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Lee BC, Hu YC, Lin YH, Chen YF, Hsieh HJ, Lee CW. The Clinical Outcome of Carotid Blowout Syndrome Showing Non-bleeding Angiography. Cardiovasc Intervent Radiol 2024; 47:955-961. [PMID: 38653811 DOI: 10.1007/s00270-024-03723-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 03/29/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVE Patient with carotid blowout syndrome (CBS) may demonstrated non-bleeding digital subtraction angiography (DSA) without identifying pseudoaneurysm or contrast extravasation. Our objective is to evaluate the clinical outcomes for this specific subset of patients. MATERIALS AND METHODS A retrospective observational study was conducted on 172 CBS patients who received DSA for evaluation of transarterial embolization (TAE) between 2005 and 2022, of whom 19 patients had non-bleeding DSA and did not undergo TAE. RESULTS The age (55.2 ± 7.3 vs. 54.8 ± 11.1), male sex (17/19 vs. 135/153), tumor size (5.6 ± 2.4 vs. 5.2 ± 2.2), cancer locations were similar (P > 0.05) between both groups; except for there were more pseudoaneurysm/active bleeding (85.6% vs. 0%) and less vascular irregularity (14.4% vs. 94.7%) in the TAE group (P < 0.001). In the multivariable Cox regression model adjusting for age, sex, and tumor size, non-bleeding DSA group was independently associated with recurrent bleeding compared to TAE group (adjusted hazard ratio = 3.5, 95% confidence interval: 1.9-6.4, P < 0.001). Furthermore, the presence of vascular irregularity was associated with segmental recurrent bleeding (adjusted HR = 8.0, 95% CI 2.7-23.3, P < 0.001). CONCLUSION Patient showing non-bleeding DSA thus not having TAE had higher risk of recurrent bleeding, compared to patient who received TAE. Level of Evidence Level 4, Case Series.
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Affiliation(s)
- Bo-Ching Lee
- Graduate Institute of Clinical Medicine, National Taiwan University, Taipei, Taiwan
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
- Department of Medical Imaging, Yun-Lin Branch, National Taiwan University Hospital, No.579, Sec. 2, Yunlin Rd., Douliu City, Yunlin County, 640, Taiwan
| | - Yung-Ching Hu
- College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yen-Heng Lin
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Ya-Fang Chen
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Hong-Jen Hsieh
- Department of Medical Imaging, Yun-Lin Branch, National Taiwan University Hospital, No.579, Sec. 2, Yunlin Rd., Douliu City, Yunlin County, 640, Taiwan.
| | - Chung-Wei Lee
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
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Awad A, Pal K, Maniakas A, Zafereo M, Grosu H, Cabanillas M, Chen SR. Carotid blowout into the trachea: unusual entity with unexpected management outcome. J Neurointerv Surg 2024; 16:743-746. [PMID: 37532452 DOI: 10.1136/jnis-2023-020630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/21/2023] [Indexed: 08/04/2023]
Abstract
We present a case report of a patient with a history of aggressive thyroid cancer managed by surgery, chemotherapy, and radiation to the neck. A year later, he presented with hemoptysis. Endobronchial ultrasound showed a pulsatile vessel; however, a CT scan and conventional angiogram were negative. Three days later, a repeat angiogram revealed a pseudoaneurysm arising from the right common carotid artery. Carotid sacrifice was performed after passing balloon test occlusion. Three years later the patient presented with coil herniation into the trachea. The carotid stump was closed with a vascular plug to prevent rebleeding from coil removal. Four months later the patient experienced an intractable cough and underwent laryngoscopy-assisted removal of the residual coil mass. This case report discusses the rare scenario of a carotid blowout into the trachea and the subsequent course of events.
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Affiliation(s)
- Ahmed Awad
- Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Koustav Pal
- Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Anastasios Maniakas
- Head & Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mark Zafereo
- Head & Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Horiana Grosu
- Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria Cabanillas
- Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Stephen R Chen
- Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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3
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Jiang JL, Chang JTC, Yeh CH, Chang TY, Huang BS, Sung PS, Lin CY, Fan KH, Wei YC, Liu CH. Incidence of Carotid Blowout Syndrome in Patients with Head and Neck Cancer after Radiation Therapy: A Cohort Study. Diagnostics (Basel) 2024; 14:1222. [PMID: 38928638 PMCID: PMC11202696 DOI: 10.3390/diagnostics14121222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 06/02/2024] [Accepted: 06/04/2024] [Indexed: 06/28/2024] Open
Abstract
Carotid blowout syndrome (CBS) is a rare yet life-threatening complication that occurs after radiation therapy (RT). This study aimed to determine the incidence of CBS in patients with head and neck cancer (HNC) undergoing contemporary RT and to explore potential discrepancies in the risk of CBS between nasopharyngeal cancer (NPC) and non-NPC patients. A total of 1084 patients with HNC who underwent RT between 2013 and 2023 were included in the study. All patients were under regular follow-ups at the radio-oncology department, and underwent annual contrast-enhanced computed tomography and/or magnetic resonance imaging for cancer recurrence surveillance. Experienced neuroradiologists and vascular neurologists reviewed the recruited patients' images. Patients were further referred to the neurology department for radiation vasculopathy evaluation. The primary outcome of this study was CBS. Patients were categorized into NPC and non-NPC groups and survival analysis was employed to compare the CBS risk between the two groups. A review of the literature on CBS incidence was also conducted. Among the enrolled patients, the incidence of CBS in the HNC, NPC, and non-NPC groups was 0.8%, 0.9%, and 0.7%, respectively. Kaplan-Meier analysis revealed no significant difference between the NPC and non-NPC groups (p = 0.34). Combining the findings for our cohort with those of previous studies revealed that the cumulative incidence of CBS in patients with HNC is 5% (95% CI = 3-7%) after both surgery and RT, 4% (95% CI = 2-6%) after surgery alone, and 5% (95% CI = 3-7%) after RT alone. Our findings indicate a low incidence of CBS in patients with HNC undergoing contemporary RT. Patients with NPC may have a CBS risk close to that of non-NPC patients. However, the low incidence of CBS could be a potentially cause of selection bias and underestimation bias.
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Grants
- CMRPG3M0811, CMRPG381503, CMRPG3C0763, CMRPG3G0261, CFRPG3L0011, and BMRPF99 Chang Gung Memorial Hospital
- grants 106-2511-S-182A-002-MY2, 108-2314-B-182A-050-MY3, 111-2314-B-182A-133-MY3, NMRPG3M6231-3, NMRPG3G6411-2, and NMRPG3J6131-3 Ministry of Science and Technology
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Affiliation(s)
- Jian-Lin Jiang
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 33333, Taiwan
| | - Joseph Tung-Chieh Chang
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Department of Radiation Oncology, Proton and Radiation Therapy Center, Chang Gung Medical Foundation, Linkou Chang Gung Memorial Hospital, Taoyuan 33333, Taiwan
- Taipei Chang Gung Head & Neck Oncology Group, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 33333, Taiwan
| | - Chih-Hua Yeh
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Department of Neuroradiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 33333, Taiwan
| | - Ting-Yu Chang
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 33333, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Bing-Shen Huang
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Department of Radiation Oncology, Proton and Radiation Therapy Center, Chang Gung Medical Foundation, Linkou Chang Gung Memorial Hospital, Taoyuan 33333, Taiwan
- Taipei Chang Gung Head & Neck Oncology Group, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 33333, Taiwan
| | - Pi-Shan Sung
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
| | - Chien-Yu Lin
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Department of Radiation Oncology, Proton and Radiation Therapy Center, Chang Gung Medical Foundation, Linkou Chang Gung Memorial Hospital, Taoyuan 33333, Taiwan
- Taipei Chang Gung Head & Neck Oncology Group, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 33333, Taiwan
- Radiation Research Core Laboratory, Chang Gung University, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 33333, Taiwan
| | - Kang-Hsing Fan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Department of Radiation Oncology, Proton and Radiation Therapy Center, Chang Gung Medical Foundation, Linkou Chang Gung Memorial Hospital, Taoyuan 33333, Taiwan
- Department of Radiation Oncology, New Taipei Municipal Tu-Cheng Hospital, New Taipei City 236, Taiwan
| | - Yi-Chia Wei
- Department of Neurology, Keelung Chang Gung Memorial Hospital, Keelung 83301, Taiwan
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Chi-Hung Liu
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 33333, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei 10055, Taiwan
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Ranganathan K, Kavitha L. Clinical aspects of oral cancer and potentially malignant disorders in South and Southeast Asia. Oral Dis 2024. [PMID: 38817004 DOI: 10.1111/odi.15008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 04/29/2024] [Accepted: 05/08/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Oral cancer and Oral Potentially Malignant Disorders (OPMD) are major health problems in South and Southeast Asia. AIMS To describe and discuss the clinical aspects of Oral Cancer and OPMD in South and Southeast Asia. MATERIALS AND METHODS Literature review of concepts and data over the last four decades. DISCUSSION Asian countries account for about two-thirds of new cases of oral cancer (OC) globally, with the highest burden in the South and Southeast Asian countries, including Pakistan and India. Habits, dietary patterns, socioeconomic status, and access to routine dental care play a crucial role in defining the demographics and clinical presentation of OC in these regions and significantly influence the morbidity and mortality of the disease. This region sees the use of different types of tobacco with or without areca nut (AN), such as pan masala, gutka, gul, snuff, mawa, and mishri. Tobacco use is high among men in Sri Lanka, Myanmar, Maldives, Bangladesh, Nepal, India and Bhutan. Areca nut is the fourth most common addictive substance globally and is frequently used in South and Southeast Asian countries, including Southeast China, Hainan Island, India, Taiwan, and the Pacific Islands, and immigrants from these regions in Africa, Europe, and North America. The use of these products results in mucosal alterations with varied clinical presentation of Oral Potentially Malignant Disorders (OPMDs) and OC. We discuss here the different types of OPMD and OC, the diagnostic aids and their relevance in clinical practice, and factors that influence their prognosis.
