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Zhou J, Yang K, Zhang X, Liu Z, Dmytriw AA, Xie W, Yang K, Wang X, Xu W, Wang T, Jiao L. A systematic review and meta-analysis of endovascular treatment of carotid blowout syndrome. J Clin Neurosci 2025; 133:111024. [PMID: 39755031 DOI: 10.1016/j.jocn.2024.111024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2024] [Revised: 12/28/2024] [Accepted: 12/29/2024] [Indexed: 01/06/2025]
Abstract
Carotid Blowout Syndrome (CBS) is a rare and life-threatening condition that necessitates prompt intervention to prevent fatal hemorrhage. This study compares the outcomes of two primary endovascular approaches: reconstructive interventions, which aim to preserve carotid artery function using stents or balloon angioplasty, and deconstructive interventions, which involve vessel occlusion to halt bleeding. A systematic review and meta-analysis were performed by searching multiple databases for relevant studies published from January 2000 to August 2023. A total of 28 studies involving 554 patients were included, with 214 undergoing reconstructive interventions and 340 receiving deconstructive procedures. Results indicated an overall 30-day mortality rate of 10%, with no significant difference between intervention types. However, the reconstructive group exhibited higher rates of rebleeding beyond 24 h and severe technical complications. While complication rates decreased over time, an increase in long-term mortality was noted for both approaches. These findings highlight the need for enhanced strategies in CBS management, particularly in reducing long-term mortality and addressing complications associated with reconstructive interventions. OBJECTIVES Carotid blowout syndrome (CBS) is a rare and life-threatening condition that requires prompt intervention to prevent fatal hemorrhage. Two primary endovascular approaches are used: reconstructive interventions, which aim to preserve the carotid artery's function through stenting or balloon angioplasty, and deconstructive interventions, which focus on vessel occlusion to stop bleeding. This study aimed to compare these methods regarding prognosis, complication rates, and outcome trends over time. METHODS A systematic review and meta-analysis were conducted, searching multiple databases for studies published from January 2000 to August 2023. Eligible studies included randomized controlled trials and observational studies reporting outcomes and complications of endovascular interventions for CBS. RESULTS The analysis included 28 studies with a total of 554 patients, of whom 214 received reconstructive interventions and 340 underwent deconstructive procedures. The overall 30-day mortality rate was 10%, with no significant difference between the two intervention types. However, the reconstructive group showed a higher incidence of rebleeding beyond 24 h and severe technical complications. While complication rates decreased over time, long-term mortality increased. CONCLUSIONS This study found no significant differences between reconstructive and deconstructive endovascular interventions in most aspects of CBS prognosis. However, reconstructive approaches, particularly those involving stents, were associated with a higher risk of rebleeding beyond 24 h and severe technical complications. Additionally, the data suggest an increase in long-term mortality rates for both methods, highlighting areas for potential improvement in CBS management and intervention strategies. Compared to previous meta-analyses, this study includes more recent and comprehensive literature, evaluating a wider range of prognostic indicators, such as transient ischemic attacks, infection rates, late-stage rebleeding, and severe procedural complications. These findings provide an updated and nuanced understanding of the risks and outcomes associated with CBS interventions, offering valuable insights that could guide clinical decision-making and future research on optimal intervention strategies.
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Affiliation(s)
- Jia Zhou
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China; Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Kun Yang
- Neurological Intensive Care Unit, Tai'an Central Hospital Affiliated to Qingdao University, Tai'an, Shandong, 271000, China
| | - Xiao Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China; Sir William Dunn School of Pathology, University of Oxford, Oxford OX1 3RE, United Kingdom; China International Neuroscience Institute (China-INI), Beijing 100053, China
| | - Zhichao Liu
- Sir William Dunn School of Pathology, University of Oxford, Oxford OX1 3RE, United Kingdom
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Weidun Xie
- Department of Computer Science, City University of Hong Kong, Kowloon 999077, Hong Kong Special Administrative Region
| | - Kun Yang
- Department of Evidence-Based Medicine, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Xue Wang
- Medical Library, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Wenlong Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China; China International Neuroscience Institute (China-INI), Beijing 100053, China
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China; China International Neuroscience Institute (China-INI), Beijing 100053, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China; China International Neuroscience Institute (China-INI), Beijing 100053, China; Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China.
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Zhu WY, Huang J, Lu ZQ, Yang S, Huang G, Zhou LW, Shun Pan Cheung G, Yu-Wai Chan J, Wu PA. Management of post-radiation carotid blowout syndrome in patients with head and neck cancer: A systematic review. Radiother Oncol 2024; 200:110502. [PMID: 39197500 DOI: 10.1016/j.radonc.2024.110502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 07/07/2024] [Accepted: 08/18/2024] [Indexed: 09/01/2024]
Abstract
BACKGROUND AND PURPOSE Carotid blowout syndrome (CBS) is a rare but potentially life-threatening complication that can occur in patients with head and neck cancer (HNC), especially with a history of radiotherapy. This study aimed to review and initially compare managements for post-radiation CBS in patients with HNC. MATERIALS AND METHODS A systematic review of published studies was performed. Information including management, survival, and complication were collected. RESULTS A total of 39 articles and 917 cases were included in the systematic review. The interval between radiation therapy and CBS ranged from 1.2 years to 17.8 years. The managements of CBS included embolization, stent, bypass surgery, surgical ligation, electrocoagulation, flap coverage, arterial repair, and nasopharyngeal packing. The cumulative 30-day, 1-year, and 2-year overall survival rates were 85.2 %, 48.9 %, and 37.0 %, respectively, with a median survival time of 11.3 months. Disease progression and rebleeding were the most common death causes. The lowest rebleeding rate and neurologic complications rate were presented in cases receiving bypass surgery at 1.4 % and 10.8 %, respectively. The highest rebleeding rate of 35.6 % was showed in cases underwent stent, and the highest neurologic complications rate of 32.0 % was showed in cases underwent ligation. CONCLUSION Post-radiation CBS in patients with HNC had a low survival rate and high complication rate. Rebleeding and neurologic complication were common complications. Endovascular embolization and stent were the mainstream management, and bypass surgery presented a promising outcome in survival and complication for selected patients.
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Affiliation(s)
- Wang-Yong Zhu
- Department of Dental Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China; Department of Clinical Oncology, Shenzhen Key Laboratory for Cancer Metastasis and Personalized Therapy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Jiang Huang
- Department of Dental Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China; Department of Clinical Oncology, Shenzhen Key Laboratory for Cancer Metastasis and Personalized Therapy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Zhao-Qun Lu
- Department of Surgery, Division of Otolaryngology, Head and Neck Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China; Department of Clinical Oncology, Shenzhen Key Laboratory for Cancer Metastasis and Personalized Therapy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Siyi Yang
- Department of Surgery, Division of Otolaryngology, Head and Neck Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China; Department of Clinical Oncology, Shenzhen Key Laboratory for Cancer Metastasis and Personalized Therapy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Guan Huang
- Department of Surgery, Division of Otolaryngology, Head and Neck Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China; Department of Clinical Oncology, Shenzhen Key Laboratory for Cancer Metastasis and Personalized Therapy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Li-Wei Zhou
- Department of Dental Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China; Department of Clinical Oncology, Shenzhen Key Laboratory for Cancer Metastasis and Personalized Therapy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Gary Shun Pan Cheung
- Department of Dental Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China; Department of Clinical Oncology, Shenzhen Key Laboratory for Cancer Metastasis and Personalized Therapy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Jimmy Yu-Wai Chan
- Department of Surgery, Division of Otolaryngology, Head and Neck Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Ping-An Wu
- Department of Surgery, Division of Otolaryngology, Head and Neck Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China; Department of Clinical Oncology, Shenzhen Key Laboratory for Cancer Metastasis and Personalized Therapy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.
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Slijepcevic AA, Roh J, Pipkorn P, Lipsey K, Bradley JP. Carotid Blowout Syndrome in Head and Neck Cancer Patients: Management of Patients At Risk for CBS. Laryngoscope 2023; 133:576-587. [PMID: 35575599 DOI: 10.1002/lary.30157] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/16/2022] [Accepted: 04/09/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Carotid blowout syndrome (CBS) is an acute, rare life-threatening hemorrhage that occurs in patients with a history of head and neck cancer and radiation therapy. The primary objective of this review was to identify risk factors and assess treatment and survival outcomes following CBS. METHODS A systematic review of published literature was performed. Information including risk factors, treatment, and outcomes of CBS were collected. RESULTS A total of 49 articles and 2220 patients were included in the systematic review. Risk factors for developing CBS included a history of radiation therapy, wound complications, and advanced tumor stage. The initial management of CBS included establishing a stable airway, gaining hemostasis, and repletion of blood loss. Endovascular and surgical procedures treat CBS with infrequent rates of rebleeding and periprocedural complications. Short-term survival following treatment of CBS shows high survival rates when considering CBS-related complications and underlying disease, however, long-term survival related to the underlying disease demonstrated high mortality. CONCLUSIONS Identifying patients at risk for CBS enables practitioners to counsel patients on life-saving interventions and expected outcomes following treatment of CBS. Treatment of CBS is associated with high short-term survival, although long-term survival related to underlying disease is low. LEVEL OF EVIDENCE N/A Laryngoscope, 133:576-587, 2023.
