Contemporary management of carotid blowout syndrome utilizing endovascular techniques

Incidence of Carotid Blowout Syndrome in Patients with Head and Neck Cancer after Radiation Therapy: A Cohort Study

Carotid blowout syndrome (CBS) is a rare yet life-threatening complication that occurs after radiation therapy (RT). This study aimed to determine the incidence of CBS in patients with head and neck cancer (HNC) undergoing contemporary RT and to explore potential discrepancies in the risk of CBS between nasopharyngeal cancer (NPC) and non-NPC patients. A total of 1084 patients with HNC who underwent RT between 2013 and 2023 were included in the study. All patients were under regular follow-ups at the radio-oncology department, and underwent annual contrast-enhanced computed tomography and/or magnetic resonance imaging for cancer recurrence surveillance. Experienced neuroradiologists and vascular neurologists reviewed the recruited patients' images. Patients were further referred to the neurology department for radiation vasculopathy evaluation. The primary outcome of this study was CBS. Patients were categorized into NPC and non-NPC groups and survival analysis was employed to compare the CBS risk between the two groups. A review of the literature on CBS incidence was also conducted. Among the enrolled patients, the incidence of CBS in the HNC, NPC, and non-NPC groups was 0.8%, 0.9%, and 0.7%, respectively. Kaplan-Meier analysis revealed no significant difference between the NPC and non-NPC groups (p = 0.34). Combining the findings for our cohort with those of previous studies revealed that the cumulative incidence of CBS in patients with HNC is 5% (95% CI = 3-7%) after both surgery and RT, 4% (95% CI = 2-6%) after surgery alone, and 5% (95% CI = 3-7%) after RT alone. Our findings indicate a low incidence of CBS in patients with HNC undergoing contemporary RT. Patients with NPC may have a CBS risk close to that of non-NPC patients. However, the low incidence of CBS could be a potentially cause of selection bias and underestimation bias.

Endovascular Management of Post-Irradiated Carotid Blowout Syndrome in Patients with Lower Neck Cancers

OBJECTIVE

Lower neck cancers (LNCs) include specific tumour types and have some different vascular supply or collaterals from other head and neck cancers. This prospective study evaluated the outcome of endovascular management of post-irradiated carotid blowout syndrome (PCBS) in patients with LNC by comparing reconstructive management (RE) and deconstructive management (DE).

METHODS

This was a single centre, prospective cohort study. Patients with LNC complicated by PCBS between 2015 and 2021 were enrolled for RE or DE. RE was performed by stent graft placement covering the pathological lesion and preventive external carotid artery (ECA) embolisation without balloon test occlusion (BTO). DE was performed after successful BTO by permanent coil or adhesive agent embolisation of the internal carotid artery (ICA) and ECA to common carotid artery, or ICA occlusion alone if the pathological lesion was ICA only. Cross occlusion included the proximal and distal ends of the pathological lesion in all patients. Re-bleeding events, haemostatic period, and neurological complications were evaluated.

RESULTS

Fifty-nine patients (mean age 58.5 years; 56 male) were enrolled, including 28 patients undergoing RE and 31 patients undergoing DE. Three patients originally grouped to DE were transferred to RE owing to failed BTO. The results of RE vs. DE were as follows: rebleeding events, 13/28 (46%) vs. 10/31 (32%) (p = .27); haemostatic period, 9.4 ± 14.0 months vs. 14.2 ± 27.8 months (p = .59); neurological complication, 4/28 (14%) vs. 5/31 (16%) (p = .84); and survival time, 11.8 ± 14.6 months vs. 15.1 ± 27.5 months (p = .61).

CONCLUSION

No difference in rebleeding risk or neurological complications was observed between the DE and RE groups. RE could be used as a potential routine treatment for PCBS in patients with LNC.

