Endovascular management of carotid blowout

A systematic review and meta-analysis of endovascular treatment of carotid blowout syndrome

Carotid Blowout Syndrome (CBS) is a rare and life-threatening condition that necessitates prompt intervention to prevent fatal hemorrhage. This study compares the outcomes of two primary endovascular approaches: reconstructive interventions, which aim to preserve carotid artery function using stents or balloon angioplasty, and deconstructive interventions, which involve vessel occlusion to halt bleeding. A systematic review and meta-analysis were performed by searching multiple databases for relevant studies published from January 2000 to August 2023. A total of 28 studies involving 554 patients were included, with 214 undergoing reconstructive interventions and 340 receiving deconstructive procedures. Results indicated an overall 30-day mortality rate of 10%, with no significant difference between intervention types. However, the reconstructive group exhibited higher rates of rebleeding beyond 24 h and severe technical complications. While complication rates decreased over time, an increase in long-term mortality was noted for both approaches. These findings highlight the need for enhanced strategies in CBS management, particularly in reducing long-term mortality and addressing complications associated with reconstructive interventions.

OBJECTIVES

Carotid blowout syndrome (CBS) is a rare and life-threatening condition that requires prompt intervention to prevent fatal hemorrhage. Two primary endovascular approaches are used: reconstructive interventions, which aim to preserve the carotid artery's function through stenting or balloon angioplasty, and deconstructive interventions, which focus on vessel occlusion to stop bleeding. This study aimed to compare these methods regarding prognosis, complication rates, and outcome trends over time.

METHODS

A systematic review and meta-analysis were conducted, searching multiple databases for studies published from January 2000 to August 2023. Eligible studies included randomized controlled trials and observational studies reporting outcomes and complications of endovascular interventions for CBS.

RESULTS

The analysis included 28 studies with a total of 554 patients, of whom 214 received reconstructive interventions and 340 underwent deconstructive procedures. The overall 30-day mortality rate was 10%, with no significant difference between the two intervention types. However, the reconstructive group showed a higher incidence of rebleeding beyond 24 h and severe technical complications. While complication rates decreased over time, long-term mortality increased.

CONCLUSIONS

This study found no significant differences between reconstructive and deconstructive endovascular interventions in most aspects of CBS prognosis. However, reconstructive approaches, particularly those involving stents, were associated with a higher risk of rebleeding beyond 24 h and severe technical complications. Additionally, the data suggest an increase in long-term mortality rates for both methods, highlighting areas for potential improvement in CBS management and intervention strategies. Compared to previous meta-analyses, this study includes more recent and comprehensive literature, evaluating a wider range of prognostic indicators, such as transient ischemic attacks, infection rates, late-stage rebleeding, and severe procedural complications. These findings provide an updated and nuanced understanding of the risks and outcomes associated with CBS interventions, offering valuable insights that could guide clinical decision-making and future research on optimal intervention strategies.

Endovascular intervention for carotid blowout syndrome and predictors of recurrence: A retrospective and multicenter cohort study

INTRODUCTION

Carotid blowout syndrome (CBS) is a potentially life-threatening complication of head and neck cancer and associated treatment. In this study, we assess the safety and efficacy of deconstructive and reconstructive procedures with a focus on CBS recurrence.

METHODS

We conducted a multicenter retrospective analysis of a prospectively maintained database and identified 80 consecutive neurointerventions for CBS from 2016 to 2020. Patients were divided into 2 groups: deconstructive embolization (68 patients) and reconstructive stenting (12 patients). A comparative analysis was performed between the two groups.

