Target-specific multimodality endovascular management of carotid artery blow-out syndrome. (Original Article).

Abstract

We describe a novel multimodality endovascular approach to safely control hemorrhage from a carotid artery pseudoaneurysm and tumor vasculature associated with a squamous cell carcinoma. This approach was used in the case of a 68-year-old man who had previously undergone a laryngectomy, chemotherapy, and brachy-therapy and who subsequently experienced acute oropharyngeal bleeding. Angiography detected a carotid artery pseudoaneurysm and significant tumor vascularity. A target-specific multimodality approach was taken to embolize the potential etiologies for both the current and any future hemorrhages. Stent-assisted coiling of the pseudoaneurysm was successful. The tumor blush was treated with polyvinyl alcohol particles and both retrievable and nonretrievable coils. Endovascular surgeons have become increasingly involved in the management of patients with carotid injuries and with neoplasms in and around the skull base. Current endovascular technology provides a rapid target-specific approach to the treatmen t of carotid artery blow-out syndrome and has a greater potential to lower morbidity than does carotid sacrifice.

Introduction

Carotid artery blow-out syndrome (CBS) is an increasingly recognized complication following the treatment of head and neck malignancies. Etiologies such as postoperative irradiation, surgical disruption of the carotid artery, and tumor involvement of the vessel wall have all been implicated. Mortality rates following CBS have been reported to be as high as 100% (mean: 40%). (1) The rate of major neurologic morbidity is also high (60%). (2,3) Survival is typically less than 2 years.

Prior to the development of endovascular therapies such as stents, coils, and particle embolization, open surgical ligation was the mainstay of therapy, even though it often resulted in significant neurologic morbidity. Several cases of emergent treatment of CBS with balloons or covered stents have been reported. (4-7) In this article, we report a case of emergent CBS that was successfully treated with multiple endovascular therapies.

Case report

We evaluated a white, 68-year-old man who had a 1-night history of self-limiting hemoptysis. He had earlier undergone a laryngectomy, chemotherapy, and brachytherapy for laryngeal carcinoma, and he had also experienced a recurrence of squamous cell carcinoma of the tongue. Until his episode of hemoptysis, the man had been doing well, although he was quite cachectic and frail. On examination, he did not demonstrate any evidence of acute oropharyngeal bleeding. The patient was scheduled for angiography.

Using the Seldinger technique, we advanced a 6 French sheath into the right common femoral artery. Systemic anticoagulation was achieved with 5,000 units of heparin. Through the sheath, a 5 French Headhunter catheter (AngioDynamics; Glen Falls, N.Y.) was advanced over a hydrophilic guidewire through the aortic arch, with selective catheterization of the right common carotid artery. Superselective catheterization of the right lingual artery and the right internal maxillary artery was then carried out with a Rapid Transit microcatheter (Cordis; Miami Lakes, Fla.) over a Glidewire Gold Tip (Boston Scientific; Natick, Mass.). Branches to the blushing tumor from both of these vessels were embolized first with 500- to 700-micron polyvinyl alcohol particles and then with platinum coils. Testing was performed in the lingual and internal maxillary branches with 3 ml of lidocaine because some of the blood supply from both vessels appeared to extend into the orbit. No neurologic changes were seen.

Following embolization of numerous branches of the right lingual artery and the right internal maxillary artery, a left common carotid arteriogram was obtained. This study detected a pseudoaneurysm just below the common carotid bifurcation, which might well have been the true source of the bleeding (figure 1). In light of the fact that the patient was not actively bleeding and given that he had not been placed on any preprocedural antiplatelet medicadon, we felt it prudent to bring the patient back in the near future for definitive treatment of the pseudoaneurysm.

The patient returned to the angiography suite 2 days later. Through the sheath, a 6 French Envoy catheter (Cordis) was advanced over a hydrophilic guidewire into the aortic arch, and selective catheterization of the left common carotid artery was carried out. A 10 x 20-mm Wallstent (Boston Scientific) was then advanced across the aneurysm and deployed. The Wallstent delivery device was then removed over the wire. A 0.014-inch Prowler catheter (Cordis) was then advanced over an Endeavor (Target Therapeutics; Fremont, Calif.) 0.014-inch wire. The aneurysm was catheterized through the stent. The aneurysm was then embolized with Guglielmi electrolytically detachable coils (GDCs) (figure 2). Once this portion of the procedure was completed, the catheter and wire were advanced into the left external carotid artery. The left lingual artery was selectively catheterized. Supply to the tumor from this vessel was then embolized with 300-micron polyvinyl alcohol particles and a T1O GDC.

