Transarterial embolization for acute head and neck bleeding: eight-year experience with emphasis on rebleeding risk in cancer patients

The impact of trans-arterial embolization on the result of chemoradiotherapy in oral cavity cancer

Objectives: Evaluation of the hemostatic effect of trans-arterial embolization on patients with advanced oral cavity cancer who had bleeding complications while undergoing definitive concurrent chemoradiotherapy (CCRT). Additionally, assess the effect of trans-arterial embolization on treatment response following concurrent chemoradiotherapy, as well as overall survival (OS) and progression-free survival (PFS) in the group of patients following the intervention. Method: From September 2018-June 2021, a retrospective descriptive study was conducted on 16 patients with inoperable, locally advanced oral cavity cancer who received definitive concurrent chemoradiotherapy, experienced acute bleeding complications, and received selective intravascular intervention with various embolization materials at Vietnam National Cancer Hospital. Results: After selective embolization, 16/16 patients ceased bleeding; 1 patient re-bled for the second time after 3 weeks. The average duration of chemoradiotherapy interruption due to intervention was 6.7 days. After CCRT, 15/16 (93.75%) patients achieved a response, with 9/16 (56.25%) patients achieving a complete response. The median OS was 14 months (range, 3-26 months), and the median PFS was 10 months (range, 3-20 months). There were no significant complications, particularly neurological side effects. ConclusionsTumor bleeding is a common and serious complication of CCRT treatment in patients with locally advanced oral cavity cancer. Embolization is a safe and effective method of controlling acute bleeding that has no adverse effect on the outcome of definitive concurrent chemoradiotherapy.

Shock Index as a Predictor for Angiographic Hemostasis in Life-Threatening Traumatic Oronasal Bleeding

The objective of this retrospective study was to identify predictors of angiographic hemostasis among patients with life-threatening traumatic oronasal bleeding (ONB) and determine the threshold for timely referral or intervention. The diagnosis of traumatic, life-threatening ONB was made if the patient suffered from craniofacial trauma presenting at triage with unstable hemodynamics or required a definitive airway due to ONB, without other major bleeding identified. There were 4404 craniofacial trauma patients between January 2015 and December 2019, of which 72 (1.6%) fulfilled the diagnosis of traumatic life-threatening ONB. Of these patients, 39 (54.2%) received trans-arterial embolization (TAE), 11 (15.3%) were treated with other methods, and 22 (30.5%) were excluded. Motor vehicle accidents were the most common cause of life-threatening ONB (52%), and the internal maxillary artery was the most commonly identified hemorrhaging artery requiring embolization (84%). Shock index (SI) was significantly higher in the angiographic hemostasis group (p < 0.001). The AUC-ROC was 0.87 (95% CI, 0.88-1.00) for SI to predict angiographic hemostasis. Early recognition and timely intervention are crucial in post-traumatic, life-threatening ONB management. Patients initially presenting with SI > 0.95 were more likely to receive TAE, with the TAE group having statistically higher SI than the non-TAE group whilst receiving significantly more packed red blood cells. Hence, for patients presenting with life-threatening traumatic ONB and a SI > 0.95, TAE should be considered if preliminary attempts at hemostasis have failed.

The role of CT angiography and endovascular treatment in acute-massive head and neck bleeding

PURPOSE

To report the results of the endovascular treatment of acute-massive head and neck bleeding in a single center and underline the value of computerized tomography-angiography and endovascular treatment of this desperate patient group.

METHODS

Forty-eight patients who suffered from acute-massive head and neck bleeding and in whom conservative treatment options had failed were included in the study. To localize the site of the bleeding, computerized tomography-angiography was obtained above the supra-aortic level. Depending on the type and site of bleeding, an urgent angiographic evaluation and appropriate endovascular treatment procedure were performed in the same session immediately. Complete control of all active bleeding was determined as "technical success" at the end of the procedure.

RESULTS

The majority of the endovascular treatment indications were tumoral mass bleedings in this study. Eight patients, all of which had head and neck tumors as the cause of the bleeding underwent repeated interventional procedures due to acute re-bleeding. All patients left the angiography unit with technical success and dramatic clinical improvement. Two patients had procedure-related severe complications, such as contrast-induced nephropathy and acute cerebrovascular accident. One patient died due to massive re-bleeding during the follow-up period.