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Affiliation(s)
- Kannan Ranganathan
- Ragas Dental College and Hospital, Affiliated to The Tamil Nadu Dr. M.G.R. Medical University, Chennai, Tamil Nadu, India
| | - Loganathan Kavitha
- Ragas Dental College and Hospital, Affiliated to The Tamil Nadu Dr. M.G.R. Medical University, Chennai, Tamil Nadu, India
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5
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Brenner DA, Valdivia DJ, Ginalis EE, Dadario NB, Mashiach E, Gupta G, Sundararajan S, Nourollah-Zadeh E, Lazar E, Roychowdhury S, Sun H. Brain abscesses following carotid blowout syndrome: a case report. Radiol Case Rep 2024; 19:1319-1324. [PMID: 38292792 PMCID: PMC10825556 DOI: 10.1016/j.radcr.2023.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/03/2023] [Accepted: 12/09/2023] [Indexed: 02/01/2024] Open
Abstract
We report a case of intracranial abscesses development in a patient with head and neck cancer after emergent treatment of carotid blowout syndrome with coil embolization. Our patient is a 60-year-old male who presented with hemoptysis and hematemesis, which raised concerns for impending carotid blowout syndrome. Endovascular occlusion was successfully achieved, and the patient was discharged in stable condition. Ten days later, the patient reported headaches and right facial pain, and magnetic resonance imaging revealed multiple intracranial abscesses. Broad-spectrum intravenous antibiotics were administered, leading to a variable response with some abscesses decreasing in size and others increasing. Seven weeks from discharge, the patient had no neurological deficits, and all abscesses had decreased in size.
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Affiliation(s)
- Daniel A. Brenner
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Daniel J. Valdivia
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | | | - Nicholas B. Dadario
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Elad Mashiach
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Gaurav Gupta
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Srihari Sundararajan
- Department of Radiology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Emad Nourollah-Zadeh
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Eric Lazar
- Department of Radiology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Sudipta Roychowdhury
- Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Hai Sun
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
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6
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Buncke M, Bhatnagar K, Yang S, Tan K, Slijepcevic AA, Young G, Andersen P, Wax MK. Outcomes Following Treatment for Carotid Blowout in Head and Neck Cancer Patients. Laryngoscope 2024; 134:695-700. [PMID: 37462334 DOI: 10.1002/lary.30899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/21/2023] [Accepted: 06/27/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE The aim of the study was to determine outcomes after interventional radiology treatment of carotid blowout. METHODS Patients with head and neck cancer and who received interventional radiology treatment for carotid blowout between 2000 and 2022 were included. Pre-treatment, treatment, and post-treatment variables were evaluated. RESULTS Fourteen patients met inclusion criteria. Eleven patients (78.6%) had a history of radiation. Twelve (85.7%) blowouts occurred within 6 months of recent intervention. Initial treatment was with stenting (n = 9, 64.3%), coil embolization (n = 4, 28.6%), or both (n = 1, 7.1%). Six patients (42.9%) underwent subsequent carotid bypass. Morbidity following treatment included stroke (n = 1) and rebleeding (n = 4). Six-month survival was 57.1%. Of the patients who survived past six months, 5/8 were treated with carotid bypass and coverage. Four patients died of cancer progression, three of rebleeding, and three of medical complications. CONCLUSION The majority of carotid blowout occurs within 6 months of surgery or radiation. Many who survive will die of cancer progression or medical illness. Carotid bypass with flap coverage may be a worthwhile treatment for carotid blowout and should be considered as an adjunct to endovascular treatment. LEVEL OF EVIDENCE 4 Laryngoscope, 134:695-700, 2024.
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Affiliation(s)
- Michelle Buncke
- School of Medicine, Oregon Health & Science University, Portland, Oregon, U.S.A
- Department of Otolaryngology-Head & Neck Surgery, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Kavita Bhatnagar
- Department of Otolaryngology-Head & Neck Surgery, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Sara Yang
- Department of Otolaryngology-Head & Neck Surgery, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Kenneth Tan
- School of Medicine, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Allison A Slijepcevic
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest University, Winston-Salem, North Carolina, U.S.A
| | - Gavin Young
- Department of Otolaryngology-Head & Neck Surgery, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Peter Andersen
- Department of Otolaryngology-Head & Neck Surgery, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Mark K Wax
- Department of Otolaryngology-Head & Neck Surgery, Oregon Health & Science University, Portland, Oregon, U.S.A
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7
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Gao K, Guo W, Shang Y, Liu G, Zhai X, Li H, Shi M, Tong X. Surgical treatment of carotid blowout syndrome after radiotherapy for head and neck malignant tumors: a single-center experience. Neurosurg Rev 2023; 46:293. [PMID: 37924361 DOI: 10.1007/s10143-023-02193-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 10/10/2023] [Accepted: 10/18/2023] [Indexed: 11/06/2023]
Abstract
To explore the treatments for and manifestations of carotid blowout syndrome (CBS) and to further explore the critical role of high-flow bypass combined with parent artery isolation. The clinical data of nine patients with radiotherapy-related CBS who were admitted to our hospital from March 2020 to March 2023 were retrospectively analyzed. Relevant literature was reviewed. From March 2020 to March 2023, nine CBS patients were admitted to Tianjin Huanhu Hospital, including eight males and one female. Digital subtraction angiography was performed for all the patients; all the pseudoaneurysms were located at the petrous segment of the internal carotid artery. A balloon occlusion test was performed on four patients, which was tolerated by all patients. CT and MRI scans showed seven cases of osteonecrosis combined with infection and two cases of tumor recurrence. Emergency permanent parent artery occlusion was performed on six patients, aneurysm embolization was completed in one case, covered stent implantation was performed in one patient, and three cases were treated by cerebral bypass surgery (including two patients with failed interventional treatment). Rebleeding was found in two patients, and no rebleeding was found in the bypass group. Paralysis was found in three patients, and asymptomatic cerebral infarction without permanent neurologic impairment was found in three patients. Two patients died due to tumor progression. Emergency occlusion surgery is lifesaving in the acute phase of CBS. Endovascular therapy cannot prevent the progression of pseudoaneurysms or lower the recurrence rate of bleeding events. High-flow bypass combined with parent artery isolation is a safe and effective method that may facilitate further surgical treatment. Further research is warranted.
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Affiliation(s)
- Kaiming Gao
- Department of Neurosurgery, Tianjin Huanhu Hospital, 6 Jizhao Road, Jinnan District, Tianjin, 300350, China
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| | - Wenqiang Guo
- Department of Neurosurgery, Qilu Hospital of Shandong University (Qingdao), 758 Hefei Road, Shibei District, Qingdao, Shandong, 266035, China
| | - Yanguo Shang
- Department of Neurosurgery, Tianjin Huanhu Hospital, 6 Jizhao Road, Jinnan District, Tianjin, 300350, China
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| | - Gang Liu
- Department of Otorhinolaryngology, Tianjin Huanhu Hospital, Tianjin, China
- Department of Otorhinolaryngology, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| | - Xiang Zhai
- Department of Otorhinolaryngology, Tianjin Huanhu Hospital, Tianjin, China
- Department of Otorhinolaryngology, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| | - Haiyan Li
- Department of Otorhinolaryngology, Tianjin Huanhu Hospital, Tianjin, China
- Department of Otorhinolaryngology, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| | - Minggang Shi
- Department of Neurosurgery, Tianjin Huanhu Hospital, 6 Jizhao Road, Jinnan District, Tianjin, 300350, China.
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China.
| | - Xiaoguang Tong
- Department of Neurosurgery, Tianjin Huanhu Hospital, 6 Jizhao Road, Jinnan District, Tianjin, 300350, China.
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China.
- Laboratory of Microneurosurgery, Tianjin Neurosurgical Institute, Tianjin, China.
- Tianjin Key Laboratory of Cerebral Vascular and Neural Degenerative Diseases, Tianjin, China.
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Lee BC, Hu YC, Lin YH, Chen YF, Lee CW. The Extent of Tumor Invasion and Therapeutic Embolization Are Associated with Recurrent Hemorrhage in Patients with External Carotid Artery Blowout Syndrome. J Vasc Interv Radiol 2023; 34:1882-1891.e1. [PMID: 37482242 DOI: 10.1016/j.jvir.2023.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 07/25/2023] Open
Abstract
PURPOSE To explore the optimal strategies of therapeutic embolization for patients with carotid blowout syndrome in the external carotid artery (ECA), who may also present with arterial tumor invasion or necrosis extending to the internal carotid artery (ICA) or common carotid artery (CCA). MATERIALS AND METHODS The study included 110 patients with ECA blowout between 2005 and 2022. Antecedent cross-sectional imaging features were examined, including tumor size, extent of arterial invasion, and air-containing necrosis. Patients were divided into Groups 1 (n = 53, simultaneous ICA/CCA invasion + ECA therapeutic embolization), 2 (n = 18, simultaneous ICA/CCA invasion + ECA-ICA/CCA therapeutic embolization), and 3 (n = 39, no ICA/CCA invasion + ECA therapeutic embolization). Kaplan-Meier and multivariable Cox regression analyses were performed to evaluate associations of clinical, imaging, and therapeutic embolization characteristics with recurrent bleeding. RESULTS Multivariable Cox regression revealed that Group 1 was independently associated with a higher risk of recurrent bleeding than that in Group 2 (adjusted hazard ratio, 6.3; 95% CI, 1.7‒23.4; P = .005) and Group 3 (adjusted hazard ratio, 3.8; 95% CI, 1.8‒8.3; P = .001). In the subgroup with simultaneous ICA/CCA invasion, air-containing necrosis around the ICA/CCA was independently associated with recurrent bleeding after therapeutic embolization of the ECA (adjusted hazard ratio, 5.0; 95% CI, 1.8‒13.6; P = .002). CONCLUSIONS In patients with ECA blowout treated with therapeutic embolization, there was a lower risk of recurrent bleeding when the extents of arterial invasion and therapeutic embolization were concordant. Air-containing necrosis around the ICA/CCA was associated with recurrent bleeding, so extensive therapeutic embolization to the ICA/CCA should be evaluated in such patients.
