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Yunaiyama D, Takara Y, Kobayashi T, Muraki M, Tanaka T, Okubo M, Saguchi T, Nakai M, Saito K, Tsukahara K, Ishii Y, Homma H. Transcatheter arterial embolization for traumatic injury to the pharyngeal branch of the ascending pharyngeal artery: Two case reports. World J Clin Cases 2022; 10:12015-12021. [PMID: 36405265 PMCID: PMC9669858 DOI: 10.12998/wjcc.v10.i32.12015] [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: 08/01/2022] [Revised: 09/13/2022] [Accepted: 10/17/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The ascending pharyngeal artery (APhA) comprises the pharyngeal trunk (PT) and neuromeningeal trunk. The PT feeds the nasopharynx and adjacent tissue, which potentially connects with the sphenopalatine artery (SPA), branched from the internal maxillary artery (IMA). Due to its location deep inside the body, the PT is rarely injured by trauma. Here, we present two cases that underwent transcatheter arterial embolization (TAE) of the PT of the APhA due to trauma and iatrogenic procedure.
CASE SUMMARY Case 1 is a 49-year-old Japanese woman who underwent transoral endoscopy under sedation for a medical check-up. The nasal airway was inserted as glossoptosis occurred during sedation. Bleeding from the nasopharynx was observed during the endoscopic procedure. As the bleeding continued, the patient was referred to our hospital for further treatment. Contrast-enhanced computed tomography (CT) demonstrated extravasation in the nasopharynx originating from the right Rosenmuller fossa. TAE was performed and the extravasation disappeared after embolization. Case 2 is a 28-year-old Japanese woman who fell from the sixth floor of a building and was transported to our hospital. Contrast-enhanced CT demonstrated a complex facial fracture accompanying extravasation in the left pterygopalatine fossa to the nasopharynx. Angiography demonstrated an irregular third portion of the IMA. As angiography after TAE of the IMA demonstrated extravasation from the PT of the APhA, additional TAE to the artery was performed. The bleeding stopped after the procedure.
CONCLUSION Radiologists should be aware that the PT of the APhA can be a bleeding source, which has a potential connection with the SPA.
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Affiliation(s)
- Daisuke Yunaiyama
- Department of Radiology, Tokyo Medical University Hospital, Shinjuku-ku 160-0023, Japan
| | - Yuki Takara
- Department of Radiology, Tokyo Medical University Hospital, Shinjuku-ku 160-0023, Japan
| | - Takehiro Kobayashi
- Department of Radiology, Tokyo Medical University Hospital, Shinjuku-ku 160-0023, Japan
| | - Mika Muraki
- Department of Radiology, Tokyo Medical University Hospital, Shinjuku-ku 160-0023, Japan
| | - Taro Tanaka
- Department of Radiology, Tokyo Medical University Hospital, Shinjuku-ku 160-0023, Japan
| | - Mitsuru Okubo
- Department of Radiology, Tokyo Medical University Hospital, Shinjuku-ku 160-0023, Japan
| | - Toru Saguchi
- Department of Radiology, Tokyo Medical University Hospital, Shinjuku-ku 160-0023, Japan
| | - Motoki Nakai
- Department of Radiology, Tokyo Medical University Hospital, Shinjuku-ku 160-0023, Japan
| | - Kazuhiro Saito
- Department of Radiology, Tokyo Medical University Hospital, Shinjuku-ku 160-0023, Japan
| | - Kiyoaki Tsukahara
- Department of Otorhinolaryngology, Head and Neck Surgery, Tokyo Medical University Hospital, Shinjuku-ku 160-0023, Japan
| | - Yuri Ishii
- Department of Emergency and Critical Care Medicine, Tokyo Medical University Hospital, Shinjuku-ku 160-0023, Japan
| | - Hiroshi Homma
- Department of Emergency and Critical Care Medicine, Tokyo Medical University Hospital, Shinjuku-ku 160-0023, Japan
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Mao MH, Fan Y, Qiu R, Ren L, Hu A, Li JL, Han ZX. A Newly Designed Seed-Loading Device for Verifying the Safety of 125I Implants to the Canine Carotid Artery. Radiat Res 2021; 196:175-182. [PMID: 33979443 DOI: 10.1667/rade-21-00020.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 04/13/2021] [Indexed: 11/03/2022]
Abstract
A seed-loading device was designed and modeled using the Monte Carlo method to verify the biological effect of iodine-125 (125I) particles on blood vessels through animal experiments. The dose distribution characteristics of irradiated vessels were established by adjusting the design variables and geometry. The deviation between the actual value and the theoretical value was verified in vitro by the thermoluminescence dosimetry (TLD) method. After verification, the device was used to examine the biological effect of 125I irradiation of canine carotid arteries in two dogs (and one control dog) for 180 days. The hollow cylinder seed-loading device was constructed with an inner diameter of 0.5 cm and a length of 3.3 cm. When six seeds were loaded into a single layer, the source strength ratio of the intermediate layer to the edge layer was 0.7:1. When six layers of seeds were arranged at 0.45-cm intervals, the deviations between the maximum, minimum and mean energy fluence within 2.25 cm of the vessel wall were 2.19% and -4.12%, respectively, and -9% and 4%, respectively, when verified in vitro using TLD. The carotid arteries showed good tolerance to 0.56 kGy (range of 0.51-0.58 kGy) after 180 days of irradiation. In conclusion, this 125I seed-loading device overcomes the random distribution of seeds and lays an accurate radiophysical foundation for subsequent biological experiments. The preliminary results showed that the carotid artery has good tolerance to 0.56 kGy irradiation.