CONCLUSION

Computerized tomography-angiography is a successful imaging method to reveal the location and cause of bleeding. Endovascular treatment of acute-massive head and neck bleeding is an effective and life-saver treatment option that can be used successfully with relatively low-risk potential.

Transarterial Embolization for Bleeding in Patients with Head and Neck Cancer: Who Benefits?

OBJECTIVES/HYPOTHESIS

The present study aimed to investigate the efficacy of transarterial embolization (TAE) for bleeding in patients with head and neck cancer (HNC) and to evaluate the prognostic factors after TAE.

STUDY DESIGN

Outcome study.

METHODS

This retrospective study included 31 consecutive patients (27 men and 4 women; median age, 61 years) who presented uncontrollable hemorrhage associated with HNC and underwent emergency TAE at our institution during a 10-year period (January 2011-December 2020). This corresponded to 40 TAE procedures, including 27 cases with an unstable status (circulatory and/or respiratory insufficiency) and 10 cases with carotid blowout syndrome. The technical success rate and adverse events were analyzed on a per-procedure basis. The rebleeding and overall survival (OS) rates were analyzed on a per-patient basis, and the factors related to OS were evaluated.

RESULTS

The technical success rate was 100%. As an adverse event, cerebral infarction was found in three cases with carotid blowout syndrome. The rebleeding rate at 30 days after TAE and in the follow-up period (range, 9-3,004 days) was 17.2% and 35.5%, respectively. The median survival time was 263 days (95% confidence interval: 124.0-402.0 days). In the log-rank test, complete remission (CR) of the primary cancer at the time of the first TAE was identified as a significant influencing factor of survival.

CONCLUSION

TAE is effective for the treatment of hemorrhage associated with HNC even in patients with an unstable status. Patients with CR can gain a long life span.

LEVEL OF EVIDENCE

Level 4 Laryngoscope, 2021.

Massive Orofacial Hemorrhage Treated with the Micro Vascular Plug System

BACKGROUND

This case series describes the use of the Medtronic Micro Vascular Plug (MVP) system in the treatment of acute massive orofacial hemorrhages in patients with cancer and trauma, resulting in successful hemostasis in these emergent cases.

CASE DESCRIPTION

The first case describes a patient who presented with life-threatening oropharyngeal hemorrhage after a motor vehicle accident. In the second case, a patient with oropharyngeal cancer presented with life-threatening bleeding from an ulcerated tumor. Patients were successfully treated with a combination of MVP and coils. Immediate postprocedural imaging confirmed that homeostasis was achieved.

CONCLUSIONS

These cases demonstrate that the MVP as an embolic device is a valuable transarterial embolic treatment option in cases of acute orofacial bleeding where rapid, effective hemostasis is required.

Verification of bleeding points in carotid blowout syndrome using guidewire manipulation

PURPOSE

Carotid blowout syndrome (CBS) is a catastrophic complication of aggressive treatment of head and neck cancer. Early detection of bleeding points with embolization is a life-saving procedure; however, some bleeding points may be difficult to identify. Our aim was to determine whether guidewire manipulation (GWM) could be used to verify bleeding point locations in patients with CBS.

METHODS

Of the 92 patients with CBS referred for embolization in a 5-year period, 14 men and one woman (mean age 58 years) had bleeding points at locations that could not be definitely determined. We used GWM to verify the presence of these bleeding points. We assessed the anatomy of the ruptured arteries, technical details of GWM, and the angiographic and clinical outcomes.

RESULTS

Bleeding points were difficult to detect because of the presence of small arterial pouches (n = 6) or multiple small arterial pouches (n = 9) in the unilateral or bilateral carotid arteries. Bleeding point locations were accurately identified using GWM in the internal carotid artery (n = 7), carotid bulb (n = 4), or common carotid artery (n = 4). Balloon-assisted GWM was applied in one patient. Fiber coils (n = 15) and/or liquid adhesives (n = 2) were used to occlude the affected artery. Endovascular management was technically successful in all patients and resulted in immediate cessation of hemorrhage without recurrence in a mean 22-month clinical follow-up.

CONCLUSION

GWM is a simple and effective method for verifying bleeding points in ruptured arteries and preventing erroneous occlusion by embolization.