RESULTS

The CBS recurrence rate was 23.8 % with 84.2 % of recurrences occurring within 90 days of the primary event. The median time to rebleeding was 8.0 days (IQR: 2.0 - 28.5) with a mortality rate of 26.3 %. There was no significant difference in rates of peri-operative ischemic stroke (1.5 % vs. 0 %, p=0.672) or peri-operative mortality (1.5 % vs. 0 %, p=0.670). CBS recurrence was significantly higher in the reconstructive group (58.3 % vs. 17.6 %, p=0.002). On multivariate analysis, reconstructive stenting independently predicted rebleeding (adjusted hazard ratio 8.31, 95 % CI: 2.34-29.59, p=0.001). There was no significant association between CBS recurrence and pre-operative (p=0.600) or post-operative (p=0.275) anticoagulant/antiplatelet use.

CONCLUSION

CBS remains a challenging and potentially catastrophic complication of head and neck cancers. Reconstructive procedures, including stenting, predicted CBS recurrence independent of bleeding site or tumor invasion. Postoperative surveillance based on time intervals to CBS recurrence and engineering advancements including improved vessel reconstruction devices have the potential to reduce rehemorrhage rates and improve patient outcomes. Further clinical investigations amongst larger cohorts are needed.

Challenges and Complications in the Management of Advanced Oropharyngeal Carcinoma: Role of Post-Mortem Diagnosis and Future Perspectives

Oropharyngeal squamous-cell carcinoma (OPSCC) poses significant challenges in diagnosis, treatment, and management and has important medico-legal and forensic implications. In particular, the management of OPSCC and its treatment-related complications can often be challenging. In cases with advanced OPSCC, a loco-regional extension of the tumor can contribute to the destruction of oral cavity tissues, while the radiotherapy treatment can induce profound changes in tissue morphology and structure. These changes, which resemble tumor neoplasms and endovascular effects, are related to a higher risk of fatal bleeding, as reported in the case study illustrated, in which a hemorrhage occurred from a lingual artery, originating from an ulcerative, necrotic, hemorrhagic lesion on the tongue. Bleeding complications in OPSCC and prolonged radiotherapy are associated with high mortality and require comprehensive management strategies to improve survival and quality of life. Autopsy investigations, contributing to the definition of post-mortem diagnosis, can provide valuable insights into the pathogenetic mechanisms underlying bleeding and guide therapeutic decisions and preventive measures. The integration of autopsy and histopathological investigation into clinical practice should be considered as a necessary support to optimize the management of complications in advanced OPSCC patients, emphasizing the importance of a patient-centered approach and continued research.

Efficacy analysis of endovascular treatment for ruptured internal carotid artery pseudoaneurysm hemorrhage in patients with nasopharyngeal carcinoma after radiotherapy

Background

This study aims to evaluate the efficacy and complications of endovascular treatment for hemorrhage caused by ruptured internal carotid artery pseudoaneurysms following radiotherapy in nasopharyngeal carcinoma (NPC) patients.

Methods

This study retrospectively analyzed NPC patients who underwent endovascular treatment for ruptured internal carotid artery pseudoaneurysm hemorrhage after radiotherapy at Zhongshan People's Hospital from January 2016 to December 2022. The study aims to assess the postoperative hemostasis rate, postoperative rebleeding rate, complication rate, and 1-year postoperative survival rate.

Results

During the study period, 36 patients underwent endovascular treatment, of which 24 patients underwent embolization of the internal carotid artery and 12 patients underwent stenting of the internal carotid artery. The procedure success rate was 100%. The rebleeding rate at 1 year after the procedure was 5.6% (2/36, one patient with stent placement and one patient with coil embolization), and the complication rate was 11.1% (4/36, four patients with coil embolization patients). Two patients developed large-area cerebral infarction after the procedure, and two patients had different degrees of neurological impairment after the procedure. The 1-year survival rate was 91.7% (33/36).

Conclusion

Ruptured internal carotid artery pseudoaneurysm hemorrhage after radiotherapy is rare but life-threatening. Endovascular treatment with coil occlusion or stenting reconstruction of the internal carotid artery provides immediate hemostasis and elimination of the pseudoaneurysm with a low rate of recurrence, which may be effective in reducing patient mortality.

Brain abscesses following carotid blowout syndrome: a case report

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.

