC) patients.

METHODS

Radiated NPC patients who presented with severe oronasal bleeding and underwent digital subtraction angiography that excluded blowouts from the internal carotid artery from 2011 to 2021 were reviewed. Those who subsequently underwent embolisation of the ECA system were analysed for technical success rate, post-embolisation re-bleeding rate and complications.

RESULTS

Seventeen embolisations were performed in fifteen patients during the 10-year period. The technical success rate was 100%, however the early haemostatic rate (no re-bleed within 7 days of embolisation) was 70.6% (12/17) and the overall long-term haemostatic rate was 58.8% (10/17). The re-bleed rates of targeted and empiric embolisations were 33.3% (3/9) and 50.0% (4/8), respectively. The re-bleed rates with liquid agents, coils and particles were 0% (0/7), 33.3% (1/3) and 85.7% (6/7), respectively. Amongst the embolisations utilising liquid agents, 71.4% (5/7) were targeted, distal embolisations. All re-bleeds underwent surgical ligation or repeat embolisation; half of them further experienced recurrent bleeding. There were no significant complications with embolisation.

CONCLUSION

Although embolisation of the ECA system in NPC has a high technical success rate and is safe, re-bleeding appears to be common. Targeted, distal embolisation with liquid embolics appear to have good haemostatic effect. Clinicians should be aware that patients may need repeated procedures to secure haemostasis.

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.

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.

Retrospective analysis of massive epistaxis and pseudoaneurysms in nasopharyngeal carcinoma after radiotherapy

OBJECTIVE

Epistaxis after radiotherapy for nasopharyngeal carcinoma (NPC) is a common clinical critical illness, which often leads to death of patients. This article focuses on the relationship between massive epistaxis and pseudoaneurysm after radiotherapy in patients with NPC and discusses clinically relevant treatment strategies.

METHODS

A review was performed in 21 patients with massive epistaxis after radiotherapy for NPC from January 2011 to December 2019, and all of the patients were examined by computed tomography angiography (CTA). We also reviewed the English literature over the past 10 years to analyze the characteristics and related causes of pseudoaneurysms in terms of the clinical stage of NPC, course of radiotherapy, and affected artery. An analysis was performed on the methods of endovascular interventional treatment of such pseudoaneurysms.

RESULTS

Among the 21 patients, 19 cases had bone destruction of the skull base; 13 cases were also found to have tumor recurrence; 15 cases were in stage III or IV of NPC; pseudoaneurysms were observed in 14 cases, of which nine cases had pseudoaneurysms in the internal carotid artery (ICA), and the rest had pseudoaneurysms in the external carotid artery (ECA). These data were consistent with the results of the literature review. Analysis with imaging revealed that the petrous ICA was the common predilection site. There were 11 out of 14 cases of pseudoaneurysms with sentinel hemorrhage in the initial phase. All 14 pseudoaneurysm patients underwent endovascular interventional therapy, but one died from hemorrhagic shock during the procedure. No rebleeding was observed among the other patients during 72 h after intravascular treatment. Nevertheless, regrettably two patients died on the 10th and 17th days after intervention.

CONCLUSION

Pseudoaneurysm, which was a serious complication after radiotherapy in patients with NPC, could cause massive epistaxis with high mortality. The formation of a pseudoaneurysm was closely associated with a high carcinoma stage, re-radiotherapy, and local bone destruction and infection. Most cases had sentinel epistaxis, which was considered the bleeding characteristic. The imaging material prompted that pseudoaneurysm had a predisposition to the petrous part of the ICA, while the preferred therapy was endovascular embolization treatment.

Carotid artery ligation via sternotomy as a palliative surgery: Case report of advanced intramediastinal malignant soft tissue tumor

Under extreme conditions and in palliative settings, shared decision making with the patient is vital; narrative decisions beyond evidence could be considered. If there is a chance of symptom palliation, extended surgery should not be avoided merely because of the limited life expectancy.

