Carotid blowout syndrome in patients with head-and-neck cancers: reconstructive management by self-expandable stent-grafts

Abstract

Background and purpose: Some reports of reconstructive management of carotid blowout syndrome (CBS) with stent-grafts are promising, but some are unfavorable. This study sought to evaluate the hemostatic efficacy, safety, and outcome of reconstructive, endovascular stent-graft placement in patients with head-and-neck cancers in association with CBS.

Methods: Eight patients with head-and-neck cancers with CBS were treated with self-expandable stent-grafts. We evaluated the initial hemostatic results, complications, and outcomes by assessing the clinical and imaging findings.

Results: Immediate hemostasis was achieved in all patients. Initial complications included stroke in 1 patient and asymptomatic thrombosis of the carotid artery in 2 patients. Delayed complications included rebleeding, delayed carotid thrombosis, and brain abscess formation. Rebleeding was noted in 4 patients and was successfully managed with a second stent-graft and embolization in 2 of them. Delayed carotid thrombosis with follow-up after 3 months was found in 3 patients, 1 of whom had associated brain abscesses.

Conclusion: Although stent-grafts achieved immediate and initial hemostasis in patients with head-and-neck cancers and CBS, long-term safety, stent patency, and permanency of hemostasis appeared unfavorable. This treatment may be for temporary or emergency purposes rather than serving as a permanent measure. We suggest its applications in patients with acute CBS that precludes performance of an occlusion test, as well as when carotid occlusion poses an unusually high risk of neurologic morbidity. We also propose prophylactic antibiotic treatment and combined embolization of pathologic vascular feeders to improve outcomes.

Fig 1.

Patient 5. A, Left carotid angiogram shows a pseudoaneurysm in the bifurcation (arrow). B, After 3 fiber coils (arrowheads) were placed in the main trunk of the ECA, an 8 × 50-mm stent was deployed in the left carotid artery. C, Reconstructive CT angiography (curved multiplanar, reformatted images) of left carotid artery 2 months later shows complete obliteration of the pseudoaneurysm. Retained fiber coils in the thrombosed ECA with metallic artifact were also found (arrows). D and E, Contrast-enhanced axial CT scans of the head and neck 4 months later show septic thrombosis of the stent-graft with gas collection (arrow in panel D) and several brain abscesses (arrowheads in panel E).

Fig 2.

Patient 1. A, Right carotid angiogram shows a ruptured carotid artery in the bifurcation (vertical arrows) and an active jet of extravasation (arrowheads) through a focal skin defect on the right side of the neck during the injection of contrast medium. Obvious long-segmental stenosis of the cervical ICA was also found (horizontal arrows). B, After the deployment of an 8 × 50-mm stent from the ICA to the CCA, acute thrombosis with total occlusion of the carotid artery occurred immediately.

Fig 3.

Patient 3. Left carotid angiograms. A, Pseudoaneurysm in the cervical ICA (arrow). B, Soon after a 7 × 30-mm stent was deployed in the cervical ICA, acute thrombosis was noted in the stent and its distal end (arrowheads). C, Acute thrombosis was lysed in 10 minutes by using an intravenous antiplatelet agent. D, Rebleeding due to a pseudoaneurysm in the carotid bulb was found 3 weeks later; the lesion (arrow) was just proximal to the first stent. E, A 9 × 50-mm stent was deployed in the carotid artery, which stopped the bleeding. F, Follow-up left carotid angiogram shows preserved carotid artery and complete obliteration of the pathologic lesion 1 week later. G, Six months later, axial contrast-enhanced CT scan of the neck shows thrombosis of the left carotid artery (arrow).

Fig 4.

Patient 6. A, Right carotid angiogram shows a pseudoaneurysm in the right distal CCA (arrow). B, An 8 × 50-mm stent was deployed from the right carotid bulb to the right CCA. C, Another pseudoaneurysm in the right carotid bulb just distal to the distal end of the stent (arrow) was noted 2 months later. D, A second 8 × 50-mm stent was deployed in the right cervical ICA to overlap the first stent. Mottled gas collection (arrowheads) in the soft tissue indicates radiation necrosis. E, Right subclavian angiogram shows a pseudoaneurysm (arrow) in a branch of the right superior thyroid artery reconstituted from branches of the ipsilateral costocervical trunk via the ipsilateral ECA. The stent occludes the orifice of the right ECA. F, Direct percutaneous puncture of the main trunk of the right ECA with a spinal needle (arrowheads) was done by using a roadmap image. The needle contacted the right superior thyroid artery and showed the small pseudoaneurysm (arrow). The pseudoaneurysm was successfully embolized with a slow injection of a mixture of liquid adhesives (n-butyl cyanoacrylate and lipiodol).