Surgical treatment of carotid blowout syndrome after radiotherapy for head and neck malignant tumors: a single-center experience

To explore the treatments for and manifestations of carotid blowout syndrome (CBS) and to further explore the critical role of high-flow bypass combined with parent artery isolation. The clinical data of nine patients with radiotherapy-related CBS who were admitted to our hospital from March 2020 to March 2023 were retrospectively analyzed. Relevant literature was reviewed. From March 2020 to March 2023, nine CBS patients were admitted to Tianjin Huanhu Hospital, including eight males and one female. Digital subtraction angiography was performed for all the patients; all the pseudoaneurysms were located at the petrous segment of the internal carotid artery. A balloon occlusion test was performed on four patients, which was tolerated by all patients. CT and MRI scans showed seven cases of osteonecrosis combined with infection and two cases of tumor recurrence. Emergency permanent parent artery occlusion was performed on six patients, aneurysm embolization was completed in one case, covered stent implantation was performed in one patient, and three cases were treated by cerebral bypass surgery (including two patients with failed interventional treatment). Rebleeding was found in two patients, and no rebleeding was found in the bypass group. Paralysis was found in three patients, and asymptomatic cerebral infarction without permanent neurologic impairment was found in three patients. Two patients died due to tumor progression. Emergency occlusion surgery is lifesaving in the acute phase of CBS. Endovascular therapy cannot prevent the progression of pseudoaneurysms or lower the recurrence rate of bleeding events. High-flow bypass combined with parent artery isolation is a safe and effective method that may facilitate further surgical treatment. Further research is warranted.

Carotid Blowout Syndrome in Head and Neck Cancer Patients: Management of Patients At Risk for CBS

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.

Management of Double Carotid Blow Out with Definitive Repair After Temporizing Stent Graft Placement

Carotid blowout syndrome is a life-threatening complication for patients with head and neck cancer. Temporizing stent graft procedures improve short-term survival and can be the definitive treatment for various reasons, including a poor oncologic prognosis, unsuitability for definitive reconstruction, or a lack of operative options. A second carotid blowout will often be fatal. Preventing such events requires multidisciplinary strategic planning because of a hostile reoperative field. We have described a case of a 44-year-old man with a history of laryngeal cancer who had experienced a carotid blowout. Treated with a stent graft, the patient had experienced a second event 6 weeks later. Treatment involved excision and suture ligation with rotational muscle flap coverage.

Management of postradiation late hemorrhage following treatment for HPV-positive oropharyngeal squamous cell carcinoma

BACKGROUND

Acute oropharyngeal hemorrhage is a serious complication for patients with oropharyngeal squamous cell carcinoma (OPSCC), particularly in patients with a history of radiation therapy (RT).

METHODS

Retrospective case series from at a tertiary care center for treated patients with HPV-positive OPSCC presenting with oropharyngeal hemorrhage.

RESULTS

Median time from completion of chemoradiation to first hemorrhagic event was 186 days (range 66-1466 days). Seven patients (58%) required intervention to secure their airway. All patients were evaluated for endovascular intervention, six (50%) were embolized. Eight patients (67%) had a second hemorrhagic event; median time to second bleed was 22 days (range 3-90 days).

CONCLUSIONS

Acute oropharyngeal hemorrhage is a sequelae following treatment for HPV-positive OPSCC. The majority of bleeds occurred within a year of completion of treatment. While more research is needed to determine optimal treatment paradigms, endovascular intervention should be considered, even if noninvasive imaging does not demonstrate active bleeding.

Extracranial/Intracranial Vascular Bypass in the Treatment of Head and Neck Cancer - Related Carotid Blowout Syndrome

OBJECTIVE/HYPOTHESIS

To investigate the endovascular intervention or extracranial/intracranial (EC/IC) vascular bypass in the management of patients with head and neck cancer-related carotid blowout syndrome (CBS).

STUDY DESIGN

Retrospective case series.

METHODS

Retrospective analysis of clinical data of patients with head and neck cancer-related CBS treated by endovascular intervention and/or EC/IC vascular bypass, analysis of its bleeding control, neurological complications, and survival results.

