Carotid artery resection for head and neck cancer

Survival and complications after carotid resection for head and neck squamous cell carcinoma: A systematic review and pooled analysis

OBJECTIVE

The aim of this study is to analyze oncologic outcomes and complications rate after common or internal carotid artery (CCA/ICA) resection for head and neck squamous cell carcinoma (HNSCC).

METHODS

This study was conducted in conformity with the PRISMA statement. A systematic review and pooled analysis was performed for overall survival (OS), disease specific survival (DSS) (primary outcomes), and perioperative death rate (secondary outcome).

RESULTS

A total of 276 patients (males: 76.7%, n = 191/249) with a median age of 59 years (n = 239/276; 95% CI 55.0-61.7) who underwent CCA/ICA resection for HNSCC were included. The median follow-up time was 11 months (n = 276). Estimated pooled OS rates (95% CI) at 1 and 2 years were 52.7% (46.9-59.2) and 29.8% (24.3-36.5), respectively. The median OS (95% CI) was 14 months (12-17). Estimated pooled DSS rates (95% CI) at 1 and 2 years were 58.6% (52.7-65.2) and 34.6% (28.5-41.9), respectively. The median DSS (95% CI) was 16 months (14-19). The perioperative death rate was 6.9% (n = 19/276).

CONCLUSIONS

CCA/ICA resection should be considered as a treatment option for accurately selected patients. Multicentric prospective studies are recommended to develop a predictive score guiding the decision-making process.

Carotid body tumor resection utilizing a covered stent graft to enable resection of the tumor en bloc with the internal carotid artery

Surgical excision is the primary treatment for carotid body tumors (CBT) and infrequently involves carotid vessels reconstruction. A CBT that extends distally to the level of the skull base makes surgical reconstruction very challenging. We report a case of a 30-year-old man who presented with a CBT (Shamblin III) extending to the base of the skull. A covered stent graft was placed in the internal carotid artery. Subsequently, a successful resection of the tumor with the arterial wall en bloc was performed, leaving the stent graft exposed as a bridge between the two ends of ICA.

Carotid Artery Involvement in Advanced Recurrent Head and Neck Cancer: A Case Report and Literature Review

BACKGROUND

Surgical management of advanced head and neck tumors involving the carotid artery remains controversial with compromised survival outcomes and heightened risks of morbidity and mortality.

CASE

We describe a case of a 74-year-old lady with previous T1N0M0 left tongue squamous cell carcinoma, who developed a left nodal recurrence encasing the left external carotid artery from the carotid bifurcation. She underwent an extended left radical neck dissection with carotid artery patch plasty and remains well to date, 10 months after surgery.

DISCUSSION

Head and neck tumor recurrences are not uncommon, and radical resection of advanced tumors involving the carotid artery is increasingly performed. Various carotid interventions including tumor peeling, ligation, and resection with reconstruction were reported with differences in survival outcomes, morbidity and mortality.

CONCLUSION

An aggressive surgical approach to advanced tumors involving the carotid artery may be a viable attempt for survival prolongation but requires proper case selection and has to be weighed against the risks of complications to better optimize patient outcomes.

Sacrifice and extracranial reconstruction of the common or internal carotid artery in advanced head and neck carcinoma: Review and meta-analysis

BACKGROUND

Sacrifice and reconstruction of the carotid artery in cases of head and neck carcinoma with invasion of the common or internal carotid artery is debated.

METHODS

We conducted a systematic search of electronic databases and provide a review and meta-analysis.

RESULTS

Of the 72 articles identified, 24 met the inclusion criteria resulting in the inclusion of 357 patients. The overall perioperative 30-day mortality was 3.6% (13/357). Permanent cerebrovascular complications occurred in 3.6% (13/357). Carotid blowout episodes were encountered in 1.4% (5/357). The meta-regression analysis showed a significant difference in 1-year overall survival between reports published from 1981-1999 (37.0%) and 2001-2016 (65.4%; P = .02).

CONCLUSION

This review provides evidence that sacrifice with extracranial reconstruction of common or internal carotid artery in selected patients with head and neck carcinoma may improve survival with acceptable complication rates. However, all of the published literature is retrospective involving selected series and, therefore, precludes determining the absolute effectiveness of the surgery.