Comparison of Treatment Modalities in Postirradiation Carotid Blowout Syndrome: A Multicenter Retrospective Review

BACKGROUND

Carotid blowout syndrome (CBS) is not uncommon in our locality, where head and neck cancers, especially nasopharyngeal carcinoma, are prevalent. Traditionally, CBS has resulted in high morbidity and mortality. The treatment paradigm has evolved from open surgery to endovascular interventions, and each treatment modality has its merits and drawbacks. In the present study, we investigated the outcomes of different treatment modalities for postirradiation CBS.

METHODS

We performed a 10-year multicenter retrospective review of the outcomes after endovascular trapping, flow diverters, and bypass surgery from 2009 to 2019.

RESULTS

A total of 53 patients with 60 blowouts were included in the present study. Of the 60 blowout cases, 25 were in the flow diverter group, 27 in the endovascular trapping group, and 8 in the bypass group. The mean survival was 32.2 months, with patient age affecting overall survival (P = 0.002). The stroke rate affected the 3- and 6-month functional outcomes (odds ratio, 7.388 and 6.353; P = 0.008 and P = 0.014, respectively). Of the 24 cases in the flow diverter group, 96% had achieved immediate hemostasis, with a rebleeding rate of 20% (P = 0.009). No rebleeding had occurred with endovascular trapping or bypass. The stroke rate in the endovascular trapping, flow diverter, and bypass groups was 25.9%, 20%, and 12.5%, respectively (P = 0.696).

CONCLUSIONS

Our results have shown that endovascular trapping is the first-line treatment of CBS. For patients with contraindications to endovascular trapping, the flow diverter is an alternative. For patients who have undergone flow diversion alone, definitive treatment such as bypass surgery might be indicated for selected patients to minimize the risk of rebleeding. After endovascular trapping, surgical bypass might be considered for selected patients with a higher risk of stroke.

Endovascular treatment of blunt injury of the extracranial internal carotid artery: the prospect and dilemma

The extracranial internal carotid artery (ICA) refers to the anatomic location that reaches from the common carotid artery proximally to the skull base distally. The extracranial ICA belongs to the C1 segment of the Bouthillier classification and is at considerable risk for injury. Currently, the understanding of endovascular treatment (EVT) for blunt injury of the extracranial ICA is limited, and a comprehensive review is therefore important. In this review, we found that extracranial ICA blunt injury should be identified in patients presenting after blunt trauma, including classical dissection, pseudoaneurysm, and stenosis/occlusion. Computed tomography angiography (CTA) is the first-line method for screening for extracranial ICA blunt injury, although digital subtraction angiography (DSA) remains the "gold standard" in imaging. Antithrombotic treatment is effective for stroke prevention. However, routine EVT in the form of stenting should be reserved for patients with prolonged neurological symptoms from arterial stenosis or considerably enlarged pseudoaneurysm. Endovascular repair is now emerging as a favored therapeutic option given its demonstrated safety and positive clinical and radiographic outcomes.

Endovascular Internal Trapping by Low-Concentration N-butyl-2-Cyanoacrylate for a Ruptured Giant Common Carotid Artery Pseudoaneurysm

Treating carotid blowout syndrome following rupture of giant pseudoaneurysms is difficult because the destroyed parent artery precludes conventional treatment. We present a patient with a ruptured giant pseudoaneurysm that we occluded using a modified internal trapping technique with low-concentration N-butyl-2-cyanoacrylate (NBCA) and a minimum number of coils. An 80-year-old man with a history of chemoradiation therapy for oropharyngeal cancer presented with several episodes of active bleeding from the subsequent tracheostomy site. Radiological examination revealed a giant right common carotid artery (CCA) pseudoaneurysm. Endovascular internal trapping was performed using both NBCA and coils under proximal flow control. We slowly injected 9 ml of low-concentration NBCA, which subsequently filled the entire pseudoaneurysm. We then injected an additional 2 ml of NBCA into the proximal CCA to achieve complete obliteration. No re-bleeding was observed during the 6-month follow-up. Endovascular internal trapping using low-concentration NBCA was feasible to treat a giant CCA pseudoaneurysm. The injected low-concentration NBCA filled the entire pseudoaneurysm without the risk of catheter entrapment.