RESULTS

Thrity-seven patients were included. Twenty-five were associated with external carotid artery (ECA); twelve were associated with internal or common carotid artery (ICA/CCA). All patients with ECA hemorrhage were treated with endovascular embolization. Of the 12 patients with ICA/CCA hemorrhage, 9 underwent EC/IC bypass, 1 underwent endovascular embolization, and 3 underwent endovascular stenting. For patients with ECA-related CBS, the median survival was 6 months, and the 90-day, 1-year, and 2-year survival rates were 67.1%, 44.7%, and 33.6%, respectively; the estimated rebleeding risk at 1-month, 6-month, and 2-year was 7.1%, 20.0%, and 31.6%, respectively. For patients with ICA/CCA-related CBS, the median survival was 22.5 months, and the 90-day, 1-year, and 2-year survival rates were 92.3%, 71.8%, and 41.0%, respectively; the estimated rebleeding risk at 1 month, 6 months, and 2 years is 7.7%,15.4%, and 15.4%, respectively. ICA/CCA-related CBS patients have significantly longer survival time and lower risk of rebleeding, which may be related to the more use of EC/IC vascular bypass as a definite treatment.

CONCLUSIONS

For patients with ICA/CCA-related CBS, if there is more stable hemodynamics, longer expected survival, EC/IC vascular bypass is preferred.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1548-1556, 2021.

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.

Endovascular Considerations in Traumatic Injury of the Carotid and Vertebral Arteries

Cervical carotid and vertebral artery traumatic injuries can have a devastating natural history. This article reviews the epidemiology, mechanisms of injury, clinical presentation, and classification systems pertinent to consideration of endovascular treatment. The growing role of modern endovascular techniques for the treatment of these diseases is presented to equip endovascular surgeons with a framework for critically assessing patients presenting with traumatic cervical cerebrovascular injury.

Risk factors and nomogram for predicting carotid blowout syndrome based on computed tomography angiography

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.

Initial Data Pooling for Radiation Dose-Volume Tolerance for Carotid Artery Blowout and Other Bleeding Events in Hypofractionated Head and Neck Retreatments

PURPOSE

Dose-volume data for injury to carotid artery and other major vessels in stereotactic body radiation therapy (SBRT)/SABR head and neck reirradiation were reviewed, modeled, and summarized.

METHODS AND MATERIALS

A PubMed search of the English-language literature (stereotactic and carotid and radiation) in April 2018 found 238 major vessel maximum point doses in 6 articles that were pooled for logistic modeling. Two subsequent studies with dose-volume major vessel data were modeled separately for comparison. Attempts were made to separate carotid blowout syndrome from other bleeding events (BE) in the analysis, but we acknowledge that all except 1 data set has some element of BE interspersed.

RESULTS

Prior radiation therapy (RT) dose was not uniformly reported per patient in the studies included, but a course on the order of conventionally fractionated 70 Gy was considered for the purposes of the analysis (with an approximately ≥6-month estimated interval between prior and subsequent treatment in most cases). Factors likely associated with reduced risk of BE include nonconsecutive daily treatment, lower extent of circumferential tumor involvement around the vessel, and no surgical manipulation before or after SBRT.

CONCLUSIONS

Initial data pooling for reirradiation involving the carotid artery resulted in 3 preliminary models compared in this Hypofractionated Treatment Effects in the Clinic (HyTEC) report. More recent experiences with alternating fractionation schedules and additional risk-reduction strategies are also presented. Complications data for the most critical structures such as spinal cord and carotid artery are so limited that they cannot be viewed as strong conclusions of probability of risk, but rather, as a general guideline for consideration. There is a great need for better reporting standards as noted in the High Dose per Fraction, Hypofractionated Treatment Effects in the Clinic introductory paper.

Carotid Blowout Management in the Endovascular Era

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.