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Affiliation(s)
- Allison A Slijepcevic
- Department of Otolaryngology-Head & Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Joseph Roh
- Department of Otolaryngology-Head & Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Patrik Pipkorn
- Department of Otolaryngology-Head & Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Kim Lipsey
- Bernard Becker Medical Library, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Joseph P Bradley
- Department of Otolaryngology-Head & Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
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Xie TH, Zhao WJ, Li XL, Hou Y, Wang X, Zhang J, An XH, Liu LT. Carotid blowout syndrome caused by chronic infection: A case report. World J Clin Cases 2022; 10:5051-5056. [PMID: 35801053 PMCID: PMC9198892 DOI: 10.12998/wjcc.v10.i15.5051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/10/2022] [Accepted: 03/26/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Carotid blowout syndrome (CBS) refers to rupture of the extracranial carotid artery and its branches; as a severe complication, it usually occurs after surgery or radiotherapy for malignant tumours of the head and neck. We present a case of CBS caused by chronic infection of the external carotid artery (ECA). In this case, we did not find any evidence of head and neck tumours.
CASE SUMMARY A 42-year-old man was referred to the Emergency Department with a complaint of a lump found on the left side of his neck with pain and fever for 4 d. We diagnosed the condition as neck infection with abscess formation based on physical examination, routine blood examination, ultrasound examination and plain computed tomography (CT) and decided to perform emergency surgery. During the operation, 30 mL of grey and smelly pus was drained from the deep surface of the sternocleidomastoid muscle. The second day after the operation, the patient suddenly exhibited a large amount of haemoptysis and incision bleeding. The enhanced CT showed distal occlusion of the left ECA and irregular thickening of the broken ends of the artery encased in an uneven enhancement of soft tissue density. Infected ECA occlusion and rupture were considered. The patient was transferred to a vascular unit for transcatheter ECA embolization and recovered well.
CONCLUSION Surgeons need to pay attention to vascular lesions caused by chronic infection that may develop into acute CBS.
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Affiliation(s)
- Tian-Hao Xie
- Department of General Surgery, Affiliated Hospital of Hebei University, Baoding 071000, Hebei Province, China
| | - Wen-Jun Zhao
- Department of Ophthalmology, MEM Yinghua Hospital, Baoding 071000, Hebei Province, China
| | - Xiao-Long Li
- Department of Traumatology, The First Hospital of Hebei Medical University, Shijiazhuang 050000, Hebei Province, China
| | - Yan Hou
- Department of Imaging, Affiliated Hospital of Hebei University, Baoding 071000, Hebei Province, China
| | - Xiong Wang
- Department of General Surgery, Li County Hospital, Baoding 071400, Hebei Province, China
| | - Jing Zhang
- Department of General Surgery, Affiliated Hospital of Hebei University, Baoding 071000, Hebei Province, China
| | - Xiu-Hua An
- Department of Internal Medicine, Wangdu County Chinese Medicine Hospital, Baoding 072450, Hebei Province, China
| | - Li-Tao Liu
- Department of General Surgery, Affiliated Hospital of Hebei University, Baoding 071000, Hebei Province, China
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Predictors of survival following carotid blowout syndrome. Oral Oncol 2022; 125:105723. [DOI: 10.1016/j.oraloncology.2022.105723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/26/2021] [Accepted: 01/09/2022] [Indexed: 11/19/2022]
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Eguchi K, Kobayashi K, Takano T, Ito A, Sakai A, Ikeda A, Matsumoto Y, Omura G, Matsumoto F, Yoshimoto S. Carotid artery ligation via sternotomy as a palliative surgery: Case report of advanced intramediastinal malignant soft tissue tumor. Clin Case Rep 2021; 9:CCR33979. [PMID: 34466234 PMCID: PMC8385775 DOI: 10.1002/ccr3.3979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 02/08/2021] [Indexed: 11/22/2022] Open
Abstract
Under extreme conditions and in palliative settings, shared decision making with the patient is vital; narrative decisions beyond evidence could be considered. If there is a chance of symptom palliation, extended surgery should not be avoided merely because of the limited life expectancy.
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Affiliation(s)
- Kohtaro Eguchi
- Department of Head and Neck SurgeryNational Cancer Center HospitalTokyoJapan
| | - Kenya Kobayashi
- Department of Head and Neck SurgeryNational Cancer Center HospitalTokyoJapan
| | - Tomonari Takano
- Department of Head and Neck SurgeryNational Cancer Center HospitalTokyoJapan
| | - Akiko Ito
- Department of Head and Neck SurgeryNational Cancer Center HospitalTokyoJapan
| | - Azusa Sakai
- Department of Head and Neck SurgeryNational Cancer Center HospitalTokyoJapan
| | - Atsuo Ikeda
- Department of Head and Neck SurgeryNational Cancer Center HospitalTokyoJapan
| | - Yoshifumi Matsumoto
- Department of Head and Neck SurgeryNational Cancer Center HospitalTokyoJapan
| | - Go Omura
- Department of Head and Neck SurgeryNational Cancer Center HospitalTokyoJapan
| | - Fumihiko Matsumoto
- Department of Head and Neck SurgeryNational Cancer Center HospitalTokyoJapan
| | - Seiichi Yoshimoto
- Department of Head and Neck SurgeryNational Cancer Center HospitalTokyoJapan
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7
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Sánchez-Canteli M, Rodrigo JP, Quintana EM, Vega P, Llorente JL, López F. Embolization for Carotid Blowout in Head and Neck Cancer: Case Report of Five Patients. Vasc Endovascular Surg 2021; 56:53-57. [PMID: 34155944 DOI: 10.1177/15385744211027030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Carotid blowout syndrome (CBS) is defined as a rupture of common carotid artery or its branches. Endovascular intervention has been advocated as first line of treatment for CBS. This Case Report describes 5 patients with prior history of head and neck cancer who presented with CBS. Two patients presented as acute, 2 as impending, and one as threatened CBS. The lesions found were pseudoaneurysm and focal vascular irregularities involving the common carotid artery, cervical internal carotid artery and lingual artery. Embolization and occlusion with detachable coils of the artery was used in all patients. Technical success and immediate hemostasis were achieved in all patients. One patient presented transient cranial nerve palsy. No recurrent CBS was reported during the follow-up. In our experience, coil embolization, if possible, is a safe and efficient technique in treatment of CBS secondary to head and neck cancers.
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Affiliation(s)
- Mario Sánchez-Canteli
- Department of Otolaryngology, 16474Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Juan P Rodrigo
- Department of Otolaryngology, 16474Hospital Universitario Central de Asturias, Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias, Universidad de Oviedo, Spain
| | - Eduardo Murias Quintana
- Department of Radiology-Interventional Neuroradiology, 16474Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Pedro Vega
- Department of Radiology-Interventional Neuroradiology, 16474Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - José Luis Llorente
- Department of Otolaryngology, 16474Hospital Universitario Central de Asturias, Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias, Universidad de Oviedo, Spain
| | - Fernando López
- Department of Otolaryngology, 16474Hospital Universitario Central de Asturias, Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias, Universidad de Oviedo, Spain
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Ota N, Valenzuela JC, Chida D, Tanikawa R. Extracranial vertebral artery to middle cerebral artery bypass in therapeutic internal carotid artery occlusion for epipharyngeal carcinoma: A technical case report. Surg Neurol Int 2021; 12:149. [PMID: 33948319 PMCID: PMC8088539 DOI: 10.25259/sni_99_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/06/2021] [Indexed: 11/09/2022] Open
Abstract
Background: Vertebral artery (VA) to middle cerebral artery (MCA) bypass is a rarely selected technique because a complex expanded dissection is required, and often, a better donor artery than VA exists. A good indication for VA-MCA bypass is the treatment of head-and-neck malignancies with the sacrifice of the internal carotid artery (ICA) or for carotid artery rupture. Methods: A 23-year-old man with epipharyngeal carcinoma, treated by ligating the carotid artery with a VAMCA bypass before chemoradiotherapy, was reported. Radiographic findings showed that the bone of the carotid canal was dissolved, and the right ICA was engulfed by the tumor. As epipharyngeal carcinoma is hypersensitive to radiation, in cases where the tumor rapidly disappears, ICA may dangle in the pharynx and rupture may occur. In addition, to irradiate sufficiently, the ICA may become an obstacle. Hence, we decided to perform carotid ligation with a VA-MCA bypass before radiation and chemotherapy for the primary lesion. We selected the V3 portion of the VA as the donor on the ipsilateral side, as it can supply high-flow cerebral blood flow, which is not influenced by carcinoma and less influenced by irradiation for the epipharynx. Results: The VA-MCA bypass was completed without complications followed by endovascular occlusion of the ICA. Induction chemotherapy was initiated for the patient 2 weeks after surgery. The patient achieved a complete response following chemoradiotherapy. Conclusion: ICA ligation with VA-MCA high-flow bypass earlier than chemoradiotherapy is useful for epipharyngeal carcinoma as it prevents carotid artery rupture and allows radical intervention.