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Affiliation(s)
- Bo-Ching Lee
- Graduate Institute of Clinical Medicine, National Taiwan University, Taipei, Taiwan; Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan; Department of Medical Imaging, National Taiwan University Hospital Yun-lin Branch, Douliu, Taiwan
| | - Yung-Ching Hu
- School of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yen-Heng Lin
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Ya-Fang Chen
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Chung-Wei Lee
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan.
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9
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Karamitsou P, Karamitsou A, Galanis S, Trellopoulos G, Anestiadou E, Forozidou E, Poutoglidis A. Transarterial Embolization for Bleeding Management of a Neglected Parotid Gland Tumor. EAR, NOSE & THROAT JOURNAL 2023:1455613231189959. [PMID: 37522335 DOI: 10.1177/01455613231189959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023] Open
Affiliation(s)
- Paraskevi Karamitsou
- Department of Otorhinolaryngology-Head and Neck Surgery, "G. Papanikolaou" General Hospital, Thessaloniki, Greece
| | - Aikaterini Karamitsou
- Fourth Department of Surgery, School of Medicine, Aristotle University of Thessaloniki, "G. Papanikolaou" General Hospital, Thessaloniki, Greece
| | - Stavros Galanis
- Department of Radiology, "G. Papanikolaou" General Hospital, Thessaloniki, Greece
| | | | - Elissavet Anestiadou
- Fourth Department of Surgery, School of Medicine, Aristotle University of Thessaloniki, "G. Papanikolaou" General Hospital, Thessaloniki, Greece
| | - Evropi Forozidou
- Department of Otorhinolaryngology-Head and Neck Surgery, "G. Papanikolaou" General Hospital, Thessaloniki, Greece
| | - Alexandros Poutoglidis
- Department of Anatomy and Surgical Anatomy, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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10
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Moest T, Kesting MR, Rohde M, Lang W, Meyer A, Weber M, Lutz R. A Treatment Approach for Carotid Blowout Syndrome and Soft Tissue Reconstruction after Radiotherapy in Patients with Oral Cancer: A Report of 2 Cases. J Clin Med 2023; 12:jcm12093221. [PMID: 37176661 PMCID: PMC10179401 DOI: 10.3390/jcm12093221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/17/2023] [Accepted: 04/27/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND This retrospective case series study aims to demonstrate a salvage technique for the treatment of carotid blow-out syndrome (CBS) in irradiated head and neck cancer patients with a vessel-depleted neck. METHODS Between October 2017 and October 2021, two patients (N = 2) with CBS were treated at our institution in a multidisciplinary approach together with the Department of Vascular Surgery. Patients were characterized based on diagnoses, treatment procedures, and the subsequent postoperative course. RESULTS Surgical emergency intervention was performed in both cases. The transition zone from the common carotid artery (CCA) to the internal carotid artery (ICA) was resected and reconstructed with a xenogic (case 1) or autogenic (case 2) interposition (end-to-end anastomosis). To allow reconstruction of the vascular defect, an additional autologous vein graft was anastomosed to the interposition graft in an end-to-side technique, allowing arterial anastomosis for a free microvascular flap without re-clamping of the ICA. Because of the intraoperative ICA reconstruction, none of the patients suffered a neurological deficit. CONCLUSIONS The techniques presented in the form of two case reports allow for acute bleeding control, cerebral perfusion, and the creation of a vascular anastomosis option in the vessel-depleted neck.
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Affiliation(s)
- Tobias Moest
- Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, Glückstraße 11, 91054 Erlangen, Germany
| | - Marco Rainer Kesting
- Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, Glückstraße 11, 91054 Erlangen, Germany
| | - Maximilian Rohde
- Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, Glückstraße 11, 91054 Erlangen, Germany
| | - Werner Lang
- Department of Vascular Surgery, University Hospital Erlangen, Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Alexander Meyer
- Department of Vascular Surgery, University Hospital Erlangen, Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Manuel Weber
- Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, Glückstraße 11, 91054 Erlangen, Germany
| | - Rainer Lutz
- Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, Glückstraße 11, 91054 Erlangen, Germany
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11
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Slijepcevic AA, Roh J, Pipkorn P, Lipsey K, Bradley JP. Carotid Blowout Syndrome in Head and Neck Cancer Patients: Management of Patients At Risk for CBS. Laryngoscope 2023; 133:576-587. [PMID: 35575599 DOI: 10.1002/lary.30157] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/16/2022] [Accepted: 04/09/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Carotid blowout syndrome (CBS) is an acute, rare life-threatening hemorrhage that occurs in patients with a history of head and neck cancer and radiation therapy. The primary objective of this review was to identify risk factors and assess treatment and survival outcomes following CBS. METHODS A systematic review of published literature was performed. Information including risk factors, treatment, and outcomes of CBS were collected. RESULTS A total of 49 articles and 2220 patients were included in the systematic review. Risk factors for developing CBS included a history of radiation therapy, wound complications, and advanced tumor stage. The initial management of CBS included establishing a stable airway, gaining hemostasis, and repletion of blood loss. Endovascular and surgical procedures treat CBS with infrequent rates of rebleeding and periprocedural complications. Short-term survival following treatment of CBS shows high survival rates when considering CBS-related complications and underlying disease, however, long-term survival related to the underlying disease demonstrated high mortality. CONCLUSIONS Identifying patients at risk for CBS enables practitioners to counsel patients on life-saving interventions and expected outcomes following treatment of CBS. Treatment of CBS is associated with high short-term survival, although long-term survival related to underlying disease is low. LEVEL OF EVIDENCE N/A Laryngoscope, 133:576-587, 2023.
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Affiliation(s)
- Allison A Slijepcevic
- Department of Otolaryngology-Head & Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Joseph Roh
- Department of Otolaryngology-Head & Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Patrik Pipkorn
- Department of Otolaryngology-Head & Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Kim Lipsey
- Bernard Becker Medical Library, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Joseph P Bradley
- Department of Otolaryngology-Head & Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
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12
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Moriguchi K, Kurita T, Fujii T, Kawai K, Kubo T. Head and Neck Reconstruction With 2-Stage External Pectoralis Major Myocutaneous Flap Transfer. Ann Plast Surg 2023; 90:135-139. [PMID: 36688856 DOI: 10.1097/sap.0000000000003417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND In head and neck surgery cases where skin is severely scarred or adhered to surrounding tissue, reconstruction can be difficult to perform using microsurgical tissue or conventional pedicled pectoralis major myocutaneous flap (PMMF) transfer given the risks, which include damage to major vessels when manipulating scarred skin. For such cases, we perform a 2-stage external PMMF transfer, whereby the PMMF is directly sutured to the defect over the neck skin (without manipulation the hardened skin), and the flap division is then performed secondarily. METHODS A total of 30 patients who had histories of radiotherapy (60-70 Gy) and prior neck dissection received the 2-stage external PMMF transfer procedure. Indications for the flaps included pharyngeal fistula closure in 12 patients, reconstruction for mandibular necrosis after radiotherapy in 8 patients, salvage surgery for partial or total necrosis of the free flap in 4 patients, and simultaneous reconstruction after tumor excision in 6 patients. Two patients underwent a second external PMMF transfer from the contralateral side because of postoperative complications, yielding a total of 32 flap transfers. RESULTS Twenty-nine flaps showed complete flap survival, whereas 3 had partial necrosis. Other complications, despite complete flap survival, included large fistulas requiring additional surgery for fistula closure (1 patient) and small fistulas that were closed without requiring reoperation (7 patients). CONCLUSIONS External PMMF transfer offers a safe, simple, and effective option in cases where free flap surgery is considered difficult or the risks associated with neck manipulation are high.
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Affiliation(s)
| | | | - Takashi Fujii
- Head and Neck Surgery, Osaka Prefectural Hospital Organization, Osaka International Cancer Institute, Osaka
| | - Kenichiro Kawai
- Department of Plastic Surgery, Hyogo College of Medicine, Hyogo
| | - Tateki Kubo
- Department of Plastic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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13
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Wang CK, Ho CF, Niu KY, Wu CC, Chang YC, Hsiao CH, Yen CC. Risk factors for rebleeding and long-term outcomes in patients with head and neck cancer bleeding: a multicenter study. BMC Cancer 2022; 22:841. [PMID: 35918707 PMCID: PMC9347166 DOI: 10.1186/s12885-022-09945-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/28/2022] [Indexed: 12/24/2022] Open
Abstract
Background Acute, catastrophic bleeding in patients with head and neck cancer (HNC) is challenging and also a burden for their families and frontline physicians. This study analyzed the risk factors for rebleeding and long-term outcomes in these patients with HNC. Methods Patients who presented to the emergency department (ED) with HNC bleeding were enrolled in this study (N = 231). Variables of patients with or without rebleeding were compared, and associated factors were investigated using Cox’s proportional hazard model. Results Of the 231 patients enrolled, 112 (48.5%) experienced a recurrent bleeding event. The cumulative rebleeding incidence rate was 23% at 30 days, 49% at 180 days, and 56% at 1 year. Multivariate Cox regression analyses demonstrated that overweight-to-obesity (HR = 0.52, 95% CI 0.28–0.98, p = 0.043), laryngeal cancer (hazard ratio [HR] = 2.13, 95% confidence interval [CI] 1.07–4.23, p = 0.031), chemoradiation (HR = 1.49, 95% CI 1.001–2.94, p = 0.049), and second primary cancer (HR = 1.75, 95% CI 1.13–2.70, p = 0.012) are significant independent predictors of rebleeding, and the prognostic factors for overall survival included underweight (HR = 1.89, 95% CI 1.22–2.93, p = 0.004), heart rate > 110 beats/min (HR = 1.58, 95% CI 1.04–2.39, p = 0.032), chemoradiation (HR = 2.31, 95% CI 1.18–4.52, p = 0.015), and local recurrence (HR = 1.74, 95% CI 1.14–2.67, p = 0.011). Conclusions Overweight-to-obesity is a protective factor, while laryngeal cancer, chemoradiation and a second primary cancer are risk factors for rebleeding in patients with HNC. Our results may assist physicians in risk stratification of patients with HNC bleeding.