Bilateral Common Carotid Artery Ligation in Sheep. Could These Animals be Used as Human Models for Vascular and Cerebral Research?

Experimental animals are still used in today’s medicine to understand better physiological or pathological processes, or to develop, for example better vascular prostheses. For that reason, these animals must show some similarities with humans, from the anatomical to the physiological point of view. When developing vascular prostheses, we have to evaluate if the graft will react in the expected way and if during experimental research there will be some factors that might influence the proper functioning of vascular prostheses in the human body. We observed the consequences of bilateral common carotid artery ligation (BCCAL) or Sham operation in seventeen healthy Merinolandschaf / Württemberg sheep, aged between 2 and 4 years, after testing new types of carbon-coated ARTECOR® and ADIPOGRAFT Ra 1vk 7/350 vascular prostheses. After the follow-up period the prostheses were extirpated, so the blood supply was provided from the vertebral arteries. Sheep in both groups were not sacrificed, but were observed for 18 months. After the observation period all sheep showed no physical or neurological changes and all are still alive. Animal responses to BCCAL are different, depending on the animal species, age, and condition. In sheep, bilateral blocking of the blood fl ow in the carotid bed seems to be conceivable since the brain was sufficiently supplied with blood from the vertebral arteries.

[Resection of recurrent neck cancers with replacement of the carotid artery]

OBJECTIVES

The management of patients with recurrent neck cancer invading the carotid artery is controversial. The aim of this study was to evaluate the overall survival and healthy survival years (QALY) as well as the patency of carotid revascularization after enbloc tumor resection followed by complementary radiotherapy.

METHODS

From 2000 to 2016, 42 consecutive patients with recurrent neck cancer invading the carotid artery underwent resection of the tumor associated with reconstruction of the carotid artery with a PTFE prosthesis (n=31) or with a saphenous vein graft (n=11). In 11 cases, resection was associated with musculocutaneous flap coverage. The primary tumor was a squamous cell carcinoma of the larynx (20 patients) or of the pharynx (9 patients), undifferentiated carcinoma of unknown origin (10 patients) and anaplastic thyroid carcinoma (3 patients). All patients had postoperative radiotherapy (50-70Gy) supplemented in 16 of them by chemotherapy. Nine patients had metastatic dissemination at the time of reoperation with a recurrent tumor ulcerated to the skin in 5 of them.

RESULTS

The combined 30-day mortality and stroke rate was nil. Postoperative morbidity included dysphagia (n=8), vocal cord paralysis (n=6), late wound healing delay (n=2), transient mandibular claudication (n=1) and partial necrosis of the musculocutaneous flap (n=1). No infection and no thrombosis of the bypass were observed during follow-up [median: 31 months, range: 8-167 months]. Twenty-one patients (50%) died from the consequences of the spread of cancer, which had become metastatic, but without local recurrence. The 5-year survival rate was 50.9±8.3%. The median healthy survival year (QALY) was 3.38 [95% CI: 1.70-4.54] with a significant difference between patients without metastasis at the time of reoperation [n=33; QALY=4.02] and those with metastases [n=9; QALY=0.43; P=0.005]. Healthy life expectancy was also significantly longer in patients with laryngeal cancer [n=20, QALY=4.95] compared to patients with other types of tumors [n=22, QALY=1.67; P=0.032].

CONCLUSION

In the absence of metastases, enbloc resection of recurrent neck cancers invading the carotid artery improves the duration and quality of patient survival.

Resection of recurrent neck cancer with carotid artery replacement

OBJECTIVE

The management of patients with recurrent neck cancer invading the carotid artery is controversial. The purpose of this study was to evaluate overall survival rate, primary patency of vascular reconstructions, and quality-adjusted life-years (QALYs) after en bloc resection of the carotid artery and tumor with in-line polytetrafluoroethylene (PTFE) carotid grafting, followed by radiotherapy.