Treatment of hemorrhagic head and neck lesions by direct puncture and n-BCA embolization

Life-threatening bleeding in the head and neck region requires urgent management. These hemorrhagic lesions, for example, a ruptured pseudoaneurysm, are often treated by transarterial embolization (TAE), but prior intervention or surgery, inflammation, anatomic variants, and vessel tortuosity may render an endovascular approach challenging, time-consuming, and sometimes impossible. We report two cases of severe head and neck hemorrhages successfully embolized with n-butyl cyanoacrylate via direct puncture, and propose this approach as a fast, safe, and effective alternative to TAE.

Treatment of hemorrhagic head and neck lesions by direct puncture and nBCA embolization

Life-threatening bleeding in the head and neck region requires urgent management. These hemorrhagic lesions, for example, a ruptured pseudoaneurysm, are often treated by transarterial embolization (TAE), but prior intervention or surgery, inflammation, anatomic variants, and vessel tortuosity may render an endovascular approach challenging, time-consuming, and sometimes impossible. We report two cases of severe head and neck hemorrhages successfully embolized with n-butyl cyanoacrylate via direct puncture, and propose this approach as a fast, safe, and effective alternative to TAE.

Transarterial Embolization in Maxillofacial Intractable Potentially Life-Threatening Hemorrhage

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.

Transarterial embolization in the management of intractable epistaxis: the angiographic findings and results based on etiologies

CONCLUSIONS

Transarterial embolization (TAE) appears to be a safe and effective treatment for patients with intractable epistaxis, despite different etiologies or angiography findings. Idiopathic epistaxis is prone to present with negative angiographic findings.

OBJECTIVE

To retrospectively evaluate the safety and effectiveness of TAE for intractable epistaxis, and focus on the factors of etiology and angiographic findings.

MATERIALS AND METHODS

From March 2008 to December 2014, the data of 43 patients with intractable bleeding undergoing TAE were reviewed. The outcomes of interventional therapy were assessed according to different etiology (malignant or benign disease) and angiographic finding (positive or negative angiogram).

RESULTS

Positive angiographic findings were found in 11 of 12 cases with malignant diseases and 22 of 31 cases with benign diseases, respectively (p = 0.237). Among the 10 cases with negative angiographic findings, the negative angiography rate of idiopathic epistaxis was higher than that of epistaxis with definite etiology (p = 0.003). Bleeding was controlled successfully in all of the 43 patients after embolization. During the mean follow-up period of 24.0 ± 16.7 months, five patients relapsed. No significant difference was found in recurrence rates between malignant and benign diseases or between positive and negative angiography (p = 0.241, p = 0.704, respectively).

Endovascular Management of Post-Irradiated Carotid Blowout Syndrome

Purpose

To retrospectively evaluate the clinical and technical factors related to the outcomes of endovascular management in patients with head-and-neck cancers associated with post-irradiated carotid blowout syndrome (PCBS).

Materials and Methods

Between 2000 and 2013, 96 patients with PCBS underwent endovascular management. The 40 patients with the pathological lesions located in the external carotid artery were classified as group 1 and were treated with embolization. The other 56 patients with the pathological lesions located in the trunk of the carotid artery were divided into 2 groups as follows: group 2A comprised the 38 patients treated with embolization, and group 2B comprised the 18 patients treated with stent-graft placement. Fisher’s exact test was used to examine endovascular methods, clinical severities, and postprocedural clinical diseases as predictors of outcomes.

Results

Technical success and immediate hemostasis were achieved in all patients. The results according to endovascular methods (group 1 vs 2A vs 2B) were as follows: technical complication (1/40[2.5%] vs 9/38[23.7%] vs 9/18[50.0%], P = 0.0001); rebleeding (14/40[35.0%] vs 5/38[13.2%] vs 7/18[38.9%]), P = 0.0435). The results according to clinical severity (acute vs ongoing PCBS) were as follows: technical complication (15/47[31.9%] vs 4/49[8.2%], P = 0.0035); rebleeding (18/47[38.3%] vs 8/49[16.3%], P = 0.0155). The results according to post-procedural clinical disease (regressive vs progressive change) were as follows: alive (14/21[66.7%] vs 8/75[10.7%], P<0.0001); survival time (34.1±30.6[0.3–110] vs 3.6±4.0[0.07–22] months, P<0.0001).

Conclusion

The outcomes of endovascular management of PCBS can be improved by taking embolization as a prior way of treatment, performing endovascular intervention in slight clinical severity and aggressive management of the post-procedural clinical disease.

Acute bleeding in the head and neck: angiographic findings and endovascular management

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.