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Affiliation(s)
- Chih-Kai Wang
- Department of Emergency Medicine, Linkou Branch, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Che-Fang Ho
- Department of Otolaryngology Head and Neck Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Kuang-Yu Niu
- Department of Emergency Medicine, Keelung Branch, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chia-Chien Wu
- Department of Medical Imaging and Intervention, Linkou Branch, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yun-Chen Chang
- Department of Otolaryngology Head and Neck Surgery, Linkou Branch, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chien-Han Hsiao
- Department of Linguistics, Indiana University, Bloomington, IN, USA
| | - Chieh-Ching Yen
- Department of Emergency Medicine, Linkou Branch, Chang Gung Memorial Hospital, Taoyuan, Taiwan. .,Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Cocca AT, Levy BE, Castle JT, Wilt WS, Fleming MD, Kejner AE, Aouad RK, Tyagi SC. Management of Double Carotid Blow Out with Definitive Repair After Temporizing Stent Graft Placement. J Vasc Surg Cases Innov Tech 2022; 8:606-609. [PMID: 36248383 PMCID: PMC9556593 DOI: 10.1016/j.jvscit.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/10/2022] [Accepted: 08/17/2022] [Indexed: 11/23/2022] Open
Abstract
Carotid blowout syndrome is a life-threatening complication for patients with head and neck cancer. Temporizing stent graft procedures improve short-term survival and can be the definitive treatment for various reasons, including a poor oncologic prognosis, unsuitability for definitive reconstruction, or a lack of operative options. A second carotid blowout will often be fatal. Preventing such events requires multidisciplinary strategic planning because of a hostile reoperative field. We have described a case of a 44-year-old man with a history of laryngeal cancer who had experienced a carotid blowout. Treated with a stent graft, the patient had experienced a second event 6 weeks later. Treatment involved excision and suture ligation with rotational muscle flap coverage.
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15
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Xie TH, Zhao WJ, Li XL, Hou Y, Wang X, Zhang J, An XH, Liu LT. Carotid blowout syndrome caused by chronic infection: A case report. World J Clin Cases 2022; 10:5051-5056. [PMID: 35801053 PMCID: PMC9198892 DOI: 10.12998/wjcc.v10.i15.5051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/10/2022] [Accepted: 03/26/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Carotid blowout syndrome (CBS) refers to rupture of the extracranial carotid artery and its branches; as a severe complication, it usually occurs after surgery or radiotherapy for malignant tumours of the head and neck. We present a case of CBS caused by chronic infection of the external carotid artery (ECA). In this case, we did not find any evidence of head and neck tumours.
CASE SUMMARY A 42-year-old man was referred to the Emergency Department with a complaint of a lump found on the left side of his neck with pain and fever for 4 d. We diagnosed the condition as neck infection with abscess formation based on physical examination, routine blood examination, ultrasound examination and plain computed tomography (CT) and decided to perform emergency surgery. During the operation, 30 mL of grey and smelly pus was drained from the deep surface of the sternocleidomastoid muscle. The second day after the operation, the patient suddenly exhibited a large amount of haemoptysis and incision bleeding. The enhanced CT showed distal occlusion of the left ECA and irregular thickening of the broken ends of the artery encased in an uneven enhancement of soft tissue density. Infected ECA occlusion and rupture were considered. The patient was transferred to a vascular unit for transcatheter ECA embolization and recovered well.
CONCLUSION Surgeons need to pay attention to vascular lesions caused by chronic infection that may develop into acute CBS.
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Affiliation(s)
- Tian-Hao Xie
- Department of General Surgery, Affiliated Hospital of Hebei University, Baoding 071000, Hebei Province, China
| | - Wen-Jun Zhao
- Department of Ophthalmology, MEM Yinghua Hospital, Baoding 071000, Hebei Province, China
| | - Xiao-Long Li
- Department of Traumatology, The First Hospital of Hebei Medical University, Shijiazhuang 050000, Hebei Province, China
| | - Yan Hou
- Department of Imaging, Affiliated Hospital of Hebei University, Baoding 071000, Hebei Province, China
| | - Xiong Wang
- Department of General Surgery, Li County Hospital, Baoding 071400, Hebei Province, China
| | - Jing Zhang
- Department of General Surgery, Affiliated Hospital of Hebei University, Baoding 071000, Hebei Province, China
| | - Xiu-Hua An
- Department of Internal Medicine, Wangdu County Chinese Medicine Hospital, Baoding 072450, Hebei Province, China
| | - Li-Tao Liu
- Department of General Surgery, Affiliated Hospital of Hebei University, Baoding 071000, Hebei Province, China
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16
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Harrington CÍ, O'Keeffe N, Lennon P. Recurrent Carotid artery blow out in a head & neck patient. Int J Surg Case Rep 2022; 94:107089. [PMID: 35658281 PMCID: PMC9065702 DOI: 10.1016/j.ijscr.2022.107089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 04/12/2022] [Accepted: 04/12/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction and importance Carotid artery blowout syndrome is a rare complication of head and neck cancer treatment. It defines a rupture of the carotid artery wall through vessel wall necrosis. This is typically precipitated by radiotherapy, direct tumour invasion, or a combination of these factors. We describe a rare case of three consecutive carotid artery blowouts in a head and neck cancer patient. Case presentation A 58-year-old man with a history of T3NO hypopharyngeal squamous cell carcinoma (SCC) treated with chemotherapy and radiation presented with a four-month history of progressive dysphagia and right sided neck pain. Flexible nasendoscopy revealed laryngeal oedema and slough. A panendoscopy and biopsy showed no evidence of tumour recurrence. The patient was discharged and represented with worsening dyspnoea. He subsequently experienced a large volume hemorrhage necessitating ligation of his right external carotid artery. He underwent pharyngolaryngectomy indicated due to the extent of laryngeal radiation necrosis. Thereafter he suffered two additional acute carotid bleeds from his right common carotid necessitating ligation in theatre. Clinical discussion and conclusion This case report illustrates the key issues to be considered in patients with locally advanced hypopharyngeal squamous cell carcinoma and subsequent management of acute carotid blowout syndrome, which without prompt management, can be fatal. Carotid artery rupture, or blowout, has a high morbidity and mortality. Carotid blowout is a rare consequence of head and neck cancer treatment. Radiotherapy is the main predisposing risk factor. Acute carotid blowout requires prompt resuscitation and bleeding source control. Definitive treatment includes endovascular occlusion, stenting or surgical ligation.
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Affiliation(s)
- Cara Íosa Harrington
- Department of Otolaryngology/Head & Neck Surgery, St James' Hospital, Dublin 8, Ireland.
| | - Nicholas O'Keeffe
- Department of Otolaryngology/Head & Neck Surgery, St James' Hospital, Dublin 8, Ireland
| | - Paul Lennon
- Department of Otolaryngology/Head & Neck Surgery, St James' Hospital, Dublin 8, Ireland
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Yen CC, Yeh H, Ho CF, Hsiao CH, Niu KY, Yeh CC, Lu JX, Wu CC, Chang YC, Ng CJ. Risk factors for 30-day mortality in patients with head and neck cancer bleeding in the emergency department. Am J Emerg Med 2022; 58:9-15. [DOI: 10.1016/j.ajem.2022.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 04/27/2022] [Accepted: 05/07/2022] [Indexed: 01/06/2023] Open
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18
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Lipe DN, Viets-Upchurch J, Hanna EY, Reyes-Gibby C, Chen SR, Elsayem A, Long B. Carotid Blowout Syndrome in the Emergency Department: A Case Report and Review of the Literature. J Emerg Med 2022; 62:e29-e34. [PMID: 35065858 DOI: 10.1016/j.jemermed.2021.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 11/13/2021] [Accepted: 11/27/2021] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Demis N Lipe
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jayne Viets-Upchurch
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ehab Y Hanna
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Cielito Reyes-Gibby
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stephen R Chen
- Interventional Radiology Department, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ahmed Elsayem
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
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19
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Predictors of survival following carotid blowout syndrome. Oral Oncol 2022; 125:105723. [DOI: 10.1016/j.oraloncology.2022.105723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/26/2021] [Accepted: 01/09/2022] [Indexed: 11/19/2022]
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20
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Yen CC, Ho CF, Wu CC, Tsao YN, Chaou CH, Chen SY, Ng CJ, Yeh H. In-Hospital and Long-Term Outcomes in Patients with Head and Neck Cancer Bleeding. Medicina (B Aires) 2022; 58:medicina58020177. [PMID: 35208501 PMCID: PMC8878826 DOI: 10.3390/medicina58020177] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 12/23/2022] Open
Abstract
Background and Objectives: The purpose of the present study was to elucidate the in-hospital and long-term outcomes of patients with head and neck cancer (HNC) bleeding and to analyze the risk factors for mortality. Materials and Methods: We included patients who presented to the emergency department (ED) with HNC bleeding. Variables of patients who survived and died were compared and associated factors were investigated by logistic regression and Cox’s proportional hazard model. Results: A total of 125 patients were enrolled in the present study. Fifty-nine (52.8%) patients experienced a recurrent bleeding event. The in-hospital mortality rate was 16%. The overall survival at 1, 3 and 5 years was 48%, 41% and 34%, respectively. The median survival time was 9.2 months. Multivariate logistic regression analyses revealed that risk factors for in-hospital mortality were inotropic support (OR = 10.41; Cl 1.81–59.84; p = 0.009), hypopharyngeal cancer (OR = 4.32; Cl 1.29–14.46; p = 0.018), and M stage (OR = 5.90; Cl 1.07–32.70; p = 0.042). Multivariate Cox regression analyses indicate that heart rate >110 (beats/min) (HR = 2.02; Cl 1.16–3.51; p = 0.013), inotropic support (HR = 3.25; Cl 1.20–8.82; p = 0.021), and hypopharygneal cancer (HR = 2.22; Cl 1.21–4.06; p = 0.010) were all significant independent predictors of poorer overall survival. Conclusions: HNC bleeding commonly represents the advanced disease stage. Recognition of associated factors aids in the risk stratification of patients with HNC bleeding.