Common carotid artery ligation at the proximal side before rupture in patients with ligation or occlusion of the external carotid artery at risk of carotid blowout syndrome

BACKGROUND

Carotid blowout syndrome (CBS) is among the fatal complications in head and neck cancer treatment. However, the optimal treatment for CBS has not been established yet. This study aimed to describe our experience with two patients at high risk of CBS who underwent common carotid artery (CCA) ligation at the proximal side of the bleeding point under local anesthesia and before CCA rupture, and to review and compare the medical records of these two patients against 10 CBS cases treated in our department.

METHODS

The institutional electronic medical record was searched, and clinical information was extracted for all patients who showed CBS from 2007 to 2017. Our treatment method was performed as follows. Ligation of the proximal side of the CCA was performed under local anesthesia. The CCA was identified and clamped with two bulldog forceps for 10 minutes to check for any adverse neurological symptoms. Subsequently, the CCA was ligated using 2-0 silk threads and sutured with an absorbable suture between the silk threads. However, ligation or occlusion of the external carotid artery by previous treatment is a prerequisite for this method.

RESULTS

Eight patients received interventions, with six patients undergoing prophylactic interventions before rupture. Four patients who did not undergo treatment died owing to CBS. Two patients who underwent treatment with the novel method did not experience re-bleeding, but their conditions deteriorated owing to cancer progression.

CONCLUSION

The present method is one of the treatment choices for CBS, especially in patients with an 'impending' risk of CBS.

Pipeline Embolization Device for the Treatment of Intracranial Pseudoaneurysms

BACKGROUND

Intracranial pseudoaneurysms (PSAs) are associated with high rupture and mortality rates and have traditionally been treated by parent vessel sacrifice. There has been recent interest in using flow-diverting devices for treatment of these complex lesions while preserving flow through the parent artery. The objective of this study is to examine the safety and efficacy of these devices in the treatment of intracranial PSA.

METHODS

We performed a multi-institutional retrospective study of intracranial PSAs treated with the Pipeline Embolization Device (PED) between 2014 and 2017 at 7 institutions. Complications and clinical and radiographic outcomes were reviewed.

RESULTS

A total of 19 patients underwent PED placement for intracranial PSA. Iatrogenic injury and trauma comprised most etiologies in our series. The mean pseudoaneurysm diameter was 8.8 mm, and 18 of 19 PSAs (95%) involved the internal carotid artery (ICA). Multiple PEDs were deployed in a telescoping fashion in 7 patients (37%). Of the 18 patients with follow up imaging, 14 (78%) achieved complete pseudoaneurysm obliteration and 2 achieved near-complete obliteration (11%). Two patients (11%) were found to have significant pseudoaneurysm progression on short-term follow-up and required ICA sacrifice. No patients experienced new neurologic deficits or deterioration secondary to PED placement. No patients experienced bleeding or rebleeding from PSA.

CONCLUSIONS

In well-selected patients, the use of flow-diverting stents may be a feasible alternative to parent vessel sacrifice. Given the high morbidity and mortality associated with PSA, we recommend short- and long-term radiographic follow-up for patients treated with flow-diverting stents.

Carotid blowout syndrome: modern trends in management

Carotid blowout syndrome (CBS) refers to rupture of the carotid artery and is an uncommon complication of head and neck cancer that can be rapidly fatal without prompt diagnosis and intervention. CBS develops when a damaged arterial wall cannot sustain its integrity against the patient’s blood pressure, mainly in patients who have undergone surgical procedures and radiotherapy due to cancer of the head and neck, or have been reirradiated for a recurrent or second primary tumor in the neck. Among patients irradiated prior to surgery, CBS is usually a result of wound breakdown, pharyngocutaneous fistula and infection. This complication has often been fatal in the past, but at the present time, early diagnosis and modern technology applied to its management have decreased morbidity and mortality rates. In addition to analysis of the causes and consequences of CBS, the purpose of this paper is to critically review methods for early diagnosis of this complication and establish individualized treatment based on endovascular procedures for each patient.

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.

Safety and effectiveness of endovascular embolization or stent-graft reconstruction for treatment of acute carotid blowout syndrome in patients with head and neck cancer: Case series and systematic review of observational studies

BACKGROUND

Indications for treatment and outcomes after endovascular management of carotid blowout syndrome for patients with head and neck cancer are not well defined. We investigated the safety and effectiveness of endovascular embolization and stent-graft reconstruction.

