Background The purpose of this study was to examine outcomes of a patient cohort undergoing intervention for carotid blowout syndrome (CBS) associated with head and neck cancer. Methods Patients with head and neck cancer who presented with carotid-distribution bleeding from 2000-2014 were identified in the medical record. Primary outcomes were short and mid-term 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 (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 oro, naso, and hypopharynx. 51% of bleeds were of common carotid, 29% external carotid, and 19% internal carotid origin. 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. 10.8% of patients had perioperative stroke; other major complications were rare. Sixteen recurrent bleeding episodes involving 12 arteries occurred in 11 patients (29.73%). Median rebleeding time was seven days (IQR 6-49). Estimated recurrent bleeding risk at 30-days and 6 months was 24% and 34% respectively. 91.9% of patients survived to hospital discharge. 90-day and 1-year estimated survival was 60.9% and 36.6% respectively. Conclusions CBS 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.

invasion of the carotid, with 31 articles describing carotid reconstruction in the setting of tumor invasion. There were no reports using Artegraft for carotid reconstruction.Results: A 65-year-old man presented with a large left neck mass. Computed tomography angiography (CTA) of the neck demonstrated a complex 9.1-cm  5.9-cm  7.5-cm mass encasing and invading the cervical internal carotid artery (Fig 1). Fine-needle aspiration revealed squamous cell carcinoma. Furthermore, he had an incomplete circle of Willis on CTA and no viable vein conduit on duplex mapping. The patient underwent en bloc resection of the left neck tumor, including a portion of the cervical internal carotid artery, followed by reconstruction with the Artegraft (Fig 2). Brachytherapy catheters were left in place, followed by pectoralis major rotational flap for coverage. At the conclusion of the procedure, there were multiphasic Doppler signals throughout the graft. The procedure was well tolerated, and the patient had an uneventful course with no neurologic sequelae.Conclusions: To our knowledge, this is the first case reported of tumor invasion of the internal carotid reconstructed using Artegraft bovine heterograft as conduit. This novel approach provides an alternative to synthetic conduit when there is an increased concern for infection and need for a durable repair in a patient without suitable autologous conduit.