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Affiliation(s)
- Chieh-Ching Yen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan; (C.-C.Y.); (C.-H.C.); (S.-Y.C.); (C.-J.N.)
- College of Medicine, National Yang Ming University, Taipei 11221, Taiwan
| | - Che-Fang Ho
- Department of Otolaryngology Head and Neck Surgery, Chang Gung Memorial Hospital, Keelung 20401, Taiwan;
| | - Chia-Chien Wu
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan;
| | - Yu-Ning Tsao
- Department of Otolaryngology Head and Neck Surgery, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan;
| | - Chung-Hsien Chaou
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan; (C.-C.Y.); (C.-H.C.); (S.-Y.C.); (C.-J.N.)
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Chang Gung Medical Education Research Center, Taoyuan 33305, Taiwan
| | - Shou-Yen Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan; (C.-C.Y.); (C.-H.C.); (S.-Y.C.); (C.-J.N.)
- Chang Gung Medical Education Research Center, Taoyuan 33305, Taiwan
| | - Chip-Jin Ng
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan; (C.-C.Y.); (C.-H.C.); (S.-Y.C.); (C.-J.N.)
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Heng Yeh
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan; (C.-C.Y.); (C.-H.C.); (S.-Y.C.); (C.-J.N.)
- Correspondence: ; Tel.: +886-3-328-1200 (ext. 2143)
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Singh J, Sharma T, Tripathy T. Carotid blowout syndrome: endovascular management of a lesser known oncological emergency: case report. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2021. [DOI: 10.1186/s43055-021-00587-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Carotid blowout syndrome (CBS) refers to a fatal hemorrhagic complication of cervical carotid arteries that occurs due to rupture of the extracranial carotid artery or one of its major branches in patients treated for head and neck malignancy. In this article, we will discuss two different spectrum of CBS and endovascular approach.
Case presentation
Two cases of per oral bleeding presented in the emergency department. After patients were hemodynamically stabilized, CT angiography was done which showed type II CBS and type III CBS, respectively. This was followed by transfemoral supra-aortic digital subtraction angiogram coil embolization with scaffolding and anchoring technique, respectively, for the patients.
Conclusions
Early recognition of the predictors of CBS by a multidisciplinary team is critical. The endovascular treatment approach is relatively safe and effective with low rates of morbidity and mortality compared to surgical approach in CBS.
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22
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Joyner D, Rizvi T, Kalelioglu T, Jameson MJ, Mukherjee S. Lymph Node Dissection: Principles and Postoperative Imaging. Neuroimaging Clin N Am 2021; 32:19-36. [PMID: 34809838 DOI: 10.1016/j.nic.2021.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The management of neck nodes in head and neck cancer is critical, given a markedly increased poor prognosis in patients with nodal metastasis. The surgical management of neck nodes has undergone radical changes secondary to a paradigm shift from curative surgery to nonsurgical organ and function-preserving options, such as radiation therapy. In the neck after treatment, radiologists should be familiar with imaging findings in various types of neck dissections and post-chemoradiation changes, along with signs of residual or recurrent disease. A multidisciplinary approach is essential with well-designed evidence-based surveillance imaging protocols and standardized reporting.
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Affiliation(s)
- David Joyner
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA 22903, USA
| | - Tanvir Rizvi
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA 22903, USA
| | - Tuba Kalelioglu
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA 22903, USA
| | - Mark J Jameson
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville, VA 22903, USA
| | - Sugoto Mukherjee
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA 22903, USA.
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23
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Wu PA, Yuan GY, Zhou RM, Ho WWS, Lu ZQ, Cai JF, Yang SY, Tsang RKY, Chan JYW. Extracranial/Intracranial Vascular Bypass in the Treatment of Head and Neck Cancer - Related Carotid Blowout Syndrome. Laryngoscope 2021; 131:1548-1556. [PMID: 33571390 DOI: 10.1002/lary.29427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/01/2021] [Accepted: 01/12/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE/HYPOTHESIS To investigate the endovascular intervention or extracranial/intracranial (EC/IC) vascular bypass in the management of patients with head and neck cancer-related carotid blowout syndrome (CBS). STUDY DESIGN Retrospective case series. METHODS Retrospective analysis of clinical data of patients with head and neck cancer-related CBS treated by endovascular intervention and/or EC/IC vascular bypass, analysis of its bleeding control, neurological complications, and survival results. RESULTS Thrity-seven patients were included. Twenty-five were associated with external carotid artery (ECA); twelve were associated with internal or common carotid artery (ICA/CCA). All patients with ECA hemorrhage were treated with endovascular embolization. Of the 12 patients with ICA/CCA hemorrhage, 9 underwent EC/IC bypass, 1 underwent endovascular embolization, and 3 underwent endovascular stenting. For patients with ECA-related CBS, the median survival was 6 months, and the 90-day, 1-year, and 2-year survival rates were 67.1%, 44.7%, and 33.6%, respectively; the estimated rebleeding risk at 1-month, 6-month, and 2-year was 7.1%, 20.0%, and 31.6%, respectively. For patients with ICA/CCA-related CBS, the median survival was 22.5 months, and the 90-day, 1-year, and 2-year survival rates were 92.3%, 71.8%, and 41.0%, respectively; the estimated rebleeding risk at 1 month, 6 months, and 2 years is 7.7%,15.4%, and 15.4%, respectively. ICA/CCA-related CBS patients have significantly longer survival time and lower risk of rebleeding, which may be related to the more use of EC/IC vascular bypass as a definite treatment. CONCLUSIONS For patients with ICA/CCA-related CBS, if there is more stable hemodynamics, longer expected survival, EC/IC vascular bypass is preferred. LEVEL OF EVIDENCE 4 Laryngoscope, 131:1548-1556, 2021.
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Affiliation(s)
- Ping-An Wu
- Department of Surgery, Division of Otolaryngology, Head and Neck Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, P.R. China
| | - Guo-Yan Yuan
- Department of Surgery, Division of Neurosurgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, P.R. China
| | - Ru-Ming Zhou
- Department of Interventional Radiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, P.R. China
| | - Wilson Wai-Shing Ho
- Department of Surgery, Division of Neurosurgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, P.R. China
| | - Zhao-Qun Lu
- Department of Surgery, Division of Otolaryngology, Head and Neck Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, P.R. China
| | - Ji-Fu Cai
- Department of Neurology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, P.R. China
| | - Si-Yi Yang
- Department of Surgery, Division of Otolaryngology, Head and Neck Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, P.R. China
| | - Raymond King-Yin Tsang
- Department of Surgery, Division of Otolaryngology, Head and Neck Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, P.R. China
| | - Jimmy Yu-Wai Chan
- Department of Surgery, Division of Otolaryngology, Head and Neck Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, P.R. China
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24
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Sánchez-Canteli M, Rodrigo JP, Quintana EM, Vega P, Llorente JL, López F. Embolization for Carotid Blowout in Head and Neck Cancer: Case Report of Five Patients. Vasc Endovascular Surg 2021; 56:53-57. [PMID: 34155944 DOI: 10.1177/15385744211027030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Carotid blowout syndrome (CBS) is defined as a rupture of common carotid artery or its branches. Endovascular intervention has been advocated as first line of treatment for CBS. This Case Report describes 5 patients with prior history of head and neck cancer who presented with CBS. Two patients presented as acute, 2 as impending, and one as threatened CBS. The lesions found were pseudoaneurysm and focal vascular irregularities involving the common carotid artery, cervical internal carotid artery and lingual artery. Embolization and occlusion with detachable coils of the artery was used in all patients. Technical success and immediate hemostasis were achieved in all patients. One patient presented transient cranial nerve palsy. No recurrent CBS was reported during the follow-up. In our experience, coil embolization, if possible, is a safe and efficient technique in treatment of CBS secondary to head and neck cancers.