METHODS

A literature review was performed for studies published between 2001 and 2015 with relevance to treatment outcomes. Our institutional database was examined to identify patients treated with endovascular techniques.

RESULTS

A total of 266 patients were included. Rates of procedural stroke were higher after embolization of internal carotid artery (ICA)/common carotid artery (CCA) compared to stent graft (embolization 10.3%; stent graft 2.5%; P < .02). Stent graft of ICA/CCA was associated with higher rates of recurrent bleeding (embolization 9.1%; stent graft 31.9%; P < .01).

CONCLUSION

Both embolization and stent grafts are safe therapeutic options for acute carotid blowout syndrome. Embolization for ICA/CCA carotid blowout syndrome was associated with higher risks of procedural stroke and lower recurrent bleeding compared to stent grafts.

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.

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.

Outcomes of interventions for carotid blowout syndrome in patients with head and neck cancer

BACKGROUND

The purpose of this study was to examine outcomes of a patient cohort undergoing intervention for carotid blowout syndrome associated with head and neck cancer.

METHODS

Patients with head and neck cancer who presented with carotid distribution bleeding from 2000 to 2014 were identified in the medical record. Primary outcomes were short- and midterm mortality and recurrent bleeding. Standard statistical methods and survival analysis were used to analyze study population characteristics and outcomes.

RESULTS

Thirty-seven patients were included in the study. The mean age was 60.1 ± 11.4 years (74% male). All malignancies were squamous cell type, stage IV, in a variety of primary locations: 32% oral cavity, 24% larynx, 16% superficial neck, with the remainder in the oropharynx, nasopharynx, and hypopharynx. Fifty-one percent of bleeds were of common carotid, 29% external carotid, and 19% internal carotid origin. Among the patients, 68% presented with acute hemorrhage, 24% with impending bleed, and 8% with threatened bleed. All patients underwent intervention: 38% received endovascular coil embolization, 30% stent grafts, 22% surgical ligation, and 10% primary vessel repair or bypass grafting. Although major complications were rare, 10.8% of patients had perioperative stroke. Sixteen recurrent bleeding episodes involving 12 arteries occurred in 11 patients (29.73%). Median rebleeding time was 7 days (interquartile range, 6-49). Estimated recurrent bleeding risk at 30 days and 6 months was 24% and 34%, respectively. Of the patients, 91.9% survived to hospital discharge. The 90-day and 1-year estimated survivals were 60.9% and 36.6%, respectively.

CONCLUSIONS

Carotid blowout syndrome associated with head and neck cancer carries poor mid- and long-term prognoses; however, mortality may be related more to the advanced stage of disease rather than carotid involvement or associated intervention. Both surgical and endovascular approaches may be efficacious in cases of acute hemorrhage but carry a significant risk of periprocedural stroke and recurrent bleeding.

Direct Repair of Iatrogenic Internal Carotid Artery Injury During Endoscopic Endonasal Approach Surgery With Temporary Endovascular Balloon-Assisted Occlusion: Technical Case Report

BACKGROUND AND IMPORTANCE

Iatrogenic internal carotid artery (ICA) injuries during endoscopic endonasal approach (EEA) surgeries are associated with a high morbidity and mortality, with few acceptable methods described for repair.

CLINICAL PRESENTATION

A 13-year-old girl with a large anterior and central skull base osteoblastoma incurred an iatrogenic cavernous ICA injury during a staged EEA approach. Intraoperative angiogram was performed with balloon-assisted EEA primary microsurgical repair of the lacerated ICA.

CONCLUSION

By integrating current techniques commonly used in open aneurysm surgeries and in endovascular procedures, we developed a rapid, safe technique to repair an EEA-associated iatrogenic ICA injury.

Endovascular Management of Post-Irradiated Carotid Blowout Syndrome

Purpose

To retrospectively evaluate the clinical and technical factors related to the outcomes of endovascular management in patients with head-and-neck cancers associated with post-irradiated carotid blowout syndrome (PCBS).