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Affiliation(s)
- Nakao Ota
- Department of Neurosurgery, Sapporo Teishinkai Hospital, Higashi-ku, Sapporo, Japan
| | | | - Daiki Chida
- Department of Neurosurgery, Sapporo Teishinkai Hospital, Higashi-ku, Sapporo, Japan
| | - Rokuya Tanikawa
- Department of Neurosurgery, Sapporo Teishinkai Hospital, Higashi-ku, Sapporo, Japan
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Feng K, Hu J, Huang Q, Cai W, Zhuang Z, Liu H, Hou J, Liu X, Wang C. Risk factors and nomogram for predicting carotid blowout syndrome based on computed tomography angiography. Oral Dis 2021; 28:2131-2138. [PMID: 33772979 DOI: 10.1111/odi.13859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/03/2021] [Accepted: 03/19/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To identify independent factors for head and neck cancer (HNC) patients with carotid blowout syndrome (CBS) and construct a nomogram to predict risk of CBS preoperatively based on computed tomography angiography (CTA) imaging. SUBJECT AND METHODS From January 2010 to July 2020, 73 HNC patients who had surgery in hospitalization and underwent CTA examination for head and neck region were included in this study. Vascular alterations and the relationship between carotid artery (CA) and tumor were evaluated in CTA. Clinical and CTA imaging features were distinguished by logistic regression analysis and used to perform receiver operating curve analysis. Nomogram was created to predict risk of CBS and assessed by concordance index (C-index) and calibration curve. RESULTS Three independent risk factors were identified, including radical neck dissection, CA surrounded by tumor, and CA invaded by tumor without clear boundary. Area under curve of the combination of 3 variables was 0.836 (95% CI, 0.72-0.952, p < 0.001). The C-index of nomogram was 0.84 (95% CI, 0.73-0.94), and the calibration plot showed a good fitting between prediction and observation. CONCLUSIONS We established a useful nomogram based on CTA imaging, which showed a satisfied efficacy for evaluating risk of CBS in HNC patients preoperatively.
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Affiliation(s)
- Kun Feng
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Jing Hu
- Department of Oral and Maxillofacial Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qiuyu Huang
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Weixin Cai
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Zehang Zhuang
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Haichao Liu
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Jinsong Hou
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Xiqiang Liu
- Department of Oral and Maxillofacial Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Cheng Wang
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
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10
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Lan TL, Chang FC, Wang CW, Igawa K, Wu SH, Lo WL, Chen YW. Prevention and early management of carotid blowout syndrome for patients receiving head and neck salvage boron neutron capture therapy (BNCT). J Dent Sci 2021; 16:854-860. [PMID: 34141099 PMCID: PMC8189897 DOI: 10.1016/j.jds.2020.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 12/28/2020] [Indexed: 11/30/2022] Open
Abstract
Background/purpose The incidence rate of oral and pharyngeal cancers in Taiwan has increased gradually over the past few decades. The standard treatment strategy for oral and pharyngeal cancers includes surgery or radiotherapy, with concurrent chemotherapy in certain types of tumors. Unfortunately, in-field recurrence is sometimes inexorable. Furthermore, re-irradiation of the recurrence site may cause severe complications due to the tolerance of normal tissue to radiation therapy. One fatal complication is carotid blowout syndrome (CBS). Boron neutron capture therapy (BNCT) is a new modality of radiation therapy, which is also mentioned as targeted radiotherapy. It is a feasible treatment that has the potential to spare normal tissue from being damaged by irradiation while simultaneously treating the primary tumor. In this presentation, we will share our experience with BNCT in treating recurrent head and neck cancers, as well as the prevention and management of CBS. Materials and methods We evaluated 4 patients with head and neck cancers treated by BNCT in Taiwan. All patients had undergone surgery previously and had received postoperative concurrent chemoradiotherapy. Results The 4 patients in this study were diagnosed with head and neck malignancies. The median follow-up period after the first course of BNCT was 15.1 months. After BNCT, 2 patients developed impending CBS, and 1 of them died. The remaining 3 patients survived until the last date of follow-up. Conclusion Pre-BNCT carotid artery evaluation through computed tomography angiography and early intervention if necessary is crucial when treating patients with recurrent head and neck cancers by BNCT.
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Affiliation(s)
- Tien-Li Lan
- Division of Radiotherapy, Department of Oncology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Feng-Chi Chang
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chun-Wei Wang
- Division of Radiotherapy, Department of Oncology, Taiwan University Hospital, Taipei, Taiwan
| | - Kazuyo Igawa
- Neutron Therapy Research Center, Okayama University, Okayama, Japan
| | - Szu-Hsien Wu
- Division of Plastic and Reconstructive Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Liang Lo
- Division of Oral and Maxillofacial Surgery, Department of Stomatology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Wei Chen
- Division of Radiotherapy, Department of Oncology, Taipei Veterans General Hospital, Taipei, Taiwan
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11
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Sooby P, Tarmal A, Townsley R. Management of catastrophic haemorrhage in palliative head and neck cancer: creation of a new protocol using simulation. BMJ Open Qual 2020; 9:bmjoq-2020-001003. [PMID: 33139295 PMCID: PMC7607599 DOI: 10.1136/bmjoq-2020-001003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/15/2020] [Accepted: 10/14/2020] [Indexed: 11/23/2022] Open
Abstract
Catastrophic haemorrhage or carotid blowout a rare but devastating consequence of head and neck cancer. In most cases, this represents a terminal event, and the patient is prescribed pre-emptive analgesia and anxiolytics. There is anecdotal evidence that due to the time taken to prepare the medications that patients do not receive these drugs prior to death. We aimed to identify the drug to patient time using simulated catastrophic haemorrhage simulations. We used the current protocol for this and also proposed a new grab-bag with preprepared anxiolytic and anagelsic medications. Each scenario was repeated 16 times. The mean time for drug administration using the current policy was 124 s compared with 48 s when the grab-bag was used (p<0.01). The new protocol also reduced the variability in the drug to patient time. We aim to implement this new protocol on the head and neck ward.
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Affiliation(s)
- Paul Sooby
- ENT, NHS Ayrshire and Arran, Ayr, UK .,ENT, Queen Elizabeth University Hospital, Glasgow, UK
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12
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Kim M, Hong JH, Park SK, Kim SJ, Lee JH, Byun JH, Ko YH. Rupture of carotid artery pseudoaneurysm in the modern era of definitive chemoradiation for head and neck cancer: Two case reports. World J Clin Cases 2020; 8:4858-4865. [PMID: 33195654 PMCID: PMC7642552 DOI: 10.12998/wjcc.v8.i20.4858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/18/2020] [Accepted: 09/28/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Carotid blowout syndrome (CBS) is a rupture of the carotid artery and is mainly caused by radiation and resection of head and neck cancers or direct tumor invasion of the carotid artery wall. It is a life-threatening clinical situation. There is no established and effective mode of management of CBS. Furthermore, there is no established preceding sign or symptom; therefore, preventive efforts are not clinically meaningful.
CASE SUMMARY We described two cases of CBS that occurred in patients with head and neck cancer after definitive chemoradiotherapy (CRT) using three-dimensional conformal intensity-modulated radiation therapy. Two men aged 61 and 56 years with locally advanced head and neck cancer were treated with definitive CRT. After completing CRT, both of them achieved complete remission. Subsequently, they had persistent severe pain in the oropharyngeal mucosal region and the irradiated neck despite the use of opioid analgesics and rehabilitation for relief of contracted skin. However, continuous follow-up imaging studies showed no evidence of cancer recurrence. Eleven to twelve months after completing CRT, the patients visited the emergency room complaining about massive oronasal bleeding. Angiograms showed rupture of carotid artery pseudoaneurysms on the irradiated side. Despite attempting to secure hemostasis with carotid arterial stent insertion and coil embolization, both patients died because of repeated bleeding from the pseudoaneurysms.
CONCLUSION In patients with persistent pain in irradiated sites, clinicians should be suspicious of progressing or impending CBS, even in the three-dimensional conformal intensity-modulated radiation therapy era.
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Affiliation(s)
- Myungsoo Kim
- Department of Radiation Oncology, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon 403720, South Korea
| | - Ji Hyung Hong
- Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon 21431, South Korea
| | - Sang Kyu Park
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, South Korea
| | - Sook Jung Kim
- Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 03312, South Korea
| | - Jung Hwi Lee
- Department of Radiology, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 03312, South Korea
| | - JH Byun
- Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 03312, South Korea
| | - Yoon Ho Ko
- Department of Internal Medicine, Eun-pyeoung St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 03312, South Korea
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13
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Beer-Furlan A, Heilingoetter A, Rayle C, O'Toole T, Nielsen TJ, Crowley RW, Al-Khudari S. Management of Cutaneously Exposed Carotid Stents in Recurrent and Unresectable Head and Neck Cancer. J Neurol Surg B Skull Base 2020; 83:82-86. [DOI: 10.1055/s-0040-1716692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 07/25/2020] [Indexed: 10/23/2022] Open
Abstract
Abstract
Objective Carotid blowout syndrome (CBS) is a rare but potentially life-threatening complication of head and neck cancer (HNC) treatment. Patients with CBS are managed with covered stents, limited published information exists regarding the management of delayed complications, specifically cutaneous exposure of stents. Here, we present our experience managing cutaneously exposed carotid artery stents (CAS) in patients with recurrent and unresectable HNC.