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Affiliation(s)
- Ming-Hui Mao
- Department of Oral and Maxillary Surgery, Beijing Stomatological Hospital, Capital Medical University, Beijing, 100050, P.R. China
| | - Yi Fan
- Department of Orthodontics, Peking University School and Hospital of Stomatology, Beijing, China.,National Clinical Research Center for Oral Diseases and National Engineering Laboratory for Digital and Material Technology of Stomatology and Beijing Key Laboratory of Digital Stomatology, Beijing, China
| | - Rui Qiu
- Department of Engineering Physics, Tsinghua University, Beijing, 100084, P.R. China.,Key Laboratory of Particle and Radiation Imaging (Tsinghua University), Ministry of Education, Beijing, 100084, P.R. China
| | - Li Ren
- Nuctech Company Limited, Beijing, 100084, P.R. China
| | - Ankang Hu
- Department of Engineering Physics, Tsinghua University, Beijing, 100084, P.R. China.,Key Laboratory of Particle and Radiation Imaging (Tsinghua University), Ministry of Education, Beijing, 100084, P.R. China
| | - Jun-Li Li
- Department of Engineering Physics, Tsinghua University, Beijing, 100084, P.R. China.,Key Laboratory of Particle and Radiation Imaging (Tsinghua University), Ministry of Education, Beijing, 100084, P.R. China
| | - Zheng-Xue Han
- Department of Oral and Maxillary Surgery, Beijing Stomatological Hospital, Capital Medical University, Beijing, 100050, P.R. China
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Luo CB, Tsuei YS, Chang FC, Ting TW. Verification of bleeding points in carotid blowout syndrome using guidewire manipulation. Neuroradiology 2018; 60:835-841. [PMID: 29947941 DOI: 10.1007/s00234-018-2044-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 05/29/2018] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Chao-Bao Luo
- Department of Radiology, Taipei Veterans General Hospital, No 201, Sec. 2, Shih-Pai Road, Beitou, Taipei, 112, Taiwan, Republic of China.
- Department of Radiology, National Defense Medical Center, Taipei, Taiwan.
| | - Yuang-Seng Tsuei
- Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Neurosurgery, National Defense Medical Center, Taipei, Taiwan
| | - Feng-Chi Chang
- Department of Radiology, Taipei Veterans General Hospital, No 201, Sec. 2, Shih-Pai Road, Beitou, Taipei, 112, Taiwan, Republic of China
- Department of Radiology, National Yang-Ming University, School of Medicine, Taipei, Taiwan
| | - Ta-Wei Ting
- Department of Radiology, Tri-Service General Hospital, Taipei, Taiwan
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Timely Antecedent CT or MRI Can Help Predict Hemorrhage Site of Posttreatment Head and Neck Cancer, With Digital Subtraction Angiography Used as the Reference Standard. AJR Am J Roentgenol 2016; 206:829-36. [DOI: 10.2214/ajr.15.15354] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Irradiated superficial femoral artery rupture after free flap: a case report and review of the literature. Ann Plast Surg 2016; 74 Suppl 1:S15-8. [PMID: 25774967 DOI: 10.1097/sap.0000000000000432] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Radical oncologic resection can result in large soft tissue defects with exposure of underlying vessels. Unless immediately covered with viable soft tissue, these vessels are vulnerable to desiccation from air exposure and mechanical trauma. Local radiation treatment also contributes to a decline in vessel wall strength. We present an index case of a patient with prolonged exposure of her femoral bone and superficial femoral artery after an initial failed reconstruction of a soft tissue sarcoma resection defect. We provided coverage using a free latissimus dorsi muscle flap. Two weeks after the initial free flap operation, the patient was readmitted to emergency service with profuse bleeding from beneath the free flap. Intraoperative inspection revealed a 2-cm defect of the irradiated superficial femoral artery. The defect was repaired with cryopreserved human arterial graft, and the flap was reset. This case highlights the importance of immediate coverage of soft tissue defects after oncologic resection. If any vessels are left exposed, they should be closely inspected before a delayed flap coverage to rule out future sources of bleeding that may jeopardize the outcomes of an otherwise successful free flap operation.