Materials and Methods

Between 2000 and 2013, 96 patients with PCBS underwent endovascular management. The 40 patients with the pathological lesions located in the external carotid artery were classified as group 1 and were treated with embolization. The other 56 patients with the pathological lesions located in the trunk of the carotid artery were divided into 2 groups as follows: group 2A comprised the 38 patients treated with embolization, and group 2B comprised the 18 patients treated with stent-graft placement. Fisher’s exact test was used to examine endovascular methods, clinical severities, and postprocedural clinical diseases as predictors of outcomes.

Results

Technical success and immediate hemostasis were achieved in all patients. The results according to endovascular methods (group 1 vs 2A vs 2B) were as follows: technical complication (1/40[2.5%] vs 9/38[23.7%] vs 9/18[50.0%], P = 0.0001); rebleeding (14/40[35.0%] vs 5/38[13.2%] vs 7/18[38.9%]), P = 0.0435). The results according to clinical severity (acute vs ongoing PCBS) were as follows: technical complication (15/47[31.9%] vs 4/49[8.2%], P = 0.0035); rebleeding (18/47[38.3%] vs 8/49[16.3%], P = 0.0155). The results according to post-procedural clinical disease (regressive vs progressive change) were as follows: alive (14/21[66.7%] vs 8/75[10.7%], P<0.0001); survival time (34.1±30.6[0.3–110] vs 3.6±4.0[0.07–22] months, P<0.0001).

Conclusion

The outcomes of endovascular management of PCBS can be improved by taking embolization as a prior way of treatment, performing endovascular intervention in slight clinical severity and aggressive management of the post-procedural clinical disease.

Outcomes of endovascular occlusion and stenting in the treatment of carotid blowout

BACKGROUND AND PURPOSE

Carotid blowout is a life threatening complication of invasive head and neck cancers and their treatments. This is commonly treated with endovascular embolization and carotid stenting. Using the Nationwide Inpatient Sample, we report the immediate clinical results of patients receiving embolization and/or stenting for treatment of carotid blowout associated with head and neck cancer.

MATERIALS AND METHODS

Using the Nationwide Inpatient Sample from the period 2003-2011, we defined carotid blowout patients as those with head and neck malignancies receiving carotid stenting and/or endovascular embolization without open surgery. Outcomes studied included mortality, acute ischemic stroke, hemiplegia/paresis, and other post-operative neurologic complications. Outcomes for the endovascular embolization and carotid stenting group were compared.

RESULTS

A total of 1218 patients underwent endovascular treatment for carotid blowout. Of these, 1080 patients (88.6%) underwent embolization procedures and 138 patients (11.4%) underwent carotid stenting. The mortality rate of endovascular embolization patients was similar to that of carotid stenting patients (8.0%, 95% confidence interval (CI) = 6.5%-9.7% versus 10.2%, 95% CI=6.0%-16.4%, p = 0.36). Stroke rate was similar between embolization patients and stenting patients (2.3%, 95% CI=1.6%-3.4% vs. 3.4%, 95% CI=1.3%-8.4%, p = 0.43). Hemiplegia rates were significantly higher rate in stenting patients compared with endovascular occlusion patients (3.8%, 95% CI=1.3%-8.4% vs. 1.4%, 95% CI=1.4%-2.4%, p = 0.05). The rate of post-operative neurologic complications was higher in stenting patients compared with embolization patients (6.5%, 95% CI=3.3%-12.1% vs. 1.4%, 95% CI=0.9%-2.4%, p < 0.0001).

CONCLUSIONS

Given the natural history of carotid blowout, carotid stenting and endovascular embolization are acceptable means of treating this disease. Endovascular embolization remains the most common treatment among patients with head and neck cancers with lower overall rates of post-operative neurologic complications, including hemiplegia/paresis and stroke.

Interventional management of head and neck emergencies: carotid blowout

Involvement of the carotid artery by malignant processes of the head and neck with compromise of vessel integrity and rupture-"carotid blowout syndrome" (CBS)-is one of the most devastating complications of malignancy. Most often, it is associated with squamous cell cancer and almost always in patients who have undergone prior radiation therapy. CBS is classified as threatened, impending, or acute. Bleeding into the oral cavity or from areas of skin breakdown is a frightening experience for patients and their families and often a terminal event. Prognosis is poor with up to 50% mortality and morbidity, and surgical options are limited and risky. Endovascular management with vessel sacrifice or stent placement has become the principle treatment option in this patient population, though still associated with procedural complications, often neurologic, that can occur acutely or in a delayed fashion. This article reviews techniques and outcomes associated with endovascular treatment of CBS.