METHODS

From 2000 to 2014, 31 consecutive patients with recurrent neck cancer invading the carotid artery underwent en bloc resection and simultaneous carotid artery reconstruction with a PTFE graft, which was associated in 18 cases with a myocutaneous flap. The primary tumor was a squamous cell carcinoma of the larynx in 17 patients and of the hypopharynx in 7, an undifferentiated carcinoma of unknown origin in 4, and an anaplastic carcinoma of the thyroid in 3. All of the patients underwent postoperative radiotherapy (50-70 Gy), and 10 of them also underwent chemotherapy (doxorubicin and cisplatin).

RESULTS

None of the patients died or sustained a stroke during the first 30 days after the index procedure. Postoperative morbidity consisted of 6 transitory dysphagias, 3 vocal cord palsies, 2 wound dehiscences, 1 transitory mandibular claudication, and 1 partial myocutaneous flap necrosis. No graft infection occurred during follow-up. Fifteen patients (48%) died from metastatic cancer during a mean follow-up of 45.4 months (range, 8-175 months). None of the patients showed evidence of local recurrence, stroke, or thrombosis of the carotid reconstruction. The 5-year survival rate was 49 ± 10%. The overall number of QALYs was 3.12 (95% confidence interval, 1.87-4.37) with a significant difference between patients without metastasis at the time of redo surgery (n = 26; QALYs, 3.74) and those with metastasis (n = 5; QALYs, 0.56; P = .005). QALYs were also significantly improved in patients with cancer of the larynx (n = 17; QALYs, 4.69) compared to patients presenting with other types of tumors (n = 14; QALYs, 1.29; P = .032).

CONCLUSIONS

Aggressive en bloc resection of recurrent neck cancer with PTFE grafting can be curative in patients without metastases at the time of redo surgery. In this subset of patients, extensive neck surgery with carotid artery replacement can lead to excellent local control of the disease with improved quality of survival.

The role of neck dissection in squamous cell carcinoma of the head and neck

ORIGINAL STATEMENT

Lymph node metastases in the neck are a major prognostic factor in patients with head and neck squamous cell carcinoma (HNSCC). Assessment and treatment of lymph nodes in the neck are of utmost importance. Inappropriate management of lymph node metastases can result in regional failure. Radical neck dissection has been and is still considered the "gold standard" for the surgical management of lymph node metastases of HNSCC. However, the philosophy of treatment of the neck has evolved during the last decades. Surgeons progressively realized that extensive neck dissections were associated with a higher morbidity but not always with a better oncologic outcome than more limited procedures. Today, a comprehensive therapeutic approach of the neck is multidisciplinary, taking into account the patient's quality of life without jeopardizing cure and survival. A better understanding of the patterns of lymph node metastasis promoted the use of selective neck dissection in selected patients. Sentinel lymph node biopsy is a reliable diagnostic procedure for staging the neck in node-negative early oral cavity squamous cell carcinoma. With increasing use of chemoradiation in locally advanced HNSCC, paradigms are evolving. Currently, there are strong arguments supporting the position that neck dissection is no longer justified in patients without clinically residual disease in the neck.

[Salvage surgery in unresectable tumors of the neck. Outcome after ligation of the common carotid artery]

The aim of this study was to analyze two cases with advance tumors of the neck with infiltration of the common or internal carotid artery. Patients were surgically treated in Department of Otolaryngology Poznan University of Medical Sciences. Authors present the current state of knowledge concerning the proceedings in unresectable tumors of the neck and possibility to use the salvage surgery. Based on literature data and our own experience a risk of the carotid artery infiltrations is difficult to assay in diagnostic procedure. It decrease the possibility of radical surgery resection and indicate the most advance stage. Choosing the proper treatment requires interdisciplinary cooperation: ENT specialist, radiologist, vascular surgeon and oncologist. The high rate of complications and local recurrence rate makes the results of treatment are unsatisfactory.