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Temporal Evolution of Parotid Volume and Parotid Apparent Diffusion Coefficient in Nasopharyngeal Carcinoma Patients Treated by Intensity-Modulated Radiotherapy Investigated by Magnetic Resonance Imaging: A Pilot Study. PLoS One 2015; 10:e0137073. [PMID: 26323091 PMCID: PMC4556378 DOI: 10.1371/journal.pone.0137073] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 08/12/2015] [Indexed: 12/18/2022] Open
Abstract
Purpose To concurrently quantify the radiation-induced changes and temporal evolutions of parotid volume and parotid apparent diffusion coefficient (ADC) in nasopharyngeal carcinoma (NPC) patients treated by intensity-modulated radiotherapy by using magnetic resonance imaging (MRI). Materials and Methods A total of 11 NPC patients (9 men and 2 women; 48.7 ± 11.7 years, 22 parotid glands) were enrolled. Radiation dose, parotid sparing volume, severity of xerostomia, and radiation-to-MR interval (RMI) was recorded. MRI studies were acquired four times, including one before and three after radiotherapy. The parotid volume and the parotid ADC were measured. Statistical analysis was performed using SPSS and MedCalc. Bonferroni correction was applied for multiple comparisons. A P value less than 0.05 was considered as statistically significant. Results The parotid volume was 26.2 ± 8.0 cm3 before radiotherapy. The parotid ADC was 0.8 ± 0.15 × 10−3 mm2/sec before radiotherapy. The parotid glands received a radiation dose of 28.7 ± 4.1 Gy and a PSV of 44.1 ± 12.6%. The parotid volume was significantly smaller at MR stage 1 and stage 2 as compared to pre-RT stage (P < .005). The volume reduction ratio was 31.2 ± 13.0%, 26.1 ± 13.5%, and 17.1 ± 16.6% at stage 1, 2, and 3, respectively. The parotid ADC was significantly higher at all post-RT stages as compared to pre-RT stage reciprocally (P < .005 at stage 1 and 2, P < .05 at stage 3). The ADC increase ratio was 35.7 ± 17.4%, 27.0 ± 12.8%, and 20.2 ± 16.6% at stage 1, 2, and 3, respectively. The parotid ADC was negatively correlated to the parotid volume (R = -0.509; P < .001). The parotid ADC was positively associated with the radiation dose significantly (R2 = 0.212; P = .0001) and was negatively associated with RMI significantly (R2 = 0.203; P = .00096) significantly. Multiple regression analysis further showed that the post-RT parotid ADC was related to the radiation dose and RMI significantly (R2 = 0.3580; P < .0001). At MR stage 3, the parotid volume was negatively associated with the dry mouth grade significantly (R2 = 0.473; P < .0001), while the parotid ADC was positively associated with the dry mouth grade significantly (R2 = 0.288; P = .015). Conclusion Our pilot study successfully demonstrates the concurrent changes and temporal evolution of parotid volume and parotid ADC quantitatively in NPC patients treated by IMRT. Our results suggest that the reduction of parotid volume and increase of parotid ADC are dominated by the effect of acinar loss rather than edema at early to intermediate phases and the following recovery of parotid volume and ADC toward the baseline values might reflect the acinar regeneration of parotid glands.