Methods A single-institution retrospective analysis was performed to identify recurrent HNC patients who underwent CAS placement for CBS and complicated with cutaneous exposure of the stent between 2014 and 2016. Medical records were reviewed with attention to treatment history, pre-, intra-, and postoperative courses, anticoagulation needs, and durability of the reconstruction.
Results We identified three patients who presented with a right CAS fully exposed in a large, ulcerative wound. All patients underwent a right pectoralis major myocutaneous flap (PMMF) to cover the exposed stent within 30 days of presentation to our institution. Two of three patients attained adequate coverage of the stent for more than 30 days, while one experienced partial flap dehiscence within 12 days. Two patients developed postoperative chest hematomas, which were managed conservatively. Two of three patients were able to undergo further palliative adjuvant treatments within 60 days of the initial surgical procedure.
Conclusion In this small series, durable coverage of an exposed carotid artery with PMMF was successful in two of three patients with extensive disease burden and complex prior treatment history. No mortalities occurred within 30 days postoperatively.
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Affiliation(s)
- André Beer-Furlan
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, United States
| | - Ashley Heilingoetter
- Department of Otolaryngology—Head and Neck Surgery, Ohio State University, Columbus, Ohio, United States
| | - Christopher Rayle
- Department of Otolaryngology—Head and Neck Surgery, University of Kentucky Medical Center, Lexington, Kentucky, United States
| | - Thomas O'Toole
- Department of Otolaryngology—Head and Neck Surgery, Spectrum Health Medical Group, Grand Rapids, Michigan, United States
| | - Thomas J. Nielsen
- Department of Otolaryngology—Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, United States
| | - Richard Webster Crowley
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, United States
| | - Samer Al-Khudari
- Department of Otolaryngology—Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, United States
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14
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Ismail HH, Alhajri I, Ibrahim W. Transarterial embolization of acute carotid blowout syndrome postneck dissection. Radiol Case Rep 2020; 15:1968-1972. [PMID: 32874393 PMCID: PMC7452076 DOI: 10.1016/j.radcr.2020.07.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/21/2020] [Accepted: 07/24/2020] [Indexed: 10/26/2022] Open
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15
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Carotid Blowout Management in the Endovascular Era. World Neurosurg 2020; 141:e1010-e1016. [PMID: 32599207 DOI: 10.1016/j.wneu.2020.06.151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/17/2020] [Accepted: 06/19/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Carotid blowout syndrome (CBS) is a potential complication of head and neck cancer, and its therapy is associated with high morbidity and mortality. Recent advances in endovascular techniques have improved patient outcomes. In this study, we report outcomes of emergent endovascular intervention for CBS. METHODS We conducted a retrospective analysis of a prospectively maintained neurovascular database and identified 38 consecutive endovascular procedures for CBS from 2008-2019 at our institution. Data collection was performed on patient demographics, type of cancer, previous cancer treatments, type of CBS, location of bleed, diagnostic workup, endovascular treatment, and procedural outcomes and complications. RESULTS A total of 38 consecutive endovascular procedures for CBS were performed from 2008-2019 at our single academic institution. Technical success was achieved in 100% of endovascular procedures. Procedural stroke occurred in 1 (2.6%) procedure, procedural mortality occurred in 1 (2.6%) procedure, recurrent CBS occurred in 4 (10.5%) procedures, and fatal rehemorrhage occurred in 1 (2.6%) procedure. Regarding secondary outcomes, delayed stroke/transient ischemic attack occurred in 1 (2.6%) procedure, whereas there were no cases of delayed infectious complications. CONCLUSIONS The endovascular treatment of CBS is safe and effective with relatively low rates of morbidity and mortality compared with other currently available treatment modalities. However, the overall rate of complications demands attention and sheds light on the need for further improvement in management.
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16
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Matsumoto F, Matsumura S, Mori T, Mori A, Omura G, Matsumoto Y, Fukasawa M, Kobayashi K, Yoshimoto S. Common carotid artery ligation at the proximal side before rupture in patients with ligation or occlusion of the external carotid artery at risk of carotid blowout syndrome. Jpn J Clin Oncol 2019; 49:839-844. [PMID: 31135919 DOI: 10.1093/jjco/hyz075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/26/2019] [Accepted: 05/11/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Carotid blowout syndrome (CBS) is among the fatal complications in head and neck cancer treatment. However, the optimal treatment for CBS has not been established yet. This study aimed to describe our experience with two patients at high risk of CBS who underwent common carotid artery (CCA) ligation at the proximal side of the bleeding point under local anesthesia and before CCA rupture, and to review and compare the medical records of these two patients against 10 CBS cases treated in our department. METHODS The institutional electronic medical record was searched, and clinical information was extracted for all patients who showed CBS from 2007 to 2017. Our treatment method was performed as follows. Ligation of the proximal side of the CCA was performed under local anesthesia. The CCA was identified and clamped with two bulldog forceps for 10 minutes to check for any adverse neurological symptoms. Subsequently, the CCA was ligated using 2-0 silk threads and sutured with an absorbable suture between the silk threads. However, ligation or occlusion of the external carotid artery by previous treatment is a prerequisite for this method. RESULTS Eight patients received interventions, with six patients undergoing prophylactic interventions before rupture. Four patients who did not undergo treatment died owing to CBS. Two patients who underwent treatment with the novel method did not experience re-bleeding, but their conditions deteriorated owing to cancer progression. CONCLUSION The present method is one of the treatment choices for CBS, especially in patients with an 'impending' risk of CBS.
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Affiliation(s)
- Fumihiko Matsumoto
- Department of Head and Neck Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Satoko Matsumura
- Department of Head and Neck Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Taisuke Mori
- Department of Pathology and Clinical Laboratory, National Cancer Center Hospital, Tokyo, Japan
| | - Ayaka Mori
- Department of Head and Neck Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Go Omura
- Department of Head and Neck Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yoshifumi Matsumoto
- Department of Head and Neck Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Masahiko Fukasawa
- Department of Head and Neck Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kenya Kobayashi
- Department of Head and Neck Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Seiichi Yoshimoto
- Department of Head and Neck Oncology, National Cancer Center Hospital, Tokyo, Japan
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17
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Durmaz H, Ergun O, Birgi E, Bayir Ö, Saylam G. Endovascular management of the carotid blowout syndrome: a single-center experience. Eur Arch Otorhinolaryngol 2019; 276:2881-2886. [DOI: 10.1007/s00405-019-05548-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 07/04/2019] [Indexed: 12/13/2022]
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18
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Jong MAD, Candanedo C, Gross M, Cohen JE. Intervening in the Acute Phase of Postradiation Carotid Blowout Syndrome. Int Arch Otorhinolaryngol 2019; 23:172-177. [PMID: 30956701 PMCID: PMC6449140 DOI: 10.1055/s-0038-1676660] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 11/13/2018] [Indexed: 12/19/2022] Open
Abstract
Introduction
Acute carotid blowout syndrome (aCBS) is a severe complication of head and neck cancer (HNC). It can be defined as a rupture of the extracranial carotid arteries, or one of their branches, that causes life-threatening hemorrhage, and which nowadays can be treated with urgent endovascular intervention.
Objective
We retrospectively evaluate the endovascular management of aCBS and its outcome in years of survival.
Methods
Retrospectively, we describe our experience with endovascular control of aCBS in patients treated for HNC. We review the characteristics, pathology, endovascular treatment and morbidity and assess the gain in life years.
Results
Nine individuals were included in this study. Four patients had been previously diagnosed with laryngeal squamous cell carcinoma (SCC), one with paranasal SCC, one with nasopharyngeal carcinoma and three with oral or maxillary adenocarcinoma. All subjects underwent radiotherapy and surgical excision to different extents. Twelve endovascular procedures were performed for injuries to the internal carotid artery (
n
= 3; 25%), external carotid artery (
n
= 1; 7%) or one of their branches (
n
= 8; 67%). Deconstructive methods were used in nine procedures, and three procedures were mainly reconstructive with deployment of covered stents. Total control of bleeding was achieved in all individuals with no intraprocedural complications.
Conclusion
Endovascular therapy is an effective alternative for the management of exsanguinating CBS. In our series, this palliative therapy increased the overall patient survival by an estimated 9 months.