Carotid Blowout Syndrome in Head and Neck Cancer Patients: Management of Patients At Risk for CBS

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.

Management of Double Carotid Blow Out with Definitive Repair After Temporizing Stent Graft Placement

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.

Treatment of a patient with carotid blowout syndrome with a new deconstructive embolization technique

Carotid blowout syndrome is a rare clinical conditions with a high mortality rate, especially in patients with head and neck tumors who have received radiotherapy and chemotherapy. We present our patient who had hemangioendothelioma of the neck for 5 years and therefore received radiotherapy, fistulized to the skin on the neck and active bleeding out of the fistula area. In the radiological imaging of the patient, vessel wall irregularities in the common carotid artery (CCA) and accompanying pseudoaneurysm with a diameter of 3 cm were detected, and endovascular treatment was performed. After the patient passed the balloon occlusion test, first the proximal internal carotid artery was closed with coils. Then, the balloon was inflated proximal to the CCA and a 10% diluted glue-lipiodol mixture was injected into the entire diseased CCA bed. Closure of the distal with coil and proximal with balloon prevented the risk of off-target embolization of the glue.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Extracranial/Intracranial Vascular Bypass in the Treatment of Head and Neck Cancer - Related Carotid Blowout Syndrome

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Endovascular Treatment of Carotid Blowout Syndrome

BACKGROUND

Carotid blowout syndrome (CBS) is a life-threatening disease characterized by compromise of the carotid artery by head and neck cancer (HNC).

MATERIALS AND METHODS

We reviewed the characteristics and outcomes of all patients with carotid blowout syndrome who were treated between April 2010 and December 2019. Twelve patients with a history of HNC and radiation therapy were investigated. The balloon occlusion test (BOT) was performed in all patients to confirm collateral circulation. We placed a stent in patients who were intolerant to the BOT.

RESULTS

The patients' ages ranged from 50 to 81 years (mean: 68.1 years). Therapeutic occlusion of the affected internal carotid artery was performed in nine patients, while stenting was performed in three patients. Immediate hemostasis was achieved in all patients. Patients treated using stents were administered perioperative DAPT. One patient experienced rebleeding after surgery. Two patients had procedure-related cerebral infarctions. One patient died, but the others survived without major neurological deficits. One patient had persistent aneurysm after surgery that resolved over time.

CONCLUSION

Endovascular treatment via occlusion or stent-based reconstruction of the internal carotid artery resulted in immediate hemostasis. Carotid occlusion and covered stent application are safe and efficient techniques to treat CBS secondary to HNC. Surgeons may obtain better outcomes if they perform BOT before occlusion and design treatment accordingly.

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

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

Carotid Blowout Management in the Endovascular Era

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.

Carotid blowout syndrome: modern trends in management

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

Prediction of Borderzone Infarction by CTA in Patients Undergoing Carotid Embolization for Carotid Blowout

BACKGROUND AND PURPOSE

Permanent common carotid artery and/or ICA occlusion is an effective treatment for carotid blowout syndrome. Besides postoperative thromboembolic infarction, permanent common carotid artery and/or ICA occlusion may cause borderzone infarction when the collateral flow to the deprived brain territory is inadequate. In this study, we aimed to test the predictive value of CTA for post-permanent common carotid artery and/or ICA occlusion borderzone infarction in patients with carotid blowout syndrome.

MATERIALS AND METHODS

In this retrospective study, we included 31 patients undergoing unilateral permanent common carotid artery and/or ICA occlusion for carotid blowout syndrome between May 2009 and December 2016. The vascular diameter of the circle of Willis was evaluated using preprocedural CTA, and the risk of borderzone infarction was graded as very high risk, high risk, intermediate risk, low risk, and very low risk.

