Emergency management of carotid artery rupture

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.

Management of Carotid Blowout from Radiation Necrosis

Although the incidence of carotid blowout has decreased with the advent of better reconstructive techniques, it remains a real risk after major head and neck surgery, especially in an irradiated field. A systematic, multidisciplinary approach incorporating appropriate history and physical examination, adequate resuscitation, diagnostic computed tomography, and diagnostic and therapeutic angiography can manage most of these patients in a safe and effective manner. Surgery has a limited role in acute management, although surgical techniques are useful both for prevention of this problem and for wound management after carotid blowout.

Interventional management of head and neck emergencies: carotid blowout

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

The use of a covered stent in carotid blowout syndrome

Rupture of the extracranial carotid arteries or their major branches is known as carotid blowout syndrome (CBS). CBS is a well-recognized complication of cancer of the head and neck and subsequent radiation therapy. A few treatment modalities are available, including open ligation and different endovascular techniques, but questions regarding both the immediate and delayed complications of these procedures persist. In this case report, we describe the management of acute CBS in a 54-year-old man who had previously been treated for follicular thyroid carcinoma. The patient was hemorrhaging from a pseudoaneurysm of the left common carotid artery. A self-expanding polytetrafluoroethylene (Teflon) -covered stent was successfully deployed endovascularly, and this resulted in cessation of the bleeding and restoration of flow through the vessel. We examine the covered-stent approach to treating acute CBS, and we discuss other treatment approaches that have been described in the literature.

Management of terminal hemorrhage in patients with advanced cancer: a systematic literature review

Although terminal hemorrhage is an infrequent occurrence in advanced cancer patients, it is extremely distressing for patients, their families, and health care professionals when it does occur. By definition, there is a very short time period to support and comfort the patient, and it is vital that the management approach follows the best available evidence base. A systematic literature search was carried out to retrieve relevant publications relating to the management of terminal hemorrhage in patients with advanced cancer in whom invasive or interventional procedures are no longer appropriate. From 3,564 initial citations, 18 were appropriate to include in the final review, many of which focused on patients with head and neck tumors. The reported incidence of significant bleeding in patients with advanced cancer is 6%-14% and incidence of terminal hemorrhage 3%-12%. Key areas arising from the literature were 1) identifying patients at risk, 2) general supportive measures to use, and 3) use of sedative medication. General supportive measures included use of dark towels to camouflage blood loss, use of suction, and applying external pressure. There was variation in the recommended sedative medication (drug, dose, and route). Drugs recommended included diazepam, midazolam, diamorphine, and ketamine at varying doses and routes of administration. Current guidelines are based completely on isolated case reports and expert opinion. Clinical research is needed in this area but is difficult because of practical and ethical limitations.

Traumatic Cervical Vertebral Artery Transection Associated with a Dural Tear Leading to Subarachnoid Extravasation

Vertebral artery injuries can be seen following trauma. Most traumatic vertebral artery injuries are limited to an intimal dissection. Rarely, transection of the vertebral artery can be seen with extravasation of hemorrhage into the surrounding soft tissues of the neck. Dural tears are rare in the setting of trauma. They are usually the result of penetrating trauma or severe blunt trauma. We present a case with both a vertebral artery transection and a dural tear. The combination of these lethal injuries resulted in extravasation of hemorrhage into the soft tissues of the neck, through the dural tear, and into the subarachnoid space of the cervical spine. The subarachnoid hemorrhage extended superiorly into the brain. The diagnosis was made by computed tomography (CT) and computed tomography angiography (CTA). The treatment of traumatic vertebral artery transections and dural tears are discussed.

Endovascular management of carotid blowout syndrome in patients with head and neck cancers

Endovascular treatments for carotid blowout syndrome (CBS) have been advocated by interventional neuroradiologists. We therefore retrospectively evaluated the efficacy of endovascular treatments of CBS in 16 patients with head and neck cancers (HNC). The clinical, treatment and outcome data were evaluated in 16 HNC patients with CBS, all of whom underwent permanent embolization or covered stent graft of the affected carotid artery. All patients received multimodal treatments, including radiotherapy (mean total dose, 78.5 Gy). CBS was caused by tumor carotid invasion in 8 patients, pharyngocutaneous fistula in 7, and laryngeal chondroradionecrosis in 1, with the external and common carotid arteries being the most common rupture sites. CBS was occluded by embolization or revascularized by covered stent placement. Immediate hemostasis was achieved in all patients; however, 7 patients had recurrent CBS, all of whom were retreated effectively by endovascular management. Three patients had strokes and four had extrusion of intervention materials from the infected wounds. Most patients died of tumor progression, with a mean survival time of five months from initial CBS; only two patients survived. Endovascular therapy, by both permanent occlusion and stent grafts, is effective in hemostasis of CBS but its long-term efficacy may not be high in these HNC patients.

The emergency use of endografts in the carotid circulation to control hemorrhage in potentially contaminated fields

We report our experience with the use of endoluminal grafts to control emergency bleeding in two patients with tracheoinnominate fistulas and three patients with carotid blowouts. Systemic infectious complications were not seen. However, rebleeding occurred in one patient, and extensive stent coverage to control bleeding was required in a second. Survival was usually limited by the patient's cancer. There was one long-term survivor without cancer whose tracheostomy was placed for neurologic compromise. A review of the literature for similar cases identified 18 additional endografts placed for carotid blowout and 3 placed for tracheoinnominate fistulas. Overall, infectious complications occurred in only two patients, whereas rebleeding occurred in eight patients. On the basis of these findings, we believe that endografts are useful to control emergency hemorrhage in these two pathologies because treatment is usually palliative, given the poor survival secondary to the underlying disease. However, more extensive graft coverage may be necessary considering the erosive nature of these processes.

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

OBJECTIVES

Assess duration, efficacy, and safety of emergent transarterial embolization of acute external carotid blowout syndrome (ECBS) with N-butyl-cyanoacrylate.

METHODS

Medical records were reviewed for 16 patients (15 men, 1 woman; age range, 28-85 years) who had 17 acute ECBS events that presented with profuse transoronasal bleeding. Predisposing factors were carcinoma associated with surgery and/or radiotherapy (n = 14) or trauma (n = 3). Affected arteries were the internal maxillary artery (n = 5), superior thyroid artery (n = 4), lingual artery (n = 4), facial artery (n = 2), or ascending pharyngeal artery (n = 2).

RESULTS

Endovascular treatment successfully obliterated all acute ECBSs with cessation of profuse hemorrhage. Mean duration of procedure was 54 minutes. Three patients had recurrent carotid blowout syndrome events, with 1 resulting death. Clinical follow-up range was 2 to 23 months.

CONCLUSIONS

Transarterial N-butyl-cyanoacrylate embolization can successfully manage acute ECBS with profuse hemorrhage. The technique is both efficient and safe, and the procedure can be rapidly completed.

The management of carotid artery rupture

Carotid artery rupture is fortunately an uncommon complication of head and neck cancer treatment. Eleven episodes of carotid artery rupture following irradiation and major head and neck resection were identified over a 6-year period. We review our experience and discuss the predisposing factors that can cause this complication, important aspects of management and outcome. During this 6-year period, 11 episodes of carotid artery rupture were treated in our unit. All patients had received prior irradiation (more than 60 Gy) and undergone a major surgical resection or resections. The average age was 59 years; all patients had a salivary fistula, local infection and a manifest 'herald bleed' just before their major carotid artery rupture. These patients were resuscitated, taken to theatre and the neck explored, with control of the vessel and debridement of necrotic tissue. Soft tissue coverage was in the form of a flap. Many of the factors predisposing to carotid artery rupture can be ameliorated or treated early in order to avoid this complication. Early and aggressive nutritional support together with correction of haematological abnormalities promote wound healing and prevent tissue breakdown. The detection and treatment of infection also reduces fistula formation and wound compromise. We present our protocol for the early, aggressive management of these patients with carotid artery rupture.

Contemporary management of carotid blowout

PURPOSE OF REVIEW

The purpose of this report is to summarize existing literature with respect to carotid artery blowout and to present an up-to-date algorithm for its management that incorporates recent advances with respect to its diagnosis and treatment.

RECENT FINDINGS

Although once thought as one entity, carotid blowout is now considered to be a syndrome with clinical manifestations ranging from acute hemorrhage to asymptomatic exposure of a carotid artery. As a result, carotid blowout syndrome can present as one of three separate entities: threatened, impending, and acute carotid blowout. In recent years newer approaches to management have centered around the use of diagnostic angiography followed by definitive therapy with either carotid occlusion by coils, detachable balloons, or endovascular stents. Overall morbidity of management has decreased.

SUMMARY

Interventional radiologic techniques have revolutionized the treatment of carotid blowout syndrome, allowing more accurate diagnosis and lower treatment morbidity.

Endovascular management of impending carotid rupture in a patient with advanced head and neck cancer

PURPOSE

To describe an innovative endovascular technique combining a flexible self-expanding stent-graft to protect the common and internal carotid artery with selective coil embolization of the affected external carotid artery (ECA) branches.

CASE REPORT

A 42-year-old man presented with episodes of profuse but self-limited carotid hemorrhage from advanced squamous cell carcinoma of the neck. Despite invasion of the carotid sheath by the tumor, angiography confirmed the source of bleeding to be invasion of branches of the ECA. Successful coil embolization of the ECA and stent-graft isolation of the common/internal carotid arteries were performed. At 1-month follow-up, carotid angiography confirmed the complete occlusion of the ECA and patent stent-graft. There was no recurrent bleeding or neurological deficits at 6 months after the procedure.

CONCLUSIONS

Stent-grafts in combination with coil embolization can be used to manage patients with impending carotid rupture secondary to head and neck cancer.

Traumatic rupture of external carotid artery: report of emergency treatment with Guglielmi detachable coil

Carotid dissection is a major complication of blunt head and neck trauma. The authors describe a case report of sudden bleeding of a distal branch of the external left carotid artery caused by a fracture of the mandible. This event occurred a week after the trauma. After a first phase consisting in cardiopulmonary resuscitation and blood loss replacement, the placement of a Guglielmi detachable coil (GDC) was considered the best and safest way to stop the bleeding. Guglielmi detachable coil represents a good technique for emergency treatment of bleeding from distal carotid vessels. Given its high cost, the diagnostic study of vessels near mandible fractures should not be considered as routine in cases of head and neck trauma, but should be considered in the presence of local hemorrhage or suspicious neurologic signs.

Spontaneous late carotid-cutaneous fistula following radical neck dissection: a case report

The authors present an unusual case of a spontaneous carotid-cutaneous fistula occurring as a late complication 4 years after radical neck dissection and postoperative radiation therapy for tonsillar squamous cell carcinoma in a 50-year-old patient. The etiologic factors predisposing patients to carotid artery rupture following radical neck dissection and a surgical option for carotid artery reconstruction instead of ligation are discussed.

Preoperative permanent balloon occlusion of internal carotid artery in patients with advanced head and neck squamous cell carcinoma

OBJECTIVE/HYPOTHESIS

To determine the value of preoperative balloon occlusion in predicting the safety of carotid artery resection in advanced recurrent head and neck squamous cell carcinoma.

STUDY DESIGN

Retrospective chart review of all cases undergoing planned carotid artery resection for recurrent disease at a major university hospital.

METHODS

If the carotid artery was encased, a nonemergent carotid artery balloon test occlusion was performed for 30 minutes. If the patient tolerated this, he or she underwent permanent carotid artery occlusion.

RESULTS

Twenty-three patients were prospectively evaluated for resection. Three underwent emergent carotid artery ligation. Twenty others underwent nonemergent carotid artery test occlusion. Of these, 5 patients failed preoperative carotid artery balloon occlusion and 15 patients successfully underwent permanent carotid balloon occlusion. Although eight of these patients died of recurrent disease in less than 1 year, seven patients survived more than 1 year with two patients surviving more than 2 years.

CONCLUSIONS

Preoperative carotid balloon occlusion predicted patients who could tolerate permanent occlusion. All patients eventually developed recurrent disease, but in 14 of the 15 patients, no hemorrhages occurred.

Management of carotid artery rupture by monitored endovascular therapeutic occlusion (1988-1994)

The reported mortality (40%) and neurologic morbidity (25%) rates for carotid rupture remain unacceptably high. This study was conducted to assess the impact of endovascular detachable balloon occlusion and the changing characteristics of carotid rupture in head and neck surgery. Between January 1, 1988, and June 30, 1994, 18 carotid ruptures were identified in 15 patients. Etiologic factors included radical surgery, radiation therapy, wound complications, and recurrent or persistent carcinoma. In 15 of 18 instances of carotid rupture, patients survived without major neurologic sequelae. After the introduction of endovascular techniques in 1991, the 12 patients whose hemorrhage was definitively managed through permanent balloon occlusion survived without significant neurologic sequelae. Endovascular occlusion techniques in the monitored patient may significantly improve the outcome after carotid rupture.