Computed Tomography Angiography findings can predict massive bleeding in head and neck tumours

PURPOSE

The aim of our study was to assess CT angiography findings of head and neck tumours in predicting carotid blow out syndrome (CBS).

METHOD

We retrospectively reviewed the records of patients with head and neck cancer who underwent invasive angiography for CBS at our Institution from July 2013-2019. All routine CT angiography scans were assessed for the following findings with a univariate logistic regression analysis: 1) 360 ° involvement of the suspect artery by the tumour; 2) tissue or tumour necrosis, which was defined as an hypodense area with lack of contrast enhancement in the soft tissues of the neck or tumour mass, adjacent to the suspected vessel; 3) calibre reduction of the culprit artery; 5) jugular vein infiltration. T stage was also included in the analysis.

RESULTS

A total of 24 patients who underwent routine CT angiogram neck and embolization for CBS were included in this study. Univariate logistic regression showed as 360 ° involvement of target vessel may significantly increase the risk of bleeding (OR 11.6, CI: 1.4-91.5; p = 0.01), along with T stage (OR 14.0, p = 0.03). Tumour necrosis and calibre vessel reduction were quite influential, but not significantly (i.e. tumour necrosis OR 5.0 95 % CI: 0.8-31.0, p = 0.08). Contingency table analysis found 360 ° vessel involvement with the highest sensitivity and PPV in predicting bleeding (87.5 % and 82.35 %, respectively).

CONCLUSIONS

CT angiography imaging findings have the potential to identify patients with head and neck cancer at higher risk of bleeding.

Carotid blowout syndrome: modern trends in management

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.

Stent grafts in patients with carotid blowout syndrome: Outcome and antiplatelet therapy in preventive versus emergency cases

BACKGROUND

Carotid blowout syndrome due to tumor infiltration, fistulas, and therapy-related necrosis can occur as late as years after the treatment. Reporting our experiences with preventive and acute treatment with stent grafts and discussing different ways of antiplatelet therapy.

METHODS

We reviewed all patients between 2010 and 2016 who underwent stent graft placement and analyzed outcome, complications, and antiplatelet regime.

RESULTS

Seventeen patients were treated in 24 sessions (n = 7 threatened, n = 5 imminent, and n = 12 acute bleeding). The antiplatelet regime covered the entire range from aspirin only to loading doses of aspirin/clopidogrel, perioperative heparin, and aspirin/clopidogrel for 12 months followed by lifelong aspirin. Rare complications were not associated with the preprocedural or periprocedural but were associated with the postprocedural antiplatelet regime.

CONCLUSION

Most complications of stent graft implantations due to a carotid blowout syndrome occur postprocedurally: rare thrombotic events are linked to not taking a medication and frequent rebleedings may be reduced by an earlier reduction of dual-antiplatelet to mono-antiplatelet therapy.

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.

Outcome of carotid and subclavian blowout syndrome in patients with pharynx- and larynx carcinoma passing a standardized multidisciplinary treatment

BACKGROUND

Carotid blowout syndrome (CBS) is one of the most feared emergencies in the head and neck surgery and tends to occur in patients with head and neck cancer, wound complications, pharyngocutaneous fistulas, or after radio(chemo)therapy. CBS is always life threatening and associated with a 50% mortality/morbidity rate.

METHODS

Between 2007 and 2015, a total of 51 patients who developed CBS caused by the tumour masses or after radio(chemo)therapy were included. All patients underwent a standardised bleeding management.

RESULTS

In 86% of patients, CBS was associated with manifest carcinoma. Fifty three percent of patients were treated by transcervical surgery, in 36% of these cases surgery was supplemented by endovascular approaches. Severe complications such as re-bleeding or cerebral ischemia occurred infrequently. Seven patients died because of the acute bleeding.

CONCLUSION

CBS associated with head and neck cancer carries poor mid and long-term prognoses. An interdisciplinary standardised treatment path dramatically reduced overall morbidity and mortality.