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Affiliation(s)
- Mario Sánchez-Canteli
- Department of Otolaryngology, 16474Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Juan P Rodrigo
- Department of Otolaryngology, 16474Hospital Universitario Central de Asturias, Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias, Universidad de Oviedo, Spain
| | - Eduardo Murias Quintana
- Department of Radiology-Interventional Neuroradiology, 16474Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Pedro Vega
- Department of Radiology-Interventional Neuroradiology, 16474Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - José Luis Llorente
- Department of Otolaryngology, 16474Hospital Universitario Central de Asturias, Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias, Universidad de Oviedo, Spain
| | - Fernando López
- Department of Otolaryngology, 16474Hospital Universitario Central de Asturias, Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias, Universidad de Oviedo, Spain
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25
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Chatani S, Sato Y, Murata S, Hasegawa T, Tsukii R, Nagasawa K, Machida M, Yoshihara T, Yamaura H, Hanai N, Matsuo K, Inaba Y. Transarterial Embolization for Bleeding in Patients with Head and Neck Cancer: Who Benefits? Laryngoscope 2021; 131:E2777-E2783. [PMID: 33960405 DOI: 10.1002/lary.29611] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/07/2021] [Accepted: 04/28/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVES/HYPOTHESIS The present study aimed to investigate the efficacy of transarterial embolization (TAE) for bleeding in patients with head and neck cancer (HNC) and to evaluate the prognostic factors after TAE. STUDY DESIGN Outcome study. METHODS This retrospective study included 31 consecutive patients (27 men and 4 women; median age, 61 years) who presented uncontrollable hemorrhage associated with HNC and underwent emergency TAE at our institution during a 10-year period (January 2011-December 2020). This corresponded to 40 TAE procedures, including 27 cases with an unstable status (circulatory and/or respiratory insufficiency) and 10 cases with carotid blowout syndrome. The technical success rate and adverse events were analyzed on a per-procedure basis. The rebleeding and overall survival (OS) rates were analyzed on a per-patient basis, and the factors related to OS were evaluated. RESULTS The technical success rate was 100%. As an adverse event, cerebral infarction was found in three cases with carotid blowout syndrome. The rebleeding rate at 30 days after TAE and in the follow-up period (range, 9-3,004 days) was 17.2% and 35.5%, respectively. The median survival time was 263 days (95% confidence interval: 124.0-402.0 days). In the log-rank test, complete remission (CR) of the primary cancer at the time of the first TAE was identified as a significant influencing factor of survival. CONCLUSION TAE is effective for the treatment of hemorrhage associated with HNC even in patients with an unstable status. Patients with CR can gain a long life span. LEVEL OF EVIDENCE Level 4 Laryngoscope, 2021.
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Affiliation(s)
- Shohei Chatani
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan.,Department of Radiology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Yozo Sato
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Shinichi Murata
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Takaaki Hasegawa
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Ryota Tsukii
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Kyohei Nagasawa
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Masanori Machida
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Terutaka Yoshihara
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Hidekazu Yamaura
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Nobuhiro Hanai
- Department of Head and Neck Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Keitaro Matsuo
- Division of Cancer Epidemiology and Prevention, Aichi Cancer Center Research Institute, Nagoya, Aichi, Japan
| | - Yoshitaka Inaba
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
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26
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Zhao Z, Huang L, Chen J, Huang W, Zhang X, Ma Y, Zhu H, Liu Z. Clinical efficacy of bypass grafting in recurrent nasopharyngeal carcinoma patients with internal carotid artery invasion. Am J Otolaryngol 2021; 42:102860. [PMID: 33460978 DOI: 10.1016/j.amjoto.2020.102860] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 12/20/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND We aimed to assess the clinical efficacy of bypass grafting in recurrent nasopharyngeal carcinoma patients with internal carotid artery invasion. METHODS A retrospective analysis was performed involving 51 patients either operated by bypass grafting (n = 22) or treated with repeated chemo-radiotherapy (n = 29). RESULTS Four patients in the bypass grafting group died 3-5 months after the operation due to epistaxis and pulmonary infection (4/22, 18.2%), and three more patients exhibited a modified Rankin Scale (mRS) ≥ 2 during the follow-up (3/22, 13.6%). In the repeated chemo-radiotherapy group, 8 patients died (8/29, 27.6%), including seven patients dying within 2-3 months due to epistaxis and pulmonary infection (7/29, 24.1%). One more patient died of epistaxis after 9 months. The difference in mortality between the two treatment groups within 3 months of treatment was statistically significant (P = 0.038). CONCLUSIONS Cerebrovascular reconstruction after detailed collateral flow assessment is an effective treatment for recurrent NPC patients with internal carotid artery invasion.
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27
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Ota N, Valenzuela JC, Chida D, Tanikawa R. Extracranial vertebral artery to middle cerebral artery bypass in therapeutic internal carotid artery occlusion for epipharyngeal carcinoma: A technical case report. Surg Neurol Int 2021; 12:149. [PMID: 33948319 PMCID: PMC8088539 DOI: 10.25259/sni_99_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/06/2021] [Indexed: 11/09/2022] Open
Abstract
Background: Vertebral artery (VA) to middle cerebral artery (MCA) bypass is a rarely selected technique because a complex expanded dissection is required, and often, a better donor artery than VA exists. A good indication for VA-MCA bypass is the treatment of head-and-neck malignancies with the sacrifice of the internal carotid artery (ICA) or for carotid artery rupture. Methods: A 23-year-old man with epipharyngeal carcinoma, treated by ligating the carotid artery with a VAMCA bypass before chemoradiotherapy, was reported. Radiographic findings showed that the bone of the carotid canal was dissolved, and the right ICA was engulfed by the tumor. As epipharyngeal carcinoma is hypersensitive to radiation, in cases where the tumor rapidly disappears, ICA may dangle in the pharynx and rupture may occur. In addition, to irradiate sufficiently, the ICA may become an obstacle. Hence, we decided to perform carotid ligation with a VA-MCA bypass before radiation and chemotherapy for the primary lesion. We selected the V3 portion of the VA as the donor on the ipsilateral side, as it can supply high-flow cerebral blood flow, which is not influenced by carcinoma and less influenced by irradiation for the epipharynx. Results: The VA-MCA bypass was completed without complications followed by endovascular occlusion of the ICA. Induction chemotherapy was initiated for the patient 2 weeks after surgery. The patient achieved a complete response following chemoradiotherapy. Conclusion: ICA ligation with VA-MCA high-flow bypass earlier than chemoradiotherapy is useful for epipharyngeal carcinoma as it prevents carotid artery rupture and allows radical intervention.
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Affiliation(s)
- Nakao Ota
- Department of Neurosurgery, Sapporo Teishinkai Hospital, Higashi-ku, Sapporo, Japan
| | | | - Daiki Chida
- Department of Neurosurgery, Sapporo Teishinkai Hospital, Higashi-ku, Sapporo, Japan
| | - Rokuya Tanikawa
- Department of Neurosurgery, Sapporo Teishinkai Hospital, Higashi-ku, Sapporo, Japan
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28
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Feng K, Hu J, Huang Q, Cai W, Zhuang Z, Liu H, Hou J, Liu X, Wang C. Risk factors and nomogram for predicting carotid blowout syndrome based on computed tomography angiography. Oral Dis 2021; 28:2131-2138. [PMID: 33772979 DOI: 10.1111/odi.13859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/03/2021] [Accepted: 03/19/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To identify independent factors for head and neck cancer (HNC) patients with carotid blowout syndrome (CBS) and construct a nomogram to predict risk of CBS preoperatively based on computed tomography angiography (CTA) imaging. SUBJECT AND METHODS From January 2010 to July 2020, 73 HNC patients who had surgery in hospitalization and underwent CTA examination for head and neck region were included in this study. Vascular alterations and the relationship between carotid artery (CA) and tumor were evaluated in CTA. Clinical and CTA imaging features were distinguished by logistic regression analysis and used to perform receiver operating curve analysis. Nomogram was created to predict risk of CBS and assessed by concordance index (C-index) and calibration curve. RESULTS Three independent risk factors were identified, including radical neck dissection, CA surrounded by tumor, and CA invaded by tumor without clear boundary. Area under curve of the combination of 3 variables was 0.836 (95% CI, 0.72-0.952, p < 0.001). The C-index of nomogram was 0.84 (95% CI, 0.73-0.94), and the calibration plot showed a good fitting between prediction and observation. CONCLUSIONS We established a useful nomogram based on CTA imaging, which showed a satisfied efficacy for evaluating risk of CBS in HNC patients preoperatively.
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Affiliation(s)
- Kun Feng
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Jing Hu
- Department of Oral and Maxillofacial Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qiuyu Huang
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Weixin Cai
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Zehang Zhuang
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Haichao Liu
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Jinsong Hou
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Xiqiang Liu
- Department of Oral and Maxillofacial Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Cheng Wang
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
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29
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Zhao Z, Huang L, Chen J, Huang W, Zhang X, Ma Y, Zhu H, Liu Z. Comprehensive Treatment Strategy for Internal Carotid Artery Blowout Syndrome Caused by Nasopharyngeal Carcinoma. Otolaryngol Head Neck Surg 2020; 164:1058-1064. [PMID: 33167757 DOI: 10.1177/0194599820963129] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate a treatment strategy for internal carotid artery blowout syndrome caused by nasopharyngeal carcinoma. STUDY DESIGN A retrospective analysis of a case series was performed. SETTING Carotid blowout syndrome is a catastrophic complication caused by malignant tumor of the skull base. METHODS A retrospective analysis based on 69 patients with internal carotid artery blowout syndrome admitted to our center between April 2018 and January 2020 was performed. The patients were divided into 2 groups: an EBBA (internal carotid artery embolization + bypass based on American Society of Intervention and Therapeutic Neuroradiology/Society of Interventional Radiology [ASITN/SIR]) group and an embolization/stent group. The follow-up time was 6 to 9 months. RESULTS In the EBBA group, 41 patients (41/49, 83.7%) survived. Forty patients had a satisfactory quality of life after 3 months. No death occurred within 3 months. Nonoperative death occurred in 8 cases (8/49, 16.3%). The rate of mortality and disability was 18.4% (9/49). In the embolization/stent group, 16 patients (16/20, 80%) survived. Nonoperative death occurred in 4 cases (4/20, 20%), 3 of which occurred within 1 to 3 months. Four cases reported Modified Rankin Scale ≥2 after 3 months. The rate of mortality and disability was 40% (8/20). CONCLUSION A comprehensive revascularization strategy for internal carotid artery (ICA) embolization and intracranial and extracranial bypass grafting based on ASITN/SIR score for ICA blowout syndrome patients not only can prolong the patient survival but also greatly improve the survival probability and quality of life as well as reduce their rate of mortality or disability.