Following this procedure, the patient was prescribed 325 mg/day of aspirin and 75 mg/day of clopidogrel. The heparin was allowed to wear off. The patient was discharged 2 days later in stable condition with no new neurologic deficits. At the 2-month follow-up, no recurrent bleeding had occurred and the clopidogrel was discontinued.

Discussion

First recognized in 1962, CBS remains a complication of surgery for malignancies of the neck and skull base. Reported mortality and morbidity rates following CBS are unacceptably high, (8,9) and survival rates typically average less than 2 years following emergent carotid artery ligation. (10)

CBS has been defined as an "acute hemorrhage (usually transoral or transcervical) with exposure of part of the carotid artery" following surgery for cervical malignancy (usually squamous cell carcinoma). (2,3) The incidence of carotid rupture following radical neck dissection for malignancy is 4%, but the risks for CBS are higher following flap necrosis, wound infection, radiation to the operative bed, and recurrent carcinoma (with involvement of the carotid artery). (1) CBS hemorrhage is typically a result of a pseudoaneurysm or bleeding in neovascular tissue. (2)

Chaloupka et al subdivided CBS into three groups based primarily on its clinical manifestation: Patients with exposed carotid arteries have threatened CBS, those with leakage from a pseudoaneurysm have impending CBS, and those with a ruptured vessel have acute CBS. (2,3) Of these three groups, only those with threatened CBS should be considered for surgical reconstruction of the vessel and surrounding tissue; in the other two groups, hemodynamic instability, a limited time frame, and poor tissue quality can limit surgical intervention to vessel ligation. (7)

Osguthorpe and Hungerford described endovascular management of CBS with balloon occlusion in 1984, (1) Treating a wide-necked aneurysm with only a balloon can result in only a partial patency and can thus place the patient at risk for recurrence. (2,4,11) Preoperative permanent balloon occlusion of an internal carotid artery in patients with advanced head and neck cancer has been described for those with impending CBS. (4) Similarly, other authors have described balloon test occlusion followed by detachable balloon embolization or vessel ligation for these patients. (12) With the advancement of stent-assisted coiling, carotid sacrifice might be avoidable in many cases.

Coiling of wide-necked pseudoaneurysms places the patient at risk for coil herniation into the parent vessel. (1,5,13-16) The use of stents alone has been described for the treatment of pseudoaneurysms. (5) Additionally, stent-assisted coiling has been recommended for the management of wide-necked aneurysms, complex aneurysms, and pseudoaneurysms because the stent serves as a buttress to prevent coil herniation into the parent vessel lumen, (13-16)

Macdonald et al recently described the use of a covered stent--a 5.8-cm Jostent (Joined International; Helsingborg, Sweden)--for the emergent treatment of acute CBS. (7) This balloon-expandable stent is made up of polytetra-fluoroethylene material encompassed by two stainless-steel stents. They reported that the stent was successfully placed and resulted in the cessation of the hemorrhage and preservation of the parent vessel.

Multimodality management might be necessary for patients who require ultraemergent vessel occlusion. Temporary occlusion with an inflatable balloon can be hazardous because of the exquisite friability of the carotid artery in this setting. Additionally, a balloon can inadvertently migrate and result in continued hemorrhage in an already-unstable patient. (2) Chaloupka et al described their routine use of detachable balloons in larger segments of the carotid artery that harbored pseudoaneurysms. (2) For patients who had multiple lesions or lesions near the terminal of the internal carotid artery, they used composite occlusive management with detachable balloons and irretrievable coils. (2,3) For smaller-caliber vessel occlusions and for external carotid artery occlusion, Chaloupka et al used combinations of retrievable and nonretrievable coils. For tumor embolizations, they used polyvinyl alcohol particles and cyanoacrylate embolic mixtures. (2)

As is demonstrated by these examples of multimodality treatment and by the case we describe here, successful endovascular occlusion and hemostasis can be achieved in multiple vessels of various calibers and in cases where there are multiple sites of vessel disruption. Even though carotid artery occlusion can stop hemorrhage from CBS, hemorrhage from the related tumor vasculature would still persist. With an endovascular approach, hemorrhage from CBS, tumor vasculature, or both can be addressed while preserving the parent vessel lumen.