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Affiliation(s)
- Marrigje A de Jong
- Department of Otolaryngology/Head and Neck Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Carlos Candanedo
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Menachem Gross
- Department of Otolaryngology/Head and Neck Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - José E Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Division of Endovascular Neurosurgery and Interventional Neuroradiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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19
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Suárez C, Fernández-Alvarez V, Hamoir M, Mendenhall WM, Strojan P, Quer M, Silver CE, Rodrigo JP, Rinaldo A, Ferlito A. Carotid blowout syndrome: modern trends in management. Cancer Manag Res 2018; 10:5617-5628. [PMID: 30519108 PMCID: PMC6239123 DOI: 10.2147/cmar.s180164] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Carotid blowout syndrome (CBS) refers to rupture of the carotid artery and is an uncommon complication of head and neck cancer that can be rapidly fatal without prompt diagnosis and intervention. CBS develops when a damaged arterial wall cannot sustain its integrity against the patient’s blood pressure, mainly in patients who have undergone surgical procedures and radiotherapy due to cancer of the head and neck, or have been reirradiated for a recurrent or second primary tumor in the neck. Among patients irradiated prior to surgery, CBS is usually a result of wound breakdown, pharyngocutaneous fistula and infection. This complication has often been fatal in the past, but at the present time, early diagnosis and modern technology applied to its management have decreased morbidity and mortality rates. In addition to analysis of the causes and consequences of CBS, the purpose of this paper is to critically review methods for early diagnosis of this complication and establish individualized treatment based on endovascular procedures for each patient.
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Affiliation(s)
- Carlos Suárez
- Head & Neck Cancer Laboratory, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain, .,Head & Neck Cancer Laboratory, Instituto Universitario de Oncología del Principado de Asturias, CIBERONC, University of Oviedo, Oviedo, Spain,
| | | | - Marc Hamoir
- Department of Head and Neck Surgery, Head and Neck Oncology Program, King Albert II Cancer Institute, St Luc University Hospital, Brussels, Belgium
| | | | - Primoz Strojan
- Department of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia
| | - Miquel Quer
- Department of Otolaryngology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Carl E Silver
- Department of Surgery, University of Arizona, Phoenix, AZ, USA
| | - Juan P Rodrigo
- Head & Neck Cancer Laboratory, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain, .,Head & Neck Cancer Laboratory, Instituto Universitario de Oncología del Principado de Asturias, CIBERONC, University of Oviedo, Oviedo, Spain, .,Department of Otolaryngology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Alfio Ferlito
- International Head and Neck Scientific Group Padua, Italy
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20
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Wong DJY, Donaldson C, Lai LT, Coleman A, Giddings C, Slater LA, Chandra RV. Safety and effectiveness of endovascular embolization or stent-graft reconstruction for treatment of acute carotid blowout syndrome in patients with head and neck cancer: Case series and systematic review of observational studies. Head Neck 2017; 40:846-854. [PMID: 29155470 DOI: 10.1002/hed.25018] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 08/23/2017] [Accepted: 10/10/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Indications for treatment and outcomes after endovascular management of carotid blowout syndrome for patients with head and neck cancer are not well defined. We investigated the safety and effectiveness of endovascular embolization and stent-graft reconstruction. METHODS A literature review was performed for studies published between 2001 and 2015 with relevance to treatment outcomes. Our institutional database was examined to identify patients treated with endovascular techniques. RESULTS A total of 266 patients were included. Rates of procedural stroke were higher after embolization of internal carotid artery (ICA)/common carotid artery (CCA) compared to stent graft (embolization 10.3%; stent graft 2.5%; P < .02). Stent graft of ICA/CCA was associated with higher rates of recurrent bleeding (embolization 9.1%; stent graft 31.9%; P < .01). CONCLUSION Both embolization and stent grafts are safe therapeutic options for acute carotid blowout syndrome. Embolization for ICA/CCA carotid blowout syndrome was associated with higher risks of procedural stroke and lower recurrent bleeding compared to stent grafts.
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Affiliation(s)
- Daniel J Y Wong
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Australia
| | | | - Leon T Lai
- Department of Neurosurgery, Monash Health, Melbourne, Australia
| | | | - Charles Giddings
- Department of Otolaryngology, Monash Health, Melbourne, Australia
| | - Lee-Anne Slater
- School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Ronil V Chandra
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Australia.,School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
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21
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Venkatesan R, Hirani N, Willis M, Jana B, Cheema Z. Impending Carotid Blowout From a Large Neck Mass Treated Sequentially With Endovascular Coil Embolization Followed by Induction Chemotherapy. J Oncol Pract 2017; 14:136-138. [PMID: 29016223 DOI: 10.1200/jop.2017.025825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | - Bagi Jana
- The University of Texas Medical Branch, Galveston, TX
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22
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Bond KM, Brinjikji W, Murad MH, Cloft HJ, Lanzino G. Endovascular treatment of carotid blowout syndrome. J Vasc Surg 2017; 65:883-888. [PMID: 28236928 DOI: 10.1016/j.jvs.2016.11.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 11/10/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Carotid blowout syndrome (CBS) is a life-threatening complication of head and neck cancer and radiation therapy. Endovascular techniques have emerged as preferable alternatives to surgical ligation for treatment of CBS. We performed a systematic review and meta-analysis to study periprocedural complications and outcomes of CBS patients treated with coil embolization and covered stents. METHODS A comprehensive literature search identified studies that reported outcomes of endovascular treatment of CBS published from 2000 to April 2016. Outcomes included technical success, postoperative rebleeding, survival time, and perioperative complications. Meta-analyses were performed using a random-effects model. RESULTS Twenty-five noncomparative studies with 559 patients were included in the meta-analysis. Technical success rate was 100% in both coiling and covered stenting groups. Median survival time was 3 months (range, 0-96 months) for all CBS patients. Overall perioperative mortality was 11% (95% confidence interval [CI], 5%-17%). Postoperative rebleeding rate was 27% (95% CI, 19%-367%). Perioperative stroke and infection rates were 3% (95% CI, 1%-6%) and 1% (95% CI, 0%-5%), respectively. At last follow-up, 39% of patients were alive (95% CI, 29%-48%). CONCLUSIONS Coil embolization and stent grafts may both be safe treatment options for CBS with few perioperative complications and high rates of technical success, but prognosis after treatment remains poor. In general, noncomparative studies do not demonstrate differences between the two techniques with respect to periprocedural complications and patient outcomes.
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Affiliation(s)
| | | | - Mohammed H Murad
- Department of Science of Healthcare Delivery, Mayo Clinic, Rochester, Minn
| | - Harry J Cloft
- Department of Radiology, Mayo Clinic, Rochester, Minn
| | - Giuseppe Lanzino
- Department of Radiology, Mayo Clinic, Rochester, Minn; Department of Neurosurgery, Mayo Clinic, Rochester, Minn
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23
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Transarterial Embolization in Maxillofacial Intractable Potentially Life-Threatening Hemorrhage. J Oral Maxillofac Surg 2017; 75:1223-1231. [PMID: 28242237 DOI: 10.1016/j.joms.2017.01.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 01/26/2017] [Accepted: 01/26/2017] [Indexed: 11/23/2022]
Abstract
PURPOSE Although transarterial embolization (TAE) of vascular lesions with embolizing agents through angiographic catheters has been used for more than 45 years, reports of life-threatening maxillofacial bleeding are relatively rare and have not been updated. The authors review treatment modalities, present their experience of the past 21 years, and suggest a comprehensive algorithm and guidelines for the use of TAE in the treatment of intractable life-threatening maxillofacial hemorrhage. MATERIALS AND METHODS This article describes 28 patients treated with TAE for severe bleeding that did not respond to conservative therapies. Of these, 13 had uncontrolled epistaxis, 9 were oncologic patients, 4 were postsurgical patients, and 2 were trauma patients. RESULTS Details of patients' medical history, failed conservative therapy administered before TAE, imaging results, and blood vessels involved are presented, as are the TAE procedures and materials used, outcome, and complications. All these are discussed in relation to the available updated literature. All 9 oncologic patients (100%) had been treated with chemotherapy before the uncontrolled bleeding, and 7 also had radiotherapy administered to the maxillofacial region. Continuous anticoagulant therapy also seemed to predict such bleeding episodes. TAE resolved the bleeding in all 28 cases and rapidly in 90% of cases. Only in 3 oncologic cases did continued bleeding require 3 to 4 consecutive TAE sessions and combinations of embolizing agents. CONCLUSIONS The reported high rate of success could be the result of careful techniques, appropriate preoperative imaging, highly professional personnel, and intraoperative and perioperative treatments.