RESULTS

The performance of readers' consensus on CTA for predicting borderzone infarction was excellent, with an area under receiver operating characteristic curve of 0.938 (95% confidence interval, 0.85-1.00). We defined very high risk, high risk, and intermediate risk as positive for borderzone infarction, the sensitivity, specificity, positive predictive value, and negative predictive value of CTA for borderzone infarction were 100% (7/7), 62.5% (15/24), 43.8% (7/16), and 100% (15/15), respectively. The interobserver reliability was excellent (κ = 0.807). No significant difference in the receiver operating characteristic curves was found between the 2 readers (P = .114).

CONCLUSIONS

CTA can be used to predict borderzone infarction after permanent common carotid artery and/or ICA occlusion by measuring the collateral vessels of the circle of Willis.

Verification of bleeding points in carotid blowout syndrome using guidewire manipulation

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Endovascular treatment of carotid blowout syndrome

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A novel approach to the management of carotid blowout syndrome: the use of thrombin in a case of failed covered stenting

Acute hemorrhage relating to an expanding pseudoaneurysm of the carotid artery is referred to as carotid blowout syndrome (CBS). CBS is associated with a high morbidity and mortality. We describe the case of a patient who presented with dysphagia and a pulsatile mass in the neck. Imaging revealed a pseudoaneurysm originating from the bifurcation of the distal right common carotid artery. On neuroangiography the patient lacked sufficient collaterals to allow for vessel sacrifice. A decision was made to use covered stents to prevent flow into the pseudoaneurysm while maintaining vessel patency. Despite placement of multiple covered stents there was residual slow filling of the pseudoaneurysm. We augmented this therapy with direct percutaneous thrombin injection into the pseudoaneurysm. This resulted in complete thrombosis of the pseudoaneurysm. For recalcitrant lesions in which the usual methods of stopping blood flow to the pseudoaneurysmal sac fail, an adjuvant approach with thrombin should be considered.

A novel approach to the management of carotid blowout syndrome: the use of thrombin in a case of failed covered stenting

Acute hemorrhage relating to an expanding pseudoaneurysm of the carotid artery is referred to as carotid blowout syndrome (CBS). CBS is associated with a high morbidity and mortality. We describe the case of a patient who presented with dysphagia and a pulsatile mass in the neck. Imaging revealed a pseudoaneurysm originating from the bifurcation of the distal right common carotid artery. On neuroangiography the patient lacked sufficient collaterals to allow for vessel sacrifice. A decision was made to use covered stents to prevent flow into the pseudoaneurysm while maintaining vessel patency. Despite placement of multiple covered stents there was residual slow filling of the pseudoaneurysm. We augmented this therapy with direct percutaneous thrombin injection into the pseudoaneurysm. This resulted in complete thrombosis of the pseudoaneurysm. For recalcitrant lesions in which the usual methods of stopping blood flow to the pseudoaneurysmal sac fail, an adjuvant approach with thrombin should be considered.

Covered Stents for the Prevention and Treatment of Carotid Blowout Syndrome

BACKGROUND

Carotid blowout syndrome (CBS) is a life-threatening emergency resulting from compromise of the carotid artery caused by malignancy in the head and neck.

OBJECTIVE

To report our experience with covered stents for the prevention or treatment of carotid blowout syndrome secondary to head and neck cancer to ascertain the safety and efficacy of this technique.

METHODS

We reviewed the characteristics and outcome of all patients who underwent covered stent placement in the extracranial carotid artery in the setting of head and neck malignancy between 2006 and 2013 at the University of Miami. Patient demographics, presenting symptoms, devices used, perioperative complications, imaging, and follow-up data were reviewed.

RESULTS

Seventeen carotids in 15 patients, whose ages ranged from 20 to 84 years (mean, 70.4 years), were treated with 20 covered nitinol (Viabahn Endoprosthesis, Gore, Flagstaff, Arizona) stents. Three patients were treated acutely for bleeding from carotid blowout, and 12 were treated prophylactically for threatened carotid blowout. All patients were given periprocedural dual antiplatelet therapy. No thromboembolic or ischemic complications were noted. Hemorrhage after treatment occurred in 4 patients. In 2 patients, the hemorrhage was from a source not covered by the stent.