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Affiliation(s)
- Zhouyang Zhao
- Department of Neurosurgery, Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Lijin Huang
- Department of Neurosurgery, Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Jinhua Chen
- Department of Neurosurgery, Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Weijia Huang
- Department of Neurosurgery, Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Xiaobin Zhang
- Department of Neurosurgery, Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Yue Ma
- Department of Neurosurgery, Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Hongshen Zhu
- Department of Neurosurgery, Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Zhang Liu
- Department of Neurosurgery, Third Affiliated Hospital of Southern Medical University, Guangzhou, China
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30
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Ismail HH, Alhajri I, Ibrahim W. Transarterial embolization of acute carotid blowout syndrome postneck dissection. Radiol Case Rep 2020; 15:1968-1972. [PMID: 32874393 PMCID: PMC7452076 DOI: 10.1016/j.radcr.2020.07.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/21/2020] [Accepted: 07/24/2020] [Indexed: 10/26/2022] Open
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31
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Carotid Blowout Management in the Endovascular Era. World Neurosurg 2020; 141:e1010-e1016. [PMID: 32599207 DOI: 10.1016/j.wneu.2020.06.151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/17/2020] [Accepted: 06/19/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Carotid blowout syndrome (CBS) is a potential complication of head and neck cancer, and its therapy is associated with high morbidity and mortality. Recent advances in endovascular techniques have improved patient outcomes. In this study, we report outcomes of emergent endovascular intervention for CBS. METHODS We conducted a retrospective analysis of a prospectively maintained neurovascular database and identified 38 consecutive endovascular procedures for CBS from 2008-2019 at our institution. Data collection was performed on patient demographics, type of cancer, previous cancer treatments, type of CBS, location of bleed, diagnostic workup, endovascular treatment, and procedural outcomes and complications. RESULTS A total of 38 consecutive endovascular procedures for CBS were performed from 2008-2019 at our single academic institution. Technical success was achieved in 100% of endovascular procedures. Procedural stroke occurred in 1 (2.6%) procedure, procedural mortality occurred in 1 (2.6%) procedure, recurrent CBS occurred in 4 (10.5%) procedures, and fatal rehemorrhage occurred in 1 (2.6%) procedure. Regarding secondary outcomes, delayed stroke/transient ischemic attack occurred in 1 (2.6%) procedure, whereas there were no cases of delayed infectious complications. CONCLUSIONS The endovascular treatment of CBS is safe and effective with relatively low rates of morbidity and mortality compared with other currently available treatment modalities. However, the overall rate of complications demands attention and sheds light on the need for further improvement in management.
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32
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Sallustro M, Abualhin M, Faggioli G, Pilato A, Dall'Olio D, Simonetti L, Astarita F, Amorosa L, Gargiulo M. Multistep and Multidisciplinary Management for Post-irradiated Carotid Blowout Syndrome in a Young Patient With Oropharyngeal Carcinoma: A Case Report. Ann Vasc Surg 2020; 67:565.e1-565.e5. [PMID: 32209410 DOI: 10.1016/j.avsg.2020.02.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 02/08/2020] [Accepted: 02/16/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Carotid blowout syndrome is a severe complication of head and neck cancer, associated with high mortality and morbidity. METHODS We present a case of acute hemorrhage from the carotid artery of a 59-year-old man with a history of chemoradiotherapy for lingual base and oropharyngeal squamous cell carcinoma. The case was managed by a staged multidisciplinary approach of open arterial reconstruction, after initial endovascular hemorrhage control using stent graft. RESULTS The patient was discharged to home with patent carotid artery, no sign of infection or bleeding, and autonomous ambulation. A CT/PET scan performed 6 months later confirmed healing and absence of tumor recurrence. CONCLUSIONS A multidisciplinary approach involving vascular surgeons, ENT surgeons, plastic and maxillofacial surgeons is particularly appropriate in the management of carotid blowout syndrome to warrant a durable and effective repair of all the anatomical structures involved.
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Affiliation(s)
- Marianna Sallustro
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Policlinico Sant'Orsola- Malpighi, Bologna, Italy.
| | - Mohammad Abualhin
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Policlinico Sant'Orsola- Malpighi, Bologna, Italy
| | - GianLuca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Policlinico Sant'Orsola- Malpighi, Bologna, Italy
| | - Alessandro Pilato
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Policlinico Sant'Orsola- Malpighi, Bologna, Italy
| | - Danilo Dall'Olio
- Department of Otorhinolaryngology, Maggiore Hospital, Azienda AUSL, Bologna, Italy
| | - Luigi Simonetti
- Interventional and Urgency Radiology and Neuroradiology Unit, Maggiore Hospital, Bologna, Italy
| | - Fabio Astarita
- Department of Otorhinolaryngology, Maggiore Hospital, Azienda AUSL, Bologna, Italy
| | - Luca Amorosa
- Department of Maxillofacial Surgery, Maggiore Hospital, Azienda AUSL, Bologna, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Policlinico Sant'Orsola- Malpighi, Bologna, Italy
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33
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Lu CJ, Lin YH, Lee CW. Transcarotid Mechanical Thrombectomy for Embolic Intracranial Large Vessel Occlusion after Endovascular Deconstructice Embolization for Carotid Blowout Syndrome. Neurointervention 2020; 15:37-43. [PMID: 32070088 PMCID: PMC7105090 DOI: 10.5469/neuroint.2019.00241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 02/12/2020] [Indexed: 12/28/2022] Open
Abstract
Carotid blowout syndrome (CBS) is a fatal complication of head and neck cancer. Endovascular treatment, particularly deconstructive embolization, is effective for CBS, but it might result in thromboembolic events. We report the case of a 57-year-old man with underlying recurrent head and neck cancer who had CBS. The patient received endovascular embolization of the right internal, external, and common carotid arteries. Right internal carotid artery to middle cerebral artery embolic occlusion was noted immediately after the procedure, and left-sided weakness and facial palsy were found. Ipsilateral suprabulbar cervical internal carotid artery puncture was performed under fluoroscopic guidance, and rescue suction thrombectomy was successful. The patient had no significant neurological sequela. Transcarotid intraarterial thrombectomy is a reasonable method for managing postembolization large vessel occlusion, even in the neck, after irradiation.
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Affiliation(s)
- Chi-Ju Lu
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Heng Lin
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Chung-Wei Lee
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
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34
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Jong MAD, Candanedo C, Gross M, Cohen JE. Intervening in the Acute Phase of Postradiation Carotid Blowout Syndrome. Int Arch Otorhinolaryngol 2019; 23:172-177. [PMID: 30956701 PMCID: PMC6449140 DOI: 10.1055/s-0038-1676660] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 11/13/2018] [Indexed: 12/19/2022] Open
Abstract
Introduction
Acute carotid blowout syndrome (aCBS) is a severe complication of head and neck cancer (HNC). It can be defined as a rupture of the extracranial carotid arteries, or one of their branches, that causes life-threatening hemorrhage, and which nowadays can be treated with urgent endovascular intervention.
Objective
We retrospectively evaluate the endovascular management of aCBS and its outcome in years of survival.
Methods
Retrospectively, we describe our experience with endovascular control of aCBS in patients treated for HNC. We review the characteristics, pathology, endovascular treatment and morbidity and assess the gain in life years.
Results
Nine individuals were included in this study. Four patients had been previously diagnosed with laryngeal squamous cell carcinoma (SCC), one with paranasal SCC, one with nasopharyngeal carcinoma and three with oral or maxillary adenocarcinoma. All subjects underwent radiotherapy and surgical excision to different extents. Twelve endovascular procedures were performed for injuries to the internal carotid artery (
n
= 3; 25%), external carotid artery (
n
= 1; 7%) or one of their branches (
n
= 8; 67%). Deconstructive methods were used in nine procedures, and three procedures were mainly reconstructive with deployment of covered stents. Total control of bleeding was achieved in all individuals with no intraprocedural complications.
Conclusion
Endovascular therapy is an effective alternative for the management of exsanguinating CBS. In our series, this palliative therapy increased the overall patient survival by an estimated 9 months.
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Affiliation(s)
- Marrigje A de Jong
- Department of Otolaryngology/Head and Neck Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Carlos Candanedo
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Menachem Gross
- Department of Otolaryngology/Head and Neck Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - José E Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Division of Endovascular Neurosurgery and Interventional Neuroradiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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35
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Suárez C, Fernández-Alvarez V, Hamoir M, Mendenhall WM, Strojan P, Quer M, Silver CE, Rodrigo JP, Rinaldo A, Ferlito A. Carotid blowout syndrome: modern trends in management. Cancer Manag Res 2018; 10:5617-5628. [PMID: 30519108 PMCID: PMC6239123 DOI: 10.2147/cmar.s180164] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Carlos Suárez
- Head & Neck Cancer Laboratory, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain, .,Head & Neck Cancer Laboratory, Instituto Universitario de Oncología del Principado de Asturias, CIBERONC, University of Oviedo, Oviedo, Spain,
| | | | - Marc Hamoir
- Department of Head and Neck Surgery, Head and Neck Oncology Program, King Albert II Cancer Institute, St Luc University Hospital, Brussels, Belgium
| | | | - Primoz Strojan
- Department of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia
| | - Miquel Quer
- Department of Otolaryngology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Carl E Silver
- Department of Surgery, University of Arizona, Phoenix, AZ, USA
| | - Juan P Rodrigo
- Head & Neck Cancer Laboratory, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain, .,Head & Neck Cancer Laboratory, Instituto Universitario de Oncología del Principado de Asturias, CIBERONC, University of Oviedo, Oviedo, Spain, .,Department of Otolaryngology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Alfio Ferlito
- International Head and Neck Scientific Group Padua, Italy
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Luo CB, Tsuei YS, Chang FC, Ting TW. Verification of bleeding points in carotid blowout syndrome using guidewire manipulation. Neuroradiology 2018; 60:835-841. [PMID: 29947941 DOI: 10.1007/s00234-018-2044-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 05/29/2018] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Chao-Bao Luo
- Department of Radiology, Taipei Veterans General Hospital, No 201, Sec. 2, Shih-Pai Road, Beitou, Taipei, 112, Taiwan, Republic of China.