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24
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Vilas Boas PP, de Castro-Afonso LH, Monsignore LM, Nakiri GS, de Mello-Filho FV, Abud DG. Endovascular Management of Patients with Head and Neck Cancers Presenting with Acute Hemorrhage: A Single-Center Retrospective Study. Cardiovasc Intervent Radiol 2016; 40:510-519. [PMID: 27999918 DOI: 10.1007/s00270-016-1550-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 12/14/2016] [Indexed: 01/18/2023]
Abstract
PURPOSE Acute hemorrhage associated with cancers of the head and neck is a life-threatening condition that requires immediate action. The aim of this study was to assess the safety and efficacy of endovascular embolization for acute hemorrhage in patients with head and neck cancers. MATERIALS AND METHODS Data were retrospectively collected from patients with head and neck cancers who underwent endovascular embolization to treat acute hemorrhage. The primary endpoint was the rate of immediate control of hemorrhage during the first 24 h after embolization. The secondary endpoints were technical or clinical complications, rate of re-hemorrhage 24 h after the procedure, time from embolization to re-hemorrhage, hospitalization time, mortality rate, and time from embolization to death. RESULTS Fifty-one patients underwent endovascular embolization. The primary endpoint was achieved in 94% of patients. The rate of technical complications was 5.8%, and no clinical complication was observed. Twelve patients (23.5%) had hemorrhage recurrence after an average time of 127.5 days. The average hospitalization time was 7.4 days, the mortality rate during the follow-up period was 66.6%, and the average time from embolization to death was 132.5 days. CONCLUSION Endovascular embolization to treat acute hemorrhage in patients with head and neck cancers is a safe and effective method for the immediate control of hemorrhage and results in a high rate of hemorrhage control. Larger studies are necessary to determine which treatment strategy is best for improving patient outcomes.
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Affiliation(s)
- P P Vilas Boas
- Division of Interventional Neuroradiology, Ribeirão Preto Medical School, University of São Paulo, Avenida Bandeirantes, 3900, Monte Alegre, Ribeirão Preto, SP, 14048-090, Brazil
| | - L H de Castro-Afonso
- Division of Interventional Neuroradiology, Ribeirão Preto Medical School, University of São Paulo, Avenida Bandeirantes, 3900, Monte Alegre, Ribeirão Preto, SP, 14048-090, Brazil
| | - L M Monsignore
- Division of Interventional Neuroradiology, Ribeirão Preto Medical School, University of São Paulo, Avenida Bandeirantes, 3900, Monte Alegre, Ribeirão Preto, SP, 14048-090, Brazil
| | - G S Nakiri
- Division of Interventional Neuroradiology, Ribeirão Preto Medical School, University of São Paulo, Avenida Bandeirantes, 3900, Monte Alegre, Ribeirão Preto, SP, 14048-090, Brazil
| | - F V de Mello-Filho
- Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - D G Abud
- Division of Interventional Neuroradiology, Ribeirão Preto Medical School, University of São Paulo, Avenida Bandeirantes, 3900, Monte Alegre, Ribeirão Preto, SP, 14048-090, Brazil.
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Chiesa Estomba CM, Betances Reinoso FA, Osorio Velasquez A, Castro Macia O, Gonzalez Cortés MJ, Araujo Nores J. Carotid blowout syndrome in patients treated by larynx cancer. Braz J Otorhinolaryngol 2016; 83:653-658. [PMID: 27789194 PMCID: PMC9449226 DOI: 10.1016/j.bjorl.2016.08.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 07/17/2016] [Accepted: 08/26/2016] [Indexed: 12/18/2022] Open
Abstract
Introduction Carotid blowout syndrome is an uncommon complication for patient treated by head and neck tumors, and related to a high mortality rate. Objective The aim of this study was to study the risk of carotid blowout in a large cohort of patients treated only by larynx cancer. Methods Retrospective analysis of patients older than 18 years, treated by larynx cancer who developed a carotid blowout syndrome in a tertiary academic centre. Results 197 patients met the inclusion criteria, 192 (98.4%) were male and 5 (1.6%) were female. 6 (3%) patients developed a carotid blowout syndrome, 4 patients had a carotid blowout syndrome located in the internal carotid artery and 2 in the common carotid artery. According to the type of rupture, 3 patients suffer a type I, 2 patients a type III and 1 patient a type II. Five of those patients had previously undergone radiotherapy and all patients underwent total laryngectomy. We found a statistical correlation between open surgical procedures (p = 0.004) and radiotherapy (p = 0.023) and the development of a carotid blowout syndrome. Conclusion Carotid blowout syndrome is an uncommon complication in patients treated by larynx tumours. According to our results, patient underwent radiotherapy and patients treated with open surgical procedures with pharyngeal opening have a major risk to develop this kind of complication.
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Affiliation(s)
| | | | | | - Olalla Castro Macia
- University Hospital of Vigo, Otorhinolaryngology, Head and Neck Surgery Department, Pontevedra, Spain
| | | | - Jesus Araujo Nores
- University Hospital of Vigo, Otorhinolaryngology, Head and Neck Surgery Department, Pontevedra, Spain
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Šifrer R, Aničin A, Pohar MP, Žargi M, Pukl P, Soklič T, Strojan P. Pharyngocutaneous fistula: the incidence and the risk factors. Eur Arch Otorhinolaryngol 2016; 273:3393-9. [DOI: 10.1007/s00405-016-3963-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Accepted: 03/01/2016] [Indexed: 11/28/2022]
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Vlastarakos PV, Trinidade A, Jaberoo MC, Mochloulis G. A Limited Thoracocervical Approach for Accessing the Anterior Mediastinum in Retrosternal Goiters: Surgical Technique and Implications for the Management of Head and Neck Emergencies. EAR, NOSE & THROAT JOURNAL 2016. [DOI: 10.1177/014556131609500305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
In this article we describe the surgical management of retrosternal goiters via a limited thoracocervical approach, and we explore how the respective surgical know-how can be used in the management of the carotid blowout syndrome. Four cases involving patients who had undergone thyroidectomy via a limited thoracocervical approach are retrospectively reviewed. An acute blowout of the innominate artery managed with the same principal surgical technique is also reviewed. Tree patients had a total thyroidectomy and one had a hemithyroidectomy. No malignancy was found. There was no mortality or unexpected morbidity from the limited thoracocervical approach. The median length of the inpatient stay was 3 days. The blowout survivor lived for 9 months, with no rebleeding and with an acceptable quality of life. We conclude that a limited thoracocervical approach can be safely performed by head and neck surgeons for accessing the anterior mediastinum in retrosternal goiters, and the respective surgical know-how can be used in the immediate management of an acute carotid blowout syndrome with satisfying long-term results and provision of quality end-of-life care.
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Affiliation(s)
| | - Aaron Trinidade
- ENT Department, Lister Hospital, Stevenage,
Hertfordshire, U.K
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Murphy BA, Deng J. Advances in Supportive Care for Late Effects of Head and Neck Cancer. J Clin Oncol 2015; 33:3314-21. [PMID: 26351334 DOI: 10.1200/jco.2015.61.3836] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
As the population of head and neck cancer survivors increases, it has become increasingly important for health care providers to understand and manage late complications of therapy. Functional deficits can be categorized as general health deficits resulting in frailty or debility, head and neck-specific functional deficits such as swallowing and speech, and musculoskeletal impairment as a result of tumor and treatment. Of critical importance is the growing data indicating that swallow therapy and physical therapy may prevent or ameliorate long-term functional deficits. Oral health complications of head and neck therapy may manifest months or years after the completion of treatment. Patients with hyposalivation are at high risk for dental caries and thus require aggressive oral hygiene regimens and routine dental surveillance. Swallowing abnormalities, xerostomia, and poor dentition may result in dietary adaptations that may cause nutritional deficiencies. Identification and management of maladaptive dietary strategies are important for long-term health. Follow-up with primary care physicians for management of comorbidities such as diabetes and hyperlipidemia may help to limit late vascular complications caused by radiation therapy. Herein, we review late effects of head and neck cancer therapy, highlighting recent advances.
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Affiliation(s)
- Barbara A Murphy
- Barbara A. Murphy, Vanderbilt-Ingram Cancer Center; and Jie Deng, School of Nursing, Vanderbilt University, Nashville, TN.
| | - Jie Deng
- Barbara A. Murphy, Vanderbilt-Ingram Cancer Center; and Jie Deng, School of Nursing, Vanderbilt University, Nashville, TN
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Peguero J, Khanfar A, Mannem S, Willis M, Markowtiz A. Impending Carotid Blowout Syndrome. J Clin Oncol 2015; 33:e97-8. [DOI: 10.1200/jco.2013.48.9641] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Julio Peguero
- The University of Texas Medical Branch, Galveston, TX
| | - Anas Khanfar
- The University of Texas Medical Branch, Galveston, TX
| | - Siva Mannem
- The University of Texas Medical Branch, Galveston, TX
| | | | - Avi Markowtiz
- The University of Texas Medical Branch, Galveston, TX
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Aaronson NL, Johnson MH, Sasaki CT. Carotid stent extrusion following carotid blowout. Auris Nasus Larynx 2015; 42:176-8. [PMID: 25579083 DOI: 10.1016/j.anl.2014.10.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Revised: 10/14/2014] [Accepted: 10/21/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE We describe an unusual foreign body, a carotid stent extruded into the upper airway, and discuss the predisposing factors. METHODS This is a single patient case report with review of the literature. RESULTS Our patient is a 59 year old female treated for T3N2aM0 (stage IVa) left tonsil squamous cell carcinoma who experienced a carotid blowout treated by carotid stent placement with subsequent carotid coiling and vessel takedown. Approximately ten months later, she coughed and expelled approximately 3cm of tubular stent-appearing material into her airway causing acute stridor and dysphagia. CT angiography (CTA) showed the distal and proximal stent in proper position without evidence of extravasation. The stent was extracted transorally showing the distal end of the carotid to be patent and covered by fibrin within its lumen. Review of the literature shows that such stent extrusions, although rare, do occur. CONCLUSION Carotid stents are a valuable tool in cases of carotid blowout. However, long-term data on patient prognosis is lacking. The foreign body response triggered by stent placement can cause dislodgement. The potential for stent extrusion is greatest in patients who have preexisting ulceration or who have undergone radiation, both common in head and neck cancer patients.