CONCLUSION

The use of covered stents is a simple, safe, and effective method for treating or preventing carotid blowout syndrome in patients with head and neck malignancy. Carotid artery reconstruction with covered stents may minimize the risk of ischemic complications associated with endovascular or surgical carotid sacrifice.

Endovascular Management of Post-Irradiated Carotid Blowout Syndrome

Purpose

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

Materials and Methods

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

Results

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

Conclusion

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

Advances in Supportive Care for Late Effects of Head and Neck Cancer

As the population of head and neck cancer survivors increases, it has become increasingly important for health care providers to understand and manage late complications of therapy. Functional deficits can be categorized as general health deficits resulting in frailty or debility, head and neck-specific functional deficits such as swallowing and speech, and musculoskeletal impairment as a result of tumor and treatment. Of critical importance is the growing data indicating that swallow therapy and physical therapy may prevent or ameliorate long-term functional deficits. Oral health complications of head and neck therapy may manifest months or years after the completion of treatment. Patients with hyposalivation are at high risk for dental caries and thus require aggressive oral hygiene regimens and routine dental surveillance. Swallowing abnormalities, xerostomia, and poor dentition may result in dietary adaptations that may cause nutritional deficiencies. Identification and management of maladaptive dietary strategies are important for long-term health. Follow-up with primary care physicians for management of comorbidities such as diabetes and hyperlipidemia may help to limit late vascular complications caused by radiation therapy. Herein, we review late effects of head and neck cancer therapy, highlighting recent advances.

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

BACKGROUND AND PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Impending Carotid Blowout Stabilization Using an LT-D Tube

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.

Rare presentation of intracranial vascular blowout after tumor resection and radiation therapy

A middle-aged patient presented with a rapidly growing right dural-based extra-axial posterior clinoid mass extending to the right cavernous sinus that was surgically resected. Histological examination showed solid growth of primitive neuroectodermal tumor arising from the third nerve. Following surgical resection, the patient was further managed by radiation and chemotherapy. Two years later the patient developed new intracranial hemorrhage in the area adjacent to the previous surgical cavity. A cerebral angiogram showed contrast extravasation at the junction of the posterior communicating artery (Pcom) and the right posterior cerebral artery (PCA), with an expanding pseudoaneurysm. This was managed with N-butyl cyanoacrylate embolization. Autopsy showed microscopic recurrence of tumor into the PCA/PCom region with invasion of the wall of the Pcom. This case report illustrates the concept of vascular blowout in intracranial cerebral vasculature. It appears that, in the presence of risk factors that contribute to weakening of vessel walls (surgery, radiation, tumor recurrence), a blowout can occur intracranially.

Rare presentation of intracranial vascular blowout after tumor resection and radiation therapy

A middle-aged patient presented with a rapidly growing right dural-based extra-axial posterior clinoid mass extending to the right cavernous sinus that was surgically resected. Histological examination showed solid growth of primitive neuroectodermal tumor arising from the third nerve. Following surgical resection, the patient was further managed by radiation and chemotherapy. Two years later the patient developed new intracranial hemorrhage in the area adjacent to the previous surgical cavity. A cerebral angiogram showed contrast extravasation at the junction of the posterior communicating artery (Pcom) and the right posterior cerebral artery (PCA), with an expanding pseudoaneurysm. This was managed with N-butyl cyanoacrylate embolization. Autopsy showed microscopic recurrence of tumor into the PCA/PCom region with invasion of the wall of the Pcom. This case report illustrates the concept of vascular blowout in intracranial cerebral vasculature. It appears that, in the presence of risk factors that contribute to weakening of vessel walls (surgery, radiation, tumor recurrence), a blowout can occur intracranially.