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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: 0.9] [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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Leclère F, Mordon S, Ramboaniaina S, Schoofs M. Reconstruction mammaire en terrain irradié par lambeau libre DIEP compliqué d’une rupture spontanée de l’artère mammaire interne : à propos d’un cas. ANN CHIR PLAST ESTH 2010; 55:593-6. [DOI: 10.1016/j.anplas.2009.11.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2009] [Accepted: 11/26/2009] [Indexed: 12/16/2022]
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Cengiz M, Özyiğit G, Yazici G, Doğan A, Yildiz F, Zorlu F, Gürkaynak M, Gullu IH, Hosal S, Akyol F. Salvage reirradiaton with stereotactic body radiotherapy for locally recurrent head-and-neck tumors. Int J Radiat Oncol Biol Phys 2010; 81:104-9. [PMID: 20675075 DOI: 10.1016/j.ijrobp.2010.04.027] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Revised: 03/19/2010] [Accepted: 04/26/2010] [Indexed: 12/19/2022]
Abstract
PURPOSE In this study, we present our results of reirradiation of locally recurrent head-and-neck cancer with image-guided, fractionated, frameless stereotactic body radiotherapy technique. METHODS AND MATERIALS From July 2007 to February 2009, 46 patients were treated using the CyberKnife (Accuray, Sunnyvale, CA) at the Department of Radiation Oncology, Hacettepe University, Ankara, Turkey. All patients had recurrent, unresectable, and previously irradiated head-and-neck cancer. The most prominent site was the nasopharynx (32.6%), and the most common histopathology was epidermoid carcinoma. The planning target volume was defined as the gross tumor volume identified on magnetic resonance imaging and computed tomography. There were 22 female and 24 male patients. Median age was 53 years (range, 19-87 years). The median tumor dose with stereotactic body radiotherapy was 30 Gy (range, 18-35 Gy) in a median of five (range, one to five) fractions. RESULTS Of 37 patients whose response to therapy was evaluated, 10 patients (27%) had complete tumor regression, 11 (29.8%) had partial response, and 10 (27%) had stable disease. Ultimate local disease control was achieved in 31 patients (83.8%). The overall survival was 11.93 months in median (ranged, 11.4-17.4 months), and the median progression free survival was 10.5 months. One-year progression-free survival and overall survival were 41% and 46%, respectively. Grade II or greater long-term complications were observed in 6 (13.3%) patients. On follow-up, 8 (17.3%) patients had carotid blow-out syndrome, and 7 (15.2%) patients died of bleeding from carotid arteries. We discovered that this fatal syndrome occurred only in patients with tumor surrounding carotid arteries and carotid arteries receiving all prescribed dose. CONCLUSIONS Stereotactic body radiotherapy is an appealing treatment option for patients with recurrent head-and-neck cancer previously treated with radiation to high doses. Good local control with considerable 1-year survival is achieved with a relatively high rate of morbidity and related mortality.
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Affiliation(s)
- Mustafa Cengiz
- Department of Radiation Oncology, Hacettepe University, Faculty of Medicine, Ankara, Turkey.
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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: 5.9] [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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Chen YF, Lo YC, Lin WC, Lin CH, Chiang HJ, Chen JF, Shen WC. Transarterial embolization for control of bleeding in patients with head and neck cancer. Otolaryngol Head Neck Surg 2009; 142:90-4. [PMID: 20096229 DOI: 10.1016/j.otohns.2009.09.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Revised: 08/18/2009] [Accepted: 09/29/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This study evaluated the efficacy of transarterial embolization for the treatment of tumor bleeding in neck tumors following radiation or chemotherapy. STUDY DESIGN We performed a case series with chart review of 25 patients with clinically suspected tumor bleeding that occurred in the period between August 2003 and April 2007. SETTING All patients were admitted to and accepted treatment at China Medical University Hospital, Taiwan, R.O.C. SUBJECTS AND METHODS Twenty-five male patients (aged 32 to 88 years) with pathologically verified malignant carcinomas of the neck received radiotherapy (n = 6), radiotherapy and chemotherapy (n = 7), or initial surgery and palliative radiotherapy or chemotherapy (n = 12). Carotid artery angiography was performed to detect tumor bleeding, and affected vessels were embolized using either Gelfoam sponge (or cubes), coils, microcoils, or a combination of these methods. RESULTS By angiography, patients showed tumor vessels with tumor stain (n = 13), extravasation of the contrast agent (n = 7), stenotic vessels (n = 5), pseudoaneurysm (n = 4), and arteriovenous shunt (n = 1). Transarterial embