Endovascular treatment of epistaxis in patients irradiated for nasopharyngeal carcinoma

Management of post-radiation carotid blowout syndrome in patients with head and neck cancer: A systematic review

BACKGROUND AND PURPOSE

Carotid blowout syndrome (CBS) is a rare but potentially life-threatening complication that can occur in patients with head and neck cancer (HNC), especially with a history of radiotherapy. This study aimed to review and initially compare managements for post-radiation CBS in patients with HNC.

MATERIALS AND METHODS

A systematic review of published studies was performed. Information including management, survival, and complication were collected.

RESULTS

A total of 39 articles and 917 cases were included in the systematic review. The interval between radiation therapy and CBS ranged from 1.2 years to 17.8 years. The managements of CBS included embolization, stent, bypass surgery, surgical ligation, electrocoagulation, flap coverage, arterial repair, and nasopharyngeal packing. The cumulative 30-day, 1-year, and 2-year overall survival rates were 85.2 %, 48.9 %, and 37.0 %, respectively, with a median survival time of 11.3 months. Disease progression and rebleeding were the most common death causes. The lowest rebleeding rate and neurologic complications rate were presented in cases receiving bypass surgery at 1.4 % and 10.8 %, respectively. The highest rebleeding rate of 35.6 % was showed in cases underwent stent, and the highest neurologic complications rate of 32.0 % was showed in cases underwent ligation.

CONCLUSION

Post-radiation CBS in patients with HNC had a low survival rate and high complication rate. Rebleeding and neurologic complication were common complications. Endovascular embolization and stent were the mainstream management, and bypass surgery presented a promising outcome in survival and complication for selected patients.

Case report: Endovascular intervention of internal carotid artery pseudoaneurysm secondary to nasopharyngeal carcinoma radiotherapy

Background

Internal carotid artery pseudoaneurysm (PSA) is a serious complication after radiotherapy for nasopharyngeal carcinoma, and once it ruptures and bleeds, it will seriously affect the patient's survival and prognosis. However, because of its relatively low incidence, many medical institutions lack experience in managing this type of emergency.

Case information

In this case report, we described two cases suffered ruptured internal carotid artery PSA after radiotherapy for nasopharyngeal carcinoma, including their history, diagnosis, and treatment. Both cases underwent emergency endovascular interventions, one of which with long-term healing after embolization of the PSA, and the other one with re-bleeding after embolization and was eventually stopped by embolization of the parent artery. Ultimately, both cases received timely and effective treatment.

Conclusion

This case report detailed the diagnosis and treatment course of internal carotid artery PSA after radiotherapy for nasopharyngeal carcinoma, which enhanced the understanding of this emergency, and provided valuable information and experience for the treatment strategy of similar PSA on the internal carotid artery.

Endovascular Management of Intractable Nasopharyngeal Hemorrhage in Patients Irradiated for Nasopharyngeal Carcinoma: A Twelve-Year Experience

Purpose

To evaluate the efficacy of endovascular treatment of intractable nasopharyngeal hemorrhage after radiotherapy for nasopharyngeal carcinoma (NPC) and report the relevant endovascular therapeutic experience.

Patients and Methods

Records of patients who underwent endovascular treatment for intractable nasopharyngeal hemorrhage after irradiation for NPC from January 2007 to December 2019 were reviewed. The demographics, endovascular therapeutic details, and clinical outcomes were analyzed.

Results

Twenty-four consecutive patients were included in this study. Nineteen patients underwent embolization of the bilateral internal maxillary arteries; one patient underwent embolization of the right internal maxillary artery and the left external carotid artery; one patient underwent embolization of the left internal maxillary artery and the right internal carotid artery, and the other three patients underwent embolization of the unilateral internal carotid artery. During a mean follow-up of 600.9 days (range, 2–1658 days), twenty patients showed no recurrence of bleeding; one patient died of hemorrhagic shock; one patient had recurrent bleeding, and angiography revealed a pseudoaneurysm in the right internal carotid artery, which was then embolized with spring coil after a 30-min occlusion test. Two patients had recurrent bleeding on 2.5 months and 29.9 months respectively after the endovascular treatment, and angiography showed hypervascularity supplied by the bilateral internal maxillary arteries and then was embolized with polyvinyl alcohol particles. The three patients who received re-interventions showed no re-bleeding until the last follow-up.

Conclusion

Pseudoaneurysm and hypervascularity are the main angiographic characteristics of patients with intractable nasopharyngeal hemorrhage after radiotherapy for NPC, and endovascular treatment provides a safe and effective management approach.

Etiology and management of nasopharyngeal hemorrhage after radiotherapy for nasopharyngeal carcinoma

Objective

To analyze the etiology of nasopharyngeal hemorrhage after radiotherapy for nasopharyngeal carcinoma (NPC) and evaluate the relevant management and rescue approaches.

Methods

Seventeen cases of nasopharyngeal hemorrhage caused by radiotherapy of NPC, treated between January 2015 and March 2018, were retrospectively analyzed to study the etiology of nasopharyngeal hemorrhage. The management and rescue strategies, including anterior and posterior nostril packing, endoscopic nasopharynx electrocoagulation, and digital subtraction angiography embolization, were assessed for their effectiveness.

Results

Nasopharynx hemorrhage after radiotherapy of NPC was mainly associated with erosion of the internal carotid artery or maxillary artery by the tumor. Among the 17 cases, 11 patients were treated by digital subtraction arterial angiography embolization, and 3 were treated by endoscopic nasopharynx electrocoagulation. Overall, 13 patients survived, while 4 died.

Conclusion

Anterior and posterior nostril packing, endoscopic nasopharynx electrocoagulation, and digital subtraction angiography embolization are suitable for treating nasopharyngeal hemorrhage. However, effective hemostasis depends on early identification of the bleeding vessels.

Interventional Radiology and Bleeding Disorders: What the Oral and Maxillofacial Surgeon Needs to Know

Endovascular techniques are essential for controlling acute head and neck bleeding that cannot be controlled by local or systemic measures. Detailed knowledge of the head and neck vascular anatomy, advances in catheterization techniques, and the availability of new embolic materials have improved the safety, efficacy, and predictability of these procedures. To improve patient safety, the oral and maxillofacial surgeon must be familiar with these techniques.

Transcatheter embolization in the management of epistaxis

A majority of the population will experience epistaxis at some time in their life. Most cases will be from an anterior source and can be treated with pressure, anterior nasal packing, or cautery. Intractable epistaxis is generally posterior in origin and may require endoscopic cautery, posterior packing, surgical ligation, or embolization. Embolization has been used to treat epistaxis for more than 30 years and success can be achieved in approximately 90% of patients, with major complications occurring in approximately 2%. These excellent results require thorough knowledge of the regional anatomy, familiarity with the equipment and various agents used to achieve this type of embolization, as well as attention to detail and meticulous technique. There remains debate on several aspects of embolization, including the agent of choice, preferred size of the embolic, and the number of vessels to embolize. Advances in endoscopic surgery have evolved to the point that similar success rates for embolization and modern surgical techniques in treating epistaxis may be expected. This detailed review of pertinent vascular anatomy, embolization technique, and surgical alternatives should allow practitioners to formulate treatment algorithms that result in optimal outcomes at their institutions.

Management of intractable epistaxis in patients who received radiation therapy for nasopharyngeal carcinoma

To report clinical manifestations, bleeding point localization, and outcomes of management in 16 patients with 16 instances of intractable epistaxis after radiation therapy for nasopharyngeal carcinoma. Retrospective chart review of 16 patients with nasopharyngeal carcinoma (mean age 52.06 ± 14.37 years) with 16 instances of intractable epistaxis during the past 5 years, whose diagnosis was confirmed by angiography (n = 10) or MRI/CT imaging studies and clinical manifestations (n = 6). The mean radiation dose to the affected carotid artery was 101.37 ± 34.85 Gy. Bleeding points were detected in the internal carotid artery (n = 8) or external carotid artery (n = 8). Detachable balloons were used in one affected artery for vascular occlusion; six were treated using an absorbable gelatin sponge (n = 4) or microcoils (diameter 1 mm) (n = 2). Endovascular embolization was successful in seven radiation carotid blowout syndromes with cessation of hemorrhage. One patient underwent external carotid artery ligation and one patient recovered without treatment. The clinical follow-up was 3 months. Therapeutic endovascular embolization of intractable epistaxis is both efficient and safe. It should be considered as the primary treatment modality in intractable epistaxis of nasopharyngeal carcinoma.

Complications of embolization

Embolization is a remarkably versatile procedure used in nearly all vascular and nonvascular systems to treat a wide range of pathology. The published literature is rich with studies demonstrating the enormous therapeutic potential offered by embolization procedures, and the possibilities continue to expand with the advent of new embolization agents and techniques. Unfortunately, with this variety and innovation comes a wide spectrum of potential complications, not always easy to classify and summarize, associated with embolization. This article reviews the procedures and associated complications of arterial and venous embolization procedures, organized by vascular distribution.

Endovascular treatment of epistaxis

Epistaxis is a common condition that can be managed conservatively in most cases. When these measures, including anterior and posterior packing of the nasal cavity, are unsuccessful at controlling the bleeding, interruption of the blood supply to the sinonasal area can be performed, either by surgical ligation or by transarterial embolization. Embolization should be preceded by thorough diagnostic angiography. Aside from aiding with subsequent selective catheterization and embolization, such angiography may reveal significant anatomic anomalies, anastomoses, or an unsuspected cause of epistaxis. Taking these findings into account, the interventionalist may decide to refrain from embolization or adjust the technique to minimize the risk of adverse events, which are mostly related to inadvertent embolization of the internal carotid artery or ophthalmic artery. We present a review of the various causes of epistaxis and the treatment options, with emphasis on endovascular embolization. We also describe the protocol of our institution for endovascular management of this condition.

Treatment of profuse epistaxis in patients irradiated for nasopharyngeal carcinoma

BACKGROUND

Profuse epistaxis in patients with nasopharyngeal carcinoma (NPC) previously treated with radiotherapy (RT) can be life threatening. Surgical means to prevent rebleeding may at times be difficult and unsuccessful. We aim to investigate the characteristics of this group of patients and our experience of endovascular embolization technique in the management of epistaxis in this group of patients.

METHODS

A retrospective review of all nasopharyngeal carcinoma patients presented with profuse epistaxis during follow up after radiotherapy was carried out in a regional neurosurgical centre in Hong Kong. Seventeen patients were included for the analysis within the recent 6-year period. The age of patients was 55.5 +/- 8.358 years (mean +/- standard deviation). The sex ratio was 5:1 (M : F). Diagnostic catheter angiography was carried out in all 17 patients. Endovascular embolization was carried out in 11 patients with the joint decision of the otolaryngologist and neurointerventionist in charge .

RESULTS

Four patients underwent main trunk occlusion for internal carotid pseudoaneurysm. Seven patients underwent embolization of branches of external carotid artery. One patient required another session of external carotid artery embolization 1 month later. There was one inpatient death because of pneumonia and hepatic encephalopathy. With our protocol, there were only two patients (11.7%) with delayed rebleed at 2 and 5 months, respectively. Both patients had advanced diseases and died.

CONCLUSION

In irradiated patients with nasopharyngeal carcinoma presenting with profuse epistaxis, angiography had a high yield of pseudoaneurysm or hypervascularity and these lesions could be safely managed through endovascular embolization.

Embolization in the External Carotid Artery

The technical skill set of peripheral interventional radiologists is well-suited to the performance of most transcatheter embolization procedures in the external carotid artery (ECA). These procedures center in large part on hypervascular tumors, epistaxis, and trauma. ECA embolization in the trauma patient is well-defined, albeit in small patient series. The transcatheter treatment of epistaxis is still mostly reserved for cases that are intractable to conservative therapy. Preoperative embolotherapy for vascular tumors remains popular, although it is somewhat controversial in terms of its risk-benefit ratio. The purpose of this review is to highlight pertinent anatomy, selected technical procedural aspects, and the available literature to better characterize the role of ECA embolization in the hands of the practicing peripheral interventionist.