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Affiliation(s)
- Nicole L Aaronson
- Section of Otolaryngology, Head and Neck Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA.
| | - Michele H Johnson
- Section of Interventional Neuroradiology, Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Clarence T Sasaki
- Section of Otolaryngology, Head and Neck Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
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Spiotta AM, Turner RD, Chaudry MI, Turk AS, Hui FK, Schonholz C. Carotid sacrifice with a single Penumbra occlusion device: a feasibility study in a swine model. J Neurointerv Surg 2014; 8:99-102. [DOI: 10.1136/neurintsurg-2014-011461] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 10/25/2014] [Indexed: 11/03/2022]
Abstract
IntroductionCarotid sacrifice is a valuable tool in the treatment of select vascular lesions. Traditional coil embolization as the primary means of carotid sacrifice can be expensive, with high radiation exposure. We investigated the feasibility of a novel hybrid coil, the Penumbra occlusion device (POD), for carotid sacrifice in a swine model.MethodsA total of eight common carotid artery sacrifices were performed in fully heparinized pigs under fluoroscopic guidance. A single POD device was deployed within each vessel, and intermittent follow-up angiography was performed to assess flow.ResultsComplete carotid occlusion was achieved in all cases with a single POD (time range 2–15 min) without any coil migration or intraprocedural complications. Once the anchor zone was stable, no distal migrations were observed during either proximal soft coil packing or during hand injected angiography. Complete occlusion was verified between 2 and 15 min following POD deployment.ConclusionsCarotid artery sacrifice using a novel POD device is safe and effective, allowing for reduced radiation and material costs compared with any other described endovascular technique.
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Chen YJ, Wang CP, Wang CC, Jiang RS, Lin JC, Liu SA. Carotid blowout in patients with head and neck cancer: associated factors and treatment outcomes. Head Neck 2014; 37:265-72. [PMID: 24375817 DOI: 10.1002/hed.23590] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2013] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The purpose of this study was to investigate factors associated with carotid blowout in the cervical portion of patients with head and neck cancer in a large cohort. METHODS We reviewed patients with head and neck cancer and identified those with carotid blowout. Variables of patients with and without carotid blowout were compared and associated factors were investigated by logistic regression model. RESULTS A total of 2590 patients were included in the final analysis and 102 patients (3.9%) developed carotid blowout in the cervical region. Body mass index (BMI) <22.5 kg/M(2) , primary site in the hypopharynx or oropharynx, open wound in the neck requiring wet dressing, radical neck dissection, and total radiation dose to the neck ≥70 Gy were independent factors associated with carotid blowout. CONCLUSION After completion of treatment in patients with head and neck cancer, carotid blowout was an uncommon complication with catastrophic results. Recognition of associated factors helps physicians to identify those at risk.
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Affiliation(s)
- Yi-Juin Chen
- Department of Otolaryngology, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
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Harréus U. Surgical errors and risks - the head and neck cancer patient. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2013; 12:Doc04. [PMID: 24403972 PMCID: PMC3884539 DOI: 10.3205/cto000096] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Head and neck surgery is one of the basic principles of head and neck cancer therapy. Surgical errors and malpractice can have fatal consequences for the treated patients. It can lead to functional impairment and has impact in future chances for disease related survival. There are many risks for head and neck surgeons that can cause errors and malpractice. To avoid surgical mistakes, thorough preoperative management of patients is mandatory. As there are ensuring operability, cautious evaluation of preoperative diagnostics and operative planning. Moreover knowledge of anatomical structures of the head and neck, of the medical studies and data as well as qualification in modern surgical techniques and the surgeons ability for critical self assessment are basic and important prerequisites for head and neck surgeons in order to make out risks and to prevent from mistakes. Additionally it is important to have profound knowledge in nutrition management of cancer patients, wound healing and to realize and to be able to deal with complications, when they occur. Despite all precaution and surgical care, errors and mistakes cannot always be avoided. For that it is important to be able to deal with mistakes and to establish an appropriate and clear communication and management for such events. The manuscript comments on recognition and prevention of risks and mistakes in the preoperative, operative and postoperative phase of head and neck cancer surgery.
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Affiliation(s)
- Ulrich Harréus
- Department of Otolaryngology/Head and Neck Surgery, University Hospital Munich, Campus Grosshadern, Munich, Germany
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Dequanter D, Shahla M, Paulus P, Aubert C, Lothaire P. Transarterial endovascular treatment in the management of life-threatening carotid blowout syndrome in head and neck cancer patients: review of the literature. ACTA ACUST UNITED AC 2013; 38:341-4. [PMID: 24210746 DOI: 10.1016/j.jmv.2013.10.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 09/25/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Carotid blowout syndrome is a rare but devastating complication in patients with head and neck malignancy, and is associated with high morbidity and mortality. Bleeding from the carotid artery or its branches is a well-recognized complication following treatment or recurrence of head and neck cancer. It is an emergency situation, and the classical approach to save the patient's life is to ligate the carotid artery. But the surgical treatment is often technically difficult. Endovascular therapies were recently reported as good alternatives to surgical ligation. METHODS Retrospective review of three cases of acute or threatened carotid hemorrhage managed by endovascular therapies. RESULTS Two patients presented with acute carotid blowout, and one patient with a sentinel bleed. Two patients had previously been treated with surgery and chemo radiation. One patient was treated by chemo radiation. Two had developed pharyngocutaneous fistulas, and one had an open necrosis filled wound that surrounded the carotid artery. In two patients, stent placement resolved the acute hemorrhage. In one patient, superselective embolization was done. Mean duration follow-up was 10.2 months. No patient had residual sequelae of stenting or embolization. CONCLUSION Management of carotid blow syndrome is very critical and difficult. A multidisciplinary approach is very important in the management of carotid blow syndrome. Correct and suitable management can be life saving. An endovascular technique is a good and effective alternative with much lower morbidity rates than surgical repair or ligation.
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Affiliation(s)
- D Dequanter
- Head and Neck Department, 706, rue de Gozée, 6110 Montigny-le-Tilleul, Belgium.
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35
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Zhao LB, Shi HB, Park S, Lee DG, Shim JH, Lee DH, Suh DC. Acute bleeding in the head and neck: angiographic findings and endovascular management. AJNR Am J Neuroradiol 2013; 35:360-6. [PMID: 24136646 DOI: 10.3174/ajnr.a3761] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE Life-threatening bleeding in the head and neck requires urgent management. This study evaluated the angiographic findings related to head and neck bleeding and presents endovascular management techniques. MATERIAL AND METHODS Sixty-one consecutive patients who presented with acute bleeding in the head and neck areas and subsequently underwent endovascular therapy between January 2002 and October 2012 were included in our study. We evaluated the angiographic findings, techniques, and results of endovascular management. RESULTS Contrast leakage (n = 10), pseudoaneurysm (n = 20), or both (n = 10) were the most common life-threatening angiographic findings (66%) and were the foci of immediate embolization or endoluminal vessel reconstruction. Seventeen patients (28%) had hypervascular staining of the tumor or mucosa, and 4 patients (6%) did not have any abnormal findings. The acute bleeding was successfully controlled by endovascular management according to the bleeding foci. Carotid arterial lesions, so-called "carotid blowout," required reconstructive or deconstructive therapy. Bleeding of the external carotid artery required specific branch embolization by a combination of various embolic materials. No procedure-related complications occurred except in 1 patient who experienced acute infarction caused by thromboemboli from the covered stent. Seventeen patients (28%) were retreated due to rebleeding after the mean 20-month follow-up. CONCLUSIONS Contrast leakage or a pseudoaneurysm or both seen on angiography are active bleeding foci and targets for therapy in patients with acute bleeding in the head and neck area. Despite different bleeding-control strategies according to vessel involvement, endovascular treatment is safe and effective for controlling hemorrhage.
