Outcomes of interventions for carotid blowout syndrome in patients with head and neck cancer

Abstract

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.

Treatment of a Case of Common Carotid Artery Pseudoaneurysm That Developed after Surgery for Hypopharynx Cancer by Covered Stent Placement

“…2) Intraaneurysmal embolization may be considered as a measure to achieve temporary hemostasis, but long-term occlusion cannot be expected by this procedure. 2) Bypass surgery and artificial vessel replacement should be evaluated, 3) but they are difficult to perform as additional procedures to the neck that has been previously operated on or irradiated. 1,2) Therefore, endovascular treatment using a covered stent has recently emerged as the first choice.…”

“…Surgical treatment for CBS is highly invasive, and its outcomes are poor. [1][2][3] However, the outcomes of endovascular treatment for CBS have been reported to be more favorable compared with those of other treatments. 1,4) In the case reported here, we could prevent CBS by covered stent (Fluency Plus; Bard Peripheral Vascular, Tempe, AZ, USA) placement for common carotid artery pseudoaneurysm following treatment for hypopharynx cancer.…”

Management of Cutaneously Exposed Carotid Stents in Recurrent and Unresectable Head and Neck Cancer

“…Carotid blowout syndrome (CBS),that is, rupture of the extracranial carotid arteries or their major branches, is one of the most feared complications, with a reported incidence of 3 to 4% in patients with HNC. [3][4][5][6][7][8][9][10] CBS is associated with 60% morbidity and 40% mortality. 3,4,6,7,[10][11][12][13] In patients with advanced HNC, risk factors for the development of CBS are radiation, stripping of the carotid artery during surgery, skin breakdown, and development of mucocutaneous fistula.…”

“…However, more recently developed endovascular techniques, including selective embolization and reconstruction with covered stent grafts, have become the mainstay of treatment. [3][4][5][6][7][8]10,11,15 Immediate complications associated with the use of covered stent grafts after CBS have been extensively reported and include acute thromboembolism and iatrogenic dissection. Mid-and long-term complications may involve rebleeding (13-44% incidence) and stent thrombosis associated or not symptomatic ischemic cerebrovascular accidents.…”

“…Mid-and long-term complications may involve rebleeding (13-44% incidence) and stent thrombosis associated or not symptomatic ischemic cerebrovascular accidents. 3,5,7,8,10,[13][14][15][16] Nevertheless, the literature on cutaneous exposure of CAS and its management are scarce. 4,17 In this retrospective series, we describe our experience with recurrent unresectable HNC that underwent CAS placement for CBS treatment and complicated with cutaneous exposure of the stent.…”