Management of pseudoaneurysms of the internal carotid artery in postirradiated nasopharyngeal carcinoma patients

OBJECTIVES/HYPOTHESIS

Massive epistaxis due to ruptured pseudoaneurysm of the internal carotid artery (ICA) is an often fatal complication of radiation treatment for patients with nasopharyngeal carcinoma. We review the clinical characteristics and predictors of survival in patients suffering from this serious complication after radiotherapy.

STUDY DESIGN

Retrospective case series.

METHODS

Clinical records and radiological investigations of postirradiated NPC patients with ICA pseudoaneurysm diagnosed with digital subtraction angiography in Queen Mary Hospital from January 2003 to December 2012 were reviewed. Risk factors analyzed for survival included gender, size of initial tumor, history of second course of radiotherapy, history of previous maxillary swing nasopharyngectomy, presence of persistent disease, successful initial hemostasis, successful airway control, and endovascular treatment.

RESULTS

Twenty-six were included in the analysis. Twenty-three patients underwent endovascular treatment, and 20 (87%) had successful control of the bleeding. Eighteen (69%) patients survived. Univariate analysis showed that successful temporary control of bleeding and airway control were associated with survival.

CONCLUSIONS

Prompt bleeding control and airway management is necessary to improve survival. Endovascular treatment is a good definitive treatment option with a high success rate.

N, Aerts NR. Endovascular treatment of iatrogenic penetrating trauma of the carotid artery: case report

Carotid trauma demands early diagnosis and treatment. Open repair may be technically challenging if the trauma is at the base of the neck. We present a case of iatrogenic penetrating carotid trauma caused by insertion of a hemodialysis catheter. Treatment was accomplished by placement of a covered stent-graft in the common carotid artery, covering the puncture site. This case suggests that placement of a covered stent-graft is a good option for treatment of iatrogenic injury to the carotid artery.

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.

Rapid, sequential bilateral acute carotid blowout syndrome

INTRODUCTION

This study aims to report the treatment and outcome of sequential bilateral acute carotid artery blowout syndrome.

METHODS

From 2004 to 2010, we treated seven male patients with sequential bilateral blowout syndrome long after irradiation treatment for head and neck cancer. After first common carotid artery (CCA)-internal carotid artery (ICA) rupture, six were treated with CCA-ICA occlusion and one with graft stenting. The contralateral ICAs were normal or stenotic on angiography in all patients. After the contralateral CCA-ICA rupture, five patients received CCA-ICA occlusion, one received graft stent treatment, and one received no treatment.

RESULTS

Five of the seven patients died soon after the final treatment. Two patients developed cerebral infarctions (one treated with bilateral stenting, one treated with occlusion), one died from extensive local infection, one died soon after a third treatment, one died of progression of the disease, and one refused a second treatment and died soon after the diagnostic angiography. Two patients survived with follow-up periods of 1 and 5 years. In all seven patients, the contralateral CCA-ICA blowout occurred within 3 months after the first ICA occlusion.

CONCLUSION

Bilateral ICA occlusion is an alternative management for sequential carotid artery blowout, but the mortality is high and outcome is poor. A normal angiogram cannot exclude the possibility of rapid development of a contralateral carotid artery blowout shortly after a first episode in patients who have received radiotherapy for head and neck cancer.

Salvage of the carotid artery with covered stent after perforation with dialysis sheath. A case report

We present a rare case of carotid tear caused by iatrogenic erroneous insertion of a dialysis sheath into the common carotid artery (CCA). This was treated by placement of a covered stent-graft in the CCA over the puncture site. This treatment achieved hemostasis while preserving the carotid artery with good outcome. The technical details are presented and the relevant literature regarding treatment of carotid blowout syndrome is discussed. This case suggests that placement of a covered stent-graft is a good option not only for the "usual" blowout syndrome due to head and neck tumors, but also for treatment of iatrogenic injury to the carotid artery.