As endovascular surgeons continue to play an ever-increasing role in the management of both cerebrovascular disorders and malignancies in and around the skull base, we are beginning to see disorders such as CBS with increasing frequency. Although ligation of the common carotid artery was once the primary modality of treatment, its unacceptable rates of neurologic morbidity provided the impetus for investigators to search for alternate therapeutic strategies. Recent advances in endovascular techniques have provided us with one such alternative that carries a lower rate of morbidity. (2,3,17) Although these techniques are not free of complications (e.g., thromboembolic stroke, hypotension and reflex bradycardia, iatrogenic rupture of the carotid artery, and iatrogenic pseudoaneurysm formation), endovascular therapies do provide several novel options for focused treatment that is targeted directly to the vascular defects that can cause a potentially fatal hemorrhage.

From the Department of Neurological Surgery (Dr. Levy, Dr. Horowitz, Dr. Koebbe, and Dr. Jungreis) and the Department of Radiology (Dr. Horowitz and Dr. Jungreis), University of Pittsburgh Medical Center.

Reprint requests: Michael Horowitz, MD, Department of Neurological Surgery, University of Pittsburgh Medical Center, Suite B400, 200 Lothrop St., Pittsburgh, PA 15213-2582. Phone: [phone]; fax: [phone]; e-mail: [e-mail]

References

(1.) Citardi MJ, Chaloupka JC, Son YH, et al. Management of carotid artery rupture by monitored endovascular therapeutic occlusion (1988-1994). Laryngoscope 1995;105:1086-92.

(2.) Chaloupka JC, Putman CM, Citardi MJ, et al. Endovascular therapy for the carotid blowout syndrome in head and neck surgical patients: Diagnostic and managerial considerations. AJNR Am J Neuroradiol 1996;17:843-52.

(3.) Chaloupka JC, Roth TC, Putman CM, et al. Recurrent carotid blowout syndrome: Diagnostic and therapeutic challenges in a newly recognized subgroup of patients. AJNR Am J Neuroradiol 1999;20:1069-77.

(4.) Adams GL, Madison M, Remley K, Gapany M. Preoperative permanent balloon occlusion of internal carotid artery in patients with advanced head and neck squamous cell carcinoma. Laryngoscope 1999;109:460-6.

(5.) Higashida RT, Smith W, Gress D, et al. Intravascular stent and endovascular coil placement for a ruptured fusiform aneurysm of the basilar artery. Case report and review of the literature. J Neurosurg 1997;87:944-9.

(6.) Horowitz MB, Miller G III, Meyer Y, et al. Use of intravascular stents in the treatment of internal carotid and extracranial vertebral artery pseudoaneurysms. AJNR Am J Neuroradiol 1996;17:693-6.

(7.) Macdonald S, Gan J, McKay AJ, Edwards RD. Endovascular treatment of acute carotid blow-out syndrome. J Vasc Interv Radiol 2000;l1:1184-8.

(8.) Borsany SJ. Rupture of the carotids following radical neck surgery in irradiated patients. Ear, Nose, and Throat Monthly 1962;41:531-3.

(9.) Ketcham AS, Hoye RC. Spontaneous carotid artery hemorrhage after head and neck surgery. Am J Surg 1965;110:649-55.

(10.) Baxter WF. Survival after unplanned carotid rupture. Laryngoscope 1979;89:385-92.

(11.) Osguthorpe JD, Hungerford GD. Transarterial carotid occlusion. Case report and review of the literature. Arch Otolaryngol 1984;110:694-6.

(12.) Zimmerman MC, Mickel RA, Kessler DJ, et al. Treatment of impending carotid rupture with detachable balloon embolization. Arch Otolaryngol Head Neck Surg 1987;113:1169-75.

(13.) Lanzino G, Guterman LR, Hopkins LN. The case for stenting. Clin Neurosurg 1999;45:249-55.

(14.) Lanzino G, Wakhloo AK, Fessler RD, et al. Efficacy and current limitations of intravascular stents for intracranial internal carotid, vertebral, and basilar artery aneurysms. J Neurosurg 1999;91:538-46.

(15.) Mericle RA, Lanzino G, Wakhloo AK, et al. Stenting and secondary coiling of intracranial internal carotid artery aneurysm: Technical case report. Neurosurgery 1998;43:1229-34.

(16.) Sekhon LH, Morgan MK, Sorby W, Grinnell V Combined endovascular stent implantation and endosaccular coil placement for the treatment of a wide-necked vertebral artery aneurysm: Technical case report. Neurosurgery 1998;43:380-3.

(17.) Morrissey DD, Andersen PE, Nesbit GM, et al. Endovascular management of hemorrhage in patients with head and neck cancer. Arch Otolaryngol Head Neck Surg 1997;123:15-9.