Surgical errors and risks - the head and neck cancer patient

Head and neck surgery is one of the basic principles of head and neck cancer therapy. Surgical errors and malpractice can have fatal consequences for the treated patients. It can lead to functional impairment and has impact in future chances for disease related survival. There are many risks for head and neck surgeons that can cause errors and malpractice.

To avoid surgical mistakes, thorough preoperative management of patients is mandatory. As there are ensuring operability, cautious evaluation of preoperative diagnostics and operative planning. Moreover knowledge of anatomical structures of the head and neck, of the medical studies and data as well as qualification in modern surgical techniques and the surgeons ability for critical self assessment are basic and important prerequisites for head and neck surgeons in order to make out risks and to prevent from mistakes. Additionally it is important to have profound knowledge in nutrition management of cancer patients, wound healing and to realize and to be able to deal with complications, when they occur.

Despite all precaution and surgical care, errors and mistakes cannot always be avoided. For that it is important to be able to deal with mistakes and to establish an appropriate and clear communication and management for such events. The manuscript comments on recognition and prevention of risks and mistakes in the preoperative, operative and postoperative phase of head and neck cancer surgery.

Transarterial endovascular treatment in the management of life-threatening carotid blowout syndrome in head and neck cancer patients: review of the literature

OBJECTIVES

Carotid blowout syndrome is a rare but devastating complication in patients with head and neck malignancy, and is associated with high morbidity and mortality. Bleeding from the carotid artery or its branches is a well-recognized complication following treatment or recurrence of head and neck cancer. It is an emergency situation, and the classical approach to save the patient's life is to ligate the carotid artery. But the surgical treatment is often technically difficult. Endovascular therapies were recently reported as good alternatives to surgical ligation.

METHODS

Retrospective review of three cases of acute or threatened carotid hemorrhage managed by endovascular therapies.

RESULTS

Two patients presented with acute carotid blowout, and one patient with a sentinel bleed. Two patients had previously been treated with surgery and chemo radiation. One patient was treated by chemo radiation. Two had developed pharyngocutaneous fistulas, and one had an open necrosis filled wound that surrounded the carotid artery. In two patients, stent placement resolved the acute hemorrhage. In one patient, superselective embolization was done. Mean duration follow-up was 10.2 months. No patient had residual sequelae of stenting or embolization.

CONCLUSION

Management of carotid blow syndrome is very critical and difficult. A multidisciplinary approach is very important in the management of carotid blow syndrome. Correct and suitable management can be life saving. An endovascular technique is a good and effective alternative with much lower morbidity rates than surgical repair or ligation.

Carotid and vertebral artery sacrifice with a combination of Onyx and coils: technical note and case series

INTRODUCTION

Permanent vessel sacrifice has become a routine for the management of aneurysms, pseudoaneurysms, tumors, and carotid blowouts. The purpose of this study is to describe a new technique for carotid and vertebral artery sacrifice using a combination of Onyx and coils and to assess its feasibility, safety, and efficacy.

METHODS

The technique consists of deploying a few coils in the parent vessel under proximal flow arrest followed by Onyx embolization directly into the coil mass. A total of 41 patients underwent carotid/vertebral artery sacrifice using this technique in our institution.

RESULTS

A total of 26 internal carotid arteries and 15 vertebral arteries were treated. In all but one patient, a balloon test occlusion was performed prior to permanent arterial sacrifice. The mean number of coils used was 6.8 (range, 2-19). The total volume of Onyx used was 1.3 ml on average (range, 0.2-5.2 ml). All 41 (100%) parent arteries were successfully occluded. No distal migration of Onyx or coils was noted. Periprocedural complications occurred in 14.6% (6/41) of cases causing permanent morbidity in 7.3% (3/41). No patient developed a recurrence during the follow-up period (mean, 14 months).

CONCLUSION

Parent vessel sacrifice with a combination of Onyx and coils appears to be feasible, safe, and effective and may be an alternative to the traditional deconstruction technique with coils alone. The risk of thromboembolism exists with this technique, but there were no instances of Onyx migration.