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Affiliation(s)
- L-B Zhao
- From the Departments of Radiology and Research Institute of Radiology (L.-B.Z., H.B.S., S.P., D.-g.L., J.H.S., D.H.L., D.C.S.), University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
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Liu J, Zeng Q, Huang JJ, Hu GH. Management of infected carotid artery rupture. Eur Arch Otorhinolaryngol 2013; 271:1723-8. [DOI: 10.1007/s00405-013-2678-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 08/20/2013] [Indexed: 12/15/2022]
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Delayed carotid blow-out syndrome: a new complication of chemoradiotherapy treatment in pharyngolaryngeal carcinoma. The Journal of Laryngology & Otology 2012; 126:1189-91. [PMID: 22963758 DOI: 10.1017/s0022215112001910] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Carotid blow-out syndrome is one of the most devastating complications of head and neck carcinoma. It usually occurs as a post-operative complication or when the tumour compromises the vascular axis. METHODS AND RESULTS We report two patients who suffered carotid blow-out syndrome but who did not have the usual predisposing factors. Both patients had a pharyngolaryngeal carcinoma that was treated with chemoradiotherapy. Residual non-tumoural ulceration was seen along the lateral wall of the hypopharynx in both cases. This ulceration eventually reached the vascular axis, precipitating carotid rupture and death. CONCLUSION Residual non-tumoural ulceration of the lateral wall of the hypopharynx after chemoradiotherapy should be considered with the utmost caution. Once persistence of the tumour is excluded, surgery is indicated to protect the vascular axis, in order to prevent carotid blow-out syndrome.
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Quality of dying in head and neck cancer patients: the role of surgical palliation. Eur Arch Otorhinolaryngol 2012; 270:681-8. [DOI: 10.1007/s00405-012-2059-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Accepted: 05/15/2012] [Indexed: 11/26/2022]
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Abstract
OBJECTIVE To provide an update on the ever-increasing role that embolisation plays in the practice of otolaryngology. METHOD A literature search was performed during November 2008. The Medline, Embase, PubMed and Cochrane databases were searched. This resulted in 285 papers relevant for review. CONCLUSION The role of embolisation has expanded greatly to include the management of refractory epistaxis, pre-operative preparation of vascular tumours, vascular injuries and as an adjunct in skull base surgery.
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Zussman B, Gonzalez LF, Dumont A, Tjoumakaris S, Rosenwasser R, Hasan D, Cognetti D, Axelrod R, Jabbour P. Endovascular management of carotid blowout. World Neurosurg 2011; 78:109-14. [PMID: 22120297 DOI: 10.1016/j.wneu.2011.08.024] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Revised: 05/20/2011] [Accepted: 08/15/2011] [Indexed: 10/15/2022]
Abstract
OBJECTIVE To highlight pertinent aspects of emergent endovascular management of carotid rupture, or carotid blowout syndrome (CBS), an emergent, life-threatening complication of head and neck cancer and its treatments. METHODS A retrospective chart review was conducted of all patients with carotid blowouts at the authors' institution from 2008-2010. A systematic literature review was also performed. RESULTS Eight patients (three women and five men) with an average age of 61 years (range 47-78 years) were reviewed. Seven patients had a positive history for squamous cell carcinoma of the neck, and five patients had active malignant disease. Carotid arterial deconstruction using liquid embolic material, coil embolization, or both achieved immediate hemostasis in every case (100%). No patients died as a result of their initial hemorrhage, but one patient had lethal hemorrhage at 1 day postoperatively. Two patients experienced nonlethal postoperative complications. At an average follow-up of 3 months (range<1-8 months), three patients were alive, three had died as a result of their underlying disease, and two had died of other causes. CONCLUSIONS The treatment of patients with terminal malignant disease and CBS should provide maximum relief and minimize the risks of repeat surgery, morbidity, and mortality. Endovascular management of CBS with deconstructive techniques achieves immediate hemostasis and definitive treatment. The risks of intraoperative mortality and recurrent hemorrhage are low.
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Affiliation(s)
- Benjamin Zussman
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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McDonald MW, Moore MG, Johnstone PAS. Risk of carotid blowout after reirradiation of the head and neck: a systematic review. Int J Radiat Oncol Biol Phys 2011; 82:1083-9. [PMID: 21549520 DOI: 10.1016/j.ijrobp.2010.08.029] [Citation(s) in RCA: 151] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Revised: 08/16/2010] [Accepted: 08/17/2010] [Indexed: 11/30/2022]
Abstract
PURPOSE Carotid blowout (CB) is a rare but frequently fatal complication of head-and-neck (H&N) cancer or its treatment. We sought to determine the reported rate of CB in patients receiving salvage reirradiation for H&N cancer. METHODS AND MATERIALS A literature search identified 27 published articles on H&N reirradiation involving 1554 patients, and a pooled analysis was performed to determine the rate of CB. Treatment parameters, including prior radiation dose, interval from prior radiation, dose and fractionation of reirradiation, use of salvage surgery, and chemotherapy, were abstracted and summarized. The cumulative risk of CB was compared between groups using Fisher's exact test. RESULTS Among 1554 patients receiving salvage H&N reirradiation, there were 41 reported CBs, for a rate of 2.6%; 76% were fatal. In patients treated in a continuous course with 1.8-2-Gy daily fractions or 1.2-Gy twice-daily fractions, 36% of whom received concurrent chemotherapy, the rate of CB was 1.3%, compared with 4.5% in patients treated with 1.5 Gy twice daily in alternating weeks or with delayed accelerated hyperfractionation, all of whom received concurrent chemotherapy (p = 0.002). There was no statistically significant difference in the rate of CB between patients treated with or without concurrent chemotherapy, or between patients treated with or without salvage surgery before reirradiation. CONCLUSION Carotid blowout is an infrequent but serious complication of salvage reirradiation for H&N cancer. The rate of CB was lower among patients treated with conventional or hyperfractionated schedules compared with regimens of accelerated hyperfractionation, though heterogeneous patient populations and treatment parameters preclude definite conclusions. Given the high mortality rate of CB, discussion of the risk of CB is an important component of informed consent for salvage reirradiation.
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Affiliation(s)
- Mark W McDonald
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202-5289, USA.
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Carotid blowout syndrome with oronasal hemorrhage: magnetic resonance imaging findings. Jpn J Radiol 2011; 29:72-5. [PMID: 21264666 DOI: 10.1007/s11604-010-0503-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Accepted: 08/05/2010] [Indexed: 10/18/2022]
Abstract
Carotid blowout syndrome (CBS) is a rare but well-known complication of aggressive radiotherapy management of head and neck cancer. Reports on magnetic resonance imaging (MRI) findings of CBS are limited in the relevant literature, probably because of the angiography priority of this complication. We describe MRI findings in a patient with nasopharyngeal carcinoma complicated with CBS.
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Powitzky R, Vasan N, Krempl G, Medina J. Carotid Blowout in Patients with Head and Neck Cancer. Ann Otol Rhinol Laryngol 2010; 119:476-84. [DOI: 10.1177/000348941011900709] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives The objective was to review the clinicopathologic features of carotid blowout syndrome (CBS) in patients with head and neck cancer (HNC) and present a management algorithm. Methods We reviewed all HNC patients with a diagnosis of CBS seen at our tertiary cancer hospital from 1994 to 2009 and performed a retrospective review of all English-language studies documenting CBS cases within the past 15 years. Results Eight patients with HNC developed CBS at our institution, and another 132 HNC patients were presented in 21 studies. Patients with CBS typically have a history of radiotherapy (89%), nodal metastasis (69%), and neck dissection (63%). This disease usually occurs proximal to the carotid bifurcation and is commonly associated with soft tissue necrosis in the neck (55%) and mucocutaneous fistulas (40%). Half of CBS patients present with sentinel bleeding, but 60% of patients will develop a life-threatening hemorrhage requiring emergent intervention. Over 90% of patients with CBS were treated with endovascular therapy, and surgical ligation was rarely indicated. The morbidity and mortality rates of patients with CBS are significant; only 23% have survived without evidence of disease. Conclusions Carotid blowout syndrome is uncommon and can be rapidly fatal without prompt diagnosis and intervention. Although endovascular treatment within the carotid system can have a significant risk of mortality and neurologic morbidity, it has become the treatment of choice for CBS.
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Affiliation(s)
- Rosser Powitzky
- Department of Otorhinolaryngology, Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma
| | - Nilesh Vasan
- Department of Otorhinolaryngology, Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma
| | - Greg Krempl
- Department of Otorhinolaryngology, Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma
| | - Jesus Medina
- Department of Otorhinolaryngology, Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma
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Recent advances in oral oncology 2008; squamous cell carcinoma imaging, treatment, prognostication and treatment outcomes. Oral Oncol 2009; 45:e25-30. [PMID: 19249236 DOI: 10.1016/j.oraloncology.2008.12.011] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This paper provides a synopsis of the main papers on diagnosis, imaging, treatment, prognostication and treatment outcomes in patients with oral and oropharyngeal squamous cell carcinoma (OSCC) and head and neck SCC (HNSCC) published in 2008 in Oral Oncology - an international interdisciplinary journal which publishes high quality original research, clinical trials and review articles, and all other scientific articles relating to the aetiopathogenesis, epidemiology, prevention, clinical features, diagnosis, treatment and management of patients with neoplasms in the head and neck, and orofacial disease in patients with malignant disease.
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