Cerebral blood flow and metabolism measurement using positron emission tomography before and during internal carotid artery test occlusions: feasibility of rapid quantitative measurement of CBF and OEF/CMRO(2)

Balloon test occlusion (BTO) of the internal carotid artery (ICA) combined with cerebral blood flow (CBF) study is a sensitive test for predicting the outcome of permanent ICA occlusion. However, false negative results sometimes occur using single photon emission tomography (SPECT). We have recently developed a rapid positron emission tomography (PET) protocol that measures not only the CBF but also the cerebral oxygen metabolism before and during BTO in succession. We measured acute changes in regional CBF and OEF/CMRO(2) before and during BTO in three cases with large or giant cerebral aneurysms using the rapid PET protocol. Although no patients showed ischemic symptoms during BTO, PET studies exhibited mildly to moderately decreased CBF (9∼34%) compared to the values obtained before BTO in all cases. The average OEF during BTO was significantly increased (21% and 43%) than that of before BTO in two cases. The two cases were considered to be non-tolerant for permanent ICA occlusion and treated without ICA sacrifice. Measurement of the CBF and OEF/CMRO(2) using a rapid PET protocol before and during BTO is feasible and can be used for accurate assessment of tolerance prediction in ICA occlusion.

Carotid resection and reconstruction associated with treatment of head and neck cancer

Patients with head and neck cancer may experience carotid artery involvement. We present a series of 10 patients, all with stage IVB disease, who required carotid resection and reconstruction to achieve a complete resection. Nine of the 10 patients had previous radiation treatment to the neck. Six died of distant disease, and three died of other causes with no local or regional recurrences. Carotid resection and reconstruction can be done safely, achieving local and regional control.

[Neuroradiologic diagnostic and interventional procedures for diseases of the skull base]

Besides image-guided biopsy techniques, the emphasis in the interdisciplinary cooperation between head and neck surgery and neuroradiology is on vessel-occluding and preserving measures. Knowledge of dangerous anastomoses between extracranial and intracranial vessels is crucial. The principles of vessel-occluding procedures including materials are presented and illustrated with case examples. Embolization of glomus tumors or epistaxis and preoperative permanent vessel occlusion techniques are demonstrated as well as vessel-preserving therapies, such as placement of covered stents for improving tumor resectability or after iatrogenic laceration of the internal carotid artery.

The plastic surgeon's role in extracranial-to-intracranial bypass using a reverse great saphenous vein graft

BACKGROUND

Extracranial-to-intracranial bypass is used for flow replacement and diversion that prevent the serious complications associated with sudden ligation of the middle cerebral artery for treatment of complex tumors or aneurysms. Extracranial-to-intracranial bypass is a demanding procedure that requires experience in advanced microsurgical techniques. In this article, the authors review the first report of an extracranial-to-intracranial bypass performed by a plastic surgeon with emphasis on indications for microsurgical involvement in neurosurgical practice and on description of the surgical technique.

METHODS

Between April of 2004 and October of 2006, three extracranial-to-intracranial bypass cases were performed including one for a complex aneurysm rupture and two for resections of cranial base tumors. In every case, the intracranial approach was used by the neurosurgeon. The bypass was performed by interposing a reverse great saphenous vein graft between the superficial temporal artery, in end-to-end anastomosis, and the second segment of the middle cerebral artery, in end-to-side anastomosis.

RESULTS

In each case, postoperative cerebral angiography demonstrated complete patency of the extracranial-to-intracranial bypass. Neither of the two surviving patients at a mean follow-up of 13 months had deterioration of neurologic function, postoperative stroke, or surgery-related death. One of the patients was dead before the 6-month follow-up.

CONCLUSIONS

The reverse great saphenous vein graft is a good option for extracranial-to-intracranial bypass, with the advantages of high-flow graft, wide lumen, adequate length, easy harvest, and minimal donor-site morbidity. The plastic surgery/neurosurgery alliance allows scope for improved outcomes in complex neurosurgical cases and continues to push the frontiers of reconstructive microsurgery.

Carotid artery resection and reconstruction with expanded polytetrafluoroethylene for head and neck cancer

OBJECTIVE

There are controversies on management of carotid artery invasion in advanced head and neck cancer. En bloc resection has been considered a curative modality. In this study, we evaluated the feasibility of using expanded polytetrafluoroethylene (ePTFE) in reconstructing the common carotid artery in patients with carotid artery invasion requiring resection.

METHOD

A retrospective study including 13 patients managed from 2002 to 2005. All patients underwent en bloc resection of the tumor and internal carotid artery then reconstructed with ePTFE.