- Department of Radiology, National Defense Medical Center, Taipei, Taiwan.
| | - Yuang-Seng Tsuei
- Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Neurosurgery, National Defense Medical Center, Taipei, Taiwan
| | - Feng-Chi Chang
- Department of Radiology, Taipei Veterans General Hospital, No 201, Sec. 2, Shih-Pai Road, Beitou, Taipei, 112, Taiwan, Republic of China
- Department of Radiology, National Yang-Ming University, School of Medicine, Taipei, Taiwan
| | - Ta-Wei Ting
- Department of Radiology, Tri-Service General Hospital, Taipei, Taiwan
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Gahleitner C, Hofauer B, Storck K, Knopf A. Outcome of carotid and subclavian blowout syndrome in patients with pharynx- and larynx carcinoma passing a standardized multidisciplinary treatment. Acta Otolaryngol 2018; 138:507-512. [PMID: 29310495 DOI: 10.1080/00016489.2017.1419575] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Carotid blowout syndrome (CBS) is one of the most feared emergencies in the head and neck surgery and tends to occur in patients with head and neck cancer, wound complications, pharyngocutaneous fistulas, or after radio(chemo)therapy. CBS is always life threatening and associated with a 50% mortality/morbidity rate. METHODS Between 2007 and 2015, a total of 51 patients who developed CBS caused by the tumour masses or after radio(chemo)therapy were included. All patients underwent a standardised bleeding management. RESULTS In 86% of patients, CBS was associated with manifest carcinoma. Fifty three percent of patients were treated by transcervical surgery, in 36% of these cases surgery was supplemented by endovascular approaches. Severe complications such as re-bleeding or cerebral ischemia occurred infrequently. Seven patients died because of the acute bleeding. CONCLUSION CBS associated with head and neck cancer carries poor mid and long-term prognoses. An interdisciplinary standardised treatment path dramatically reduced overall morbidity and mortality.
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Affiliation(s)
- Constanze Gahleitner
- Department of Otorhinolaryngology/Head and Neck Surgery, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Benedikt Hofauer
- Department of Otorhinolaryngology/Head and Neck Surgery, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Katharina Storck
- Department of Otorhinolaryngology/Head and Neck Surgery, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Andreas Knopf
- Department of Otorhinolaryngology/Head and Neck Surgery, Klinikum rechts der Isar, Technische Universität München, München, Germany
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Manzoor NF, Rezaee RP, Ray A, Wick CC, Blackham K, Stepnick D, Lavertu P, Zender CA. Contemporary management of carotid blowout syndrome utilizing endovascular techniques. Laryngoscope 2016; 127:383-390. [PMID: 27900766 DOI: 10.1002/lary.26144] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2016] [Indexed: 02/06/2023]
Abstract
OBJECTIVES/HYPOTHESIS To illustrate complex interdisciplinary decision making and the utility of modern endovascular techniques in the management of patients with carotid blowout syndrome (CBS). STUDY DESIGNS Retrospective chart review. METHODS Patients treated with endovascular strategies and/or surgical modalities were included. Control of hemorrhage, neurological, and survival outcomes were studied. RESULTS Between 2004 and 2014, 33 patients had 38 hemorrhagic events related to head and neck cancer that were managed with endovascular means. Of these, 23 were localized to the external carotid artery (ECA) branches and five localized to the ECA main trunk; nine were related to the common carotid artery (CCA) or internal carotid artery (ICA), and one event was related to the innominate artery. Seven events related to the CCA/ICA or innominate artery were managed with endovascular sacrifice, whereas three cases were managed with a flow-preserving approach (covered stent). Only one patient developed permanent hemiparesis. In two of the three cases where the flow-preserving approach was used, the covered stent eventually became exposed via the overlying soft tissue defect, and definitive management using carotid revascularization or resection was employed to prevent further hemorrhage. In cases of soft tissue necrosis, vascularized tissues were used to cover the great vessels as applicable. CONCLUSIONS The use of modern endovascular approaches for management of acute CBS yields optimal results and should be employed in a coordinated manner by the head and neck surgeon and the neurointerventionalist. LEVEL OF EVIDENCE 4. Laryngoscope, 2016 127:383-390, 2017.
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Affiliation(s)
- Nauman F Manzoor
- Ear Nose and Throat Institute, University Hospitals Case Medical Center, Cleveland, Ohio, U.S.A
| | - Rod P Rezaee
- Ear Nose and Throat Institute, University Hospitals Case Medical Center, Cleveland, Ohio, U.S.A
| | - Abhishek Ray
- Department of Neuroradiology, University Hospitals Case Medical Center, Cleveland, Ohio, U.S.A
| | - Cameron C Wick
- Ear Nose and Throat Institute, University Hospitals Case Medical Center, Cleveland, Ohio, U.S.A
| | - Kristine Blackham
- Department of Radiology and Nuclear Medicine, University Hospital of Basel, Basel, Switzerland
| | - David Stepnick
- Department of Otolaryngology, Metro Health Medical Center, Cleveland, Ohio, U.S.A
| | - Pierre Lavertu
- Ear Nose and Throat Institute, University Hospitals Case Medical Center, Cleveland, Ohio, U.S.A
| | - Chad A Zender
- Ear Nose and Throat Institute, University Hospitals Case Medical Center, Cleveland, Ohio, U.S.A
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Liang NL, Guedes BD, Duvvuri U, Singh MJ, Chaer RA, Makaroun MS, Sachdev U. Outcomes of interventions for carotid blowout syndrome in patients with head and neck cancer. J Vasc Surg 2016; 63:1525-30. [PMID: 26926937 PMCID: PMC4884149 DOI: 10.1016/j.jvs.2015.12.047] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 12/21/2015] [Indexed: 01/17/2023]
Abstract
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.
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Affiliation(s)
- Nathan L Liang
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center and University of Pittsburgh School of Medicine, Pittsburgh, Pa.
| | - Brian D Guedes
- University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Umamaheswar Duvvuri
- Department of Otolaryngology, University of Pittsburgh Medical Center and University of Pittsburgh School of Medicine, and the VA Pittsburgh Health System, Pittsburgh, Pa
| | - Michael J Singh
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center and University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Rabih A Chaer
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center and University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Michel S Makaroun
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center and University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Ulka Sachdev
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center and University of Pittsburgh School of Medicine, Pittsburgh, Pa
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Chang FC, Luo CB, Lirng JF, Lin CJ, Lee HJ, Wu CC, Hung SC, Guo WY. Endovascular Management of Post-Irradiated Carotid Blowout Syndrome. PLoS One 2015; 10:e0139821. [PMID: 26439632 PMCID: PMC4595276 DOI: 10.1371/journal.pone.0139821] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Accepted: 09/17/2015] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
- Feng-Chi Chang
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- National Yang Ming University, School of Medicine, Taipei, Taiwan
- * E-mail:
| | - Chao-Bao Luo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Jiing-Feng Lirng
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Han-Jui Lee
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Chih-Chun Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Sheng-Che Hung
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- National Yang Ming University, School of Medicine, Taipei, Taiwan
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Tan TP, Arekapudi A, Metha J, Prasad A, Venkatraghavan L. Neutrophil-lymphocyte ratio as predictor of mortality and morbidity in cardiovascular surgery: a systematic review. ANZ J Surg 2015; 85:414-9. [PMID: 25781147 DOI: 10.1111/ans.13036] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2015] [Indexed: 01/18/2023]
Abstract
BACKGROUND Neutrophil-lymphocyte ratio (NLR) is an emerging biomarker of inflammation and predicts poorer outcome in cancer surgery. The prognostic value of NLR in cardiovascular surgery is unclear. METHODS Systematic review and meta-analysis of studies of in cardiovascular surgical patients were conducted to assess the role of perioperative NLR in predicting post-operative mortality and morbidity. Electronic searches were conducted on Ovid Medline, EMBASE, Cochrane Central Register of Controlled Trials and Cochrane Database of Systemic Reviews for all prospective clinical studies reporting on NLR and post-operative morbidity and mortality in cardiovascular surgical patient population. Our primary end point was all-cause post-operative mortality and the secondary end point was post-operative morbidity. Mortality outcome from prospective studies were pooled for a meta-analysis using a random-effect model. RESULTS Of the 999 citations identified, five studies with 3487 patients met the inclusion criteria. In a pooled analysis of three prospective studies of 3108 patients, a preoperative increase in NLR (>3.3 in cardiac surgery, >5 in vascular surgery) was associated with increased mortality at a mean follow-up of 34.8 months (hazard ratio 1.85, 95% confidence interval 1.46-2.36; P < 0.00001). Raised NLR value was also associated with increased cardiac mortality, amputation in vascular operations and raised risk of post-operative re-intubation. CONCLUSIONS Elevated NLR were associated with increased long-term mortality and morbidity after major cardiac and vascular surgery. NLR may guide perioperative management and risk-stratification of patients.
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Affiliation(s)
- Tze Ping Tan
- Department of Anaesthesia, Shepparton Hospital, Shepparton, Victoria, Australia
| | - Anil Arekapudi
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jigesh Metha
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Arun Prasad
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Lashmi Venkatraghavan
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
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Impending Carotid Blowout Stabilization Using an LT-D Tube. Case Rep Otolaryngol 2014; 2014:531561. [PMID: 24800093 PMCID: PMC3988831 DOI: 10.1155/2014/531561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 02/05/2014] [Indexed: 11/26/2022] Open
Abstract
Adequate stabilization of a patient presenting with a carotid blowout is one of the most challenging issues an on-call ENT surgeon can be confronted with. Reducing the bleeding and securing the airway are essential before more definitive management. We present the case of a 72-year-old patient with head and neck cancer who arrived at the emergency room with a carotid blowout and who was successfully stabilized using a King LT-D ventilation tube.
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