RESULTS

All patients had en bloc resection of the tumor together with internal carotid artery and reconstruction with ePTFE. Some patients required wound coverage with myocutaneous flaps in eight patients and local flaps in five patients. Intraoperative shunting was used in all patients. Intraoperative heparin infusion and postoperative low dose aspirin were used to prevent thrombosis. One patient developed graft blowout and he was treated with ligation without hemiplegia. One patient had minor stroke. The follow-up period was 18.4 +/- 8.6 months. No patient suffered from neurological deficit or graft occlusion. Disease survival was 61.5% in 1 year and 38.5% in 2 years. Overall survival was 18.3 months.

CONCLUSION

En bloc resection and tumor together with carotid artery and ePTFE reconstruction is shown to be a feasible modality in treatment of advanced head and neck cancer with carotid artery invasion.

Outcome of treatment for advanced cervical metastatic squamous cell carcinoma

BACKGROUND

Patients with advanced cervical metastases from mucosal squamous cell carcinoma have a poor prognosis because of their high risk of regional and distal failure. This study aims to evaluate the outcomes of patients with clinical N2 or N3 disease managed with surgery and postoperative radiotherapy.

METHODS

From a comprehensive computerized database, 181 entered patients who had neck dissection for N2 or N3 disease between 1988 and 1999 were evaluated. The mean age was 62 years, and minimum follow-up was 3 years.

RESULTS

A total of 233 neck dissections were performed in 181 patients, including 163 comprehensive and 70 selective dissections. Postoperative radiotherapy was given in 82% of cases. The local control rate was 75% at 5 years, and control of disease in the treated neck was achieved in 86%. Macroscopic extracapsular spread (ECS) significantly increased regional recurrence (p = .001). Adjuvant radiotherapy significantly improved neck control (p = .004) but did not alter survival. Patients with ECS (both microscopic and macroscopic) who received radiotherapy had a significantly better survival than did patients with ECS who did not receive radiotherapy. Disease-specific survival for the entire group was 39% at 5 years. By use of multivariate analysis, macroscopic ECS and N2c neck disease were independent adverse prognostic factors for survival (p = .001).

CONCLUSIONS

Despite a high rate of control in the treated neck, the poor survival (39%) in this patient group indicates that adjuvant therapeutic strategies need to be considered.

Salvage of advanced squamous cell carcinomas of the head and neck: internal carotid artery sacrifice and extracranial–intracranial revascularization

Object

Squamous cell carcinoma (SCC) of the head and neck may involve the carotid artery (CA) in the neck or skull base. Whether tumor resection should be associated with sacrifice of the CA is debatable.

Methods

Records obtained in five consecutive patients (three men, and two women; mean age 58 years, range 47–69 years) treated for recurrent or progressive SCC involving the internal carotid artery (ICA) at the skull base were reviewed retrospectively. The ICA was sacrificed, an extracranial–intracranial (EC–IC) bypass was performed using a saphenous vein graft, and the tumor and involved ICA segment were resected.

Gross-total resection of the SCC was achieved in four cases. One patient died of an acute postoperative stroke due to bypass occlusion and did not undergo tumor resection. No other permanent ischemic or neurological deficits were noted. The other four patients died of tumor progression (survival range 2–40 months, mean 14 months). One patient survived for more than 2 years (2-year overall survival rate 20%). Histological tumor invasion of the CA wall was verified in one of the three evaluated specimens.

Conclusions

A high rate of morbidity and mortality is associated with cases in which skull base CA sacrifice and an EC–IC bypass are performed. Not all resected arteries are shown to have malignant infiltration on histological examination. Better preoperative imaging criteria are needed to define malignant infiltration of the ICA at the skull base. Chemotherapy and radiotherapy without aggressive tumor resection may be an option for these patients.

Management of carotid artery invasion in advanced malignancies of head and neck comparison of techniques

The objective of this study was to retrospectively investigate a single institution's experience with carotid artery resection performed as part of an oncological procedure and to determine acute and convalescent complication and survival rates. We performed a record review of 28 patients with head and neck malignancy invading the carotid artery. Immediate carotid artery resection and ligation on an emergent basis was performed on 12 patients (group 1), elective resection and ligation was performed on 8 patients (group 2), and elective resection and revascularization was performed on 8 patients (group 3). In group 1, although 1 patient survived for 1 year and 1 patient survived for 2 years, 1 patient died of severe neurologic deficit, 2 patients experienced neurologic deficit with good recovery, and 1 patient was moderately disabled. In group 2, 2 patients survived without disease for 5 years, and 2 patients experienced neurologic deficit, 1 with good recovery and the other with complete recovery. In group 3, only 1 patient survived for 5 years, and within this group, 1 patient died of severe neurologic deficit, 1 patient had neurologic deficit with moderate recovery, and 1 patient had neurologic deficit with complete recovery. No significant difference in mortality and morbidity rate was observed between the "resection and ligation" group and the "resection and revascularization" group (p = .52, chi(2) = 0.79). We conclude that the surgical treatment of patients with an invaded carotid artery, including carotid resection, provides a small but real chance of 5-year survival. The methods of carotid resection and repair should be guided by clinical presentation and by preoperative and intraoperative investigations.

Carotid reconstruction in patients operated for malignant head and neck neoplasia

CONTEXT

Patients with malignant head and neck neoplasia may present simultaneous involvement of large vessels due to the growth of the tumoral mass. The therapeutic options are chemotherapy, radiotherapy, surgery or combined treatments.

OBJECTIVE

To analyze the result of surgical treatment with carotid reconstruction in patients with advanced malignant head and neck neoplasia.

DESIGN

Prospective.

SETTING

Hospital do Câncer A.C. Camargo, São Paulo, Brazil.

PARTICIPANTS

Eleven patients operated because of advanced malignant head and neck neoplasia that was involving the internal and/or common carotid artery.

MAIN MEASUREMENTS

By means of clinical examination, outpatient follow-up and duplex scanning, we analyzed the patency of the carotid grafts, vascular and non-vascular complications, disease recurrence and survival of the patients.

RESULTS

Six patients (54.5%) did not present any type of complication. There was one vascular complication represented by an occlusion of the carotid graft with a cerebrovascular stroke in one hemisphere. Non-vascular complications occurred in five patients (45.5%). During the follow-up, eight patients died (72.7%), of whom seven had loco-regional tumor recurrence and one had pulmonary and hepatic metastases (at an average of 9 months after the operation). Seven of these patients presented functioning grafts. The three patients still alive have no tumor recurrence and their grafts are functioning (an average of 9 months has passed since the operation).

CONCLUSIONS

Patients with advanced malignant head and neck neoplasia involving the carotid artery that are treated surgically present a prognosis with reservations. When the internal and/or common carotid artery is resected en-bloc with the tumor, arterial reconstruction must be performed. The long saphenous vein is a suitable vascular substitute.

Management of the carotid artery at the skull base

PURPOSE

To determine appropriate management of benign lesions with significant involvement of the carotid artery at the skull base and present an algorithm for safe treatment of these patients.

MATERIALS AND METHODS

From 1982 to 1999, 115 patients with significant parapharyngeal space masses were treated at our institution. Of these patients, 43 had lesions involving the carotid artery at the skull base and served as the basis for this study. All patients underwent preoperative computed tomography or magnetic resonance imaging scans to determine carotid involvement, and all had preoperative 4-vessel arteriograms and carotid occlusion tests with continuous electroencephalography or neurologic examination monitoring to predict safety of carotid sacrifice.

RESULTS

Of 43 patients, 41 passed carotid occlusion testing and were treated surgically. Of these patients, 33 (81%) underwent resection of their lesions with preservation of the internal carotid artery, 5 (12%) had resection with bypass or reconstruction of the artery, and 3 (7%) had en bloc resections without artery reconstruction. There were no transient or permanent neurologic sequelae in any patient.

CONCLUSIONS

When carotid artery encasement occurs in the setting of benign lesions at the skull base, safe resection with vascular preservation is possible in most cases. If carotid artery resection is necessary, vascular bypass or reconstruction is recommended to minimize neurologic morbidity.

Varying impact of common carotid artery digital compression and internal carotid artery balloon test occlusion on cerebral hemodynamics

BACKGROUND

The purpose of this study was to compare the cerebral hemodynamic changes brought about by common carotid artery (CCA) digital compression and angiographic internal carotid artery (ICA) balloon occlusion.

METHODS

Bilateral transcranial Doppler ultrasonographic monitoring of the middle cerebral artery blood velocity (VMCA) was performed in 12 subjects with neck neoplasms or traumatic carotid-cavernous fistulas. The MCA pulsatility index (PIMCA) and hemodynamic tension (Uhem MCA) were calculated.

RESULTS

Common carotid artery compression provoked the largest drop in ipsilateral VMCA, PIMCA, and Uhem MCA. Common carotid artery compression caused a steal of blood from the intra- to the extracranial circulation, with the discrepancy in hemodynamic findings between CCA and ICA test occlusions being dependent on the quantity of reversed ipsilateral ICA blood flow.

CONCLUSION

If the carotid artery is to be sacrificed, permanent ICA closure is the procedure of choice with respect to the occurrence of cerebral ischemic lesions in patients with neck neoplasms and ICA flow reversal during CCA compression.

Carotid resection and replacement with autogenous arterial graft during operation for neck malignancy

Carotid artery resection as part of the management of advanced head and neck cancers remains controversial. Since 1991, 30 patients have undergone resection of the carotid artery with immediate reconstruction using superficial femoral artery as replacement conduit. There was one stroke/death. Forty-three percent developed neck wound problems but no grafts failed or hemorrhaged. Mean follow-up was 20 months (3-76) and mean life expectancy was 16 months from the time of surgery. Fifty-eight percent were free of local recurrence at the time of death. There was a 35% disease-free survival rate at 2 years. These results compare favorably with alternative therapy including carotid ligation or shaving tumor from the carotid artery. Given the importance of cerebral perfusion and local tumor control we offer superficial femoral artery as a durable conduit for immediate extracranial carotid reconstruction in the often hostile environment associated with cancer resection in the neck.

Contralateral external carotid-middle cerebral artery bypass for carotid artery resection

Resection of the common carotid or internal carotid artery is occasionally unavoidable in cases of advanced head and neck carcinoma with carotid artery involvement. To prevent the consequent decrease in cerebral perfusion, we have developed a contralateral external carotid-middle cerebral artery bypass grafting technique. From 1990 through 1995, six patients with advanced head and neck cancer involving the carotid artery underwent total tumor resection combined with vascular reconstruction using the contralateral external carotid- middle cerebral artery bypass grafting. No bypass-related complications occurred in any patient postoperatively. Cerebral hemodynamics after surgery indicated that this bypass graft worked steadily over a long term and supplied sufficient volume of blood to the cerebral cortex on the opposite side in every case.

Resection of the internal carotid artery and replacement with greater saphenous vein: a safe procedure for en bloc cancer resections with carotid involvement

PURPOSE

Many patients who have advanced cancer of the neck will have involvement of the internal carotid artery. The management of this condition remains controversial, and a wide range of therapeutic options have been suggested including ligation, "shaving" the tumor off the carotid, or en bloc resection and replacement of the internal carotid artery by polytetrafluoroethylene, vein, or superficial femoral artery. We reviewed our experience with en bloc resections of the internal carotid artery in a consecutive series of patients who had malignancies involving the internal carotid artery at a single institution from 1989 to 1995.

METHODS

We used a retrospective chart review based on a list of 20 patients generated by the Hospital Cancer Registry and our Vascular Surgery clinical database.

RESULTS

All patients had their internal carotid artery removed and replaced with a greater saphenous vein while they were under general anesthesia. A resection of their cervical malignancy was also performed. Concomitant myocutaneous flaps were rotated over the carotid bypass in six (30%) patients. Eight (40%) of the bypass grafts were nonreversed, and 12(60%) were reversed, with a clear trend towards using nonreversed veins more recently. Shunts were used in 18(90%). Eighteen of the 20 patients had some form of intraoperative contamination including tracheostomies, pharyngostomies, or fistulas. Half of the patients had intraoperative radiation therapy, and 16(80%) patients underwent operation for recurrent cancer. During the follow-up period two (10%) patients had strokes (one minor and one major), and one patient had a graft blowout, which was treated by ligation without stroke. One patient had an asymptomatic occlusion of his graft.

CONCLUSIONS

From these results we conclude that the use of the greater saphenous vein to replace the internal carotid artery after en bloc resection is not attended by a high rate of infectious complications or graft blowout even in the presence of intraoperative tracheopharyngeal contamination and that the greater saphenous vein is the conduit of choice for replacing an internal carotid artery after cancer resections.

Emergency balloon embolization for carotid artery rupture secondary to postoperative infection

Two cases of carotid artery rupture due to postoperative infection were treated successfully with an emergency endovascular technique. A detachable balloon was attached to a 2 Fr microcatheter and was introduced through a 9 Fr guiding catheter. The balloons were detached at the rupture site and just proximal to the lesion. This technique has several advantages over surgical procedures.

Management of advanced cervical metastasis using intraoperative radiotherapy

Seventy-five patients who had advanced cervical metastasis with possible invasion of the deep muscles or carotid artery were approached with aggressive resection and intraoperative radiotherapy (IORT). All metastatic nodes were greater than 3 cm, 65% were fixed on clinical examination, and 35% involved the carotid artery. Forty-six (61%) of the patients had previously received irradiation. Fifteen of the patients required extended neck dissections with carotid resections and grafting. After the resection an average single dose of 2000 cGy of electron beam IORT was delivered. At 2 years, the local control rate within the IORT port was 68% and the absolute survival rate was 45%. Local control rates for close and microscopic margins (76% and 73%, respectively) were significantly better than the control rate for gross residual disease (25%, P < .05). The combination of extended neck dissection, including carotid artery resection if necessary, and IORT appears to offer improved control.

Vascular considerations and complications in cranial base surgery

The technical evolution of cranial base surgery has resulted in approaches that allow more radical surgical extirpation of complex cranial base lesions. Our service has extensively applied these cranial base approaches for lesions of the cranial base. A subgroup of 100 patients who had cranial base tumors involving potential manipulation or sacrifice of carotid arteries underwent 20-minute balloon test occlusions coordinated with vascular assessments consisting of a combination of the following: 1) four-vessel cerebral angiogram with compression studies; 2) occlusion transcranial Doppler ultrasonography; 3) occlusion single-photon emission computed tomography perfusion studies; and 4) xenon-133 cerebral blood flow studies. Transient neurological deficits associated with balloon test occlusion occurred in 7 of 100 patients (7%). Subsequently, 18 patients underwent permanent carotid occlusion by endovascular detachable balloons. Delayed ischemic complications (> 72 h) occurred in 4 of 18 (22%) patients. Additionally, a number of vascular complications not predicted by the balloon occlusion tests and vascular assessments were experienced. Repeat vascular assessments defined the causes and guided treatment of ischemic patients. Ischemic complications were caused by hemodynamic insufficiency, embolization, vasospasm, radiation vasculopathy, and venous anomaly. Our experience leads us to believe that no vascular assessment exists today that can predict the occurrence of vascular complications accurately. The current enthusiasm for cranial base surgery must be tempered with the sober reality that management of cerebrovascular anatomy and physiology remain significant limitations. Consideration of potential cerebrovascular complications is paramount to successful outcome and implementation of cranial base surgery.

Two cases of head and neck cancer with carotid artery reconstruction

A carotid artery reconstruction was performed on two patients of head and neck cancer with infiltration into the carotid artery. To detect any possibility of cerebral ischemia at the time of ligation of the carotid artery, a temporary occlusion test of the internal carotid artery with a balloon catheter (balloon Matas test) was performed in both cases. An artificial vessel (Case 1) and a greater saphenous vein (Case 2) were used as an implanted vessel. No neurological sequelae were observed during or after the surgery in these cases. With a recent advance in various imaging diagnosis and an improvement in surgical techniques, the radical treatment including carotid artery reconstruction is expected to improve the prognosis for the cases demonstrating tumor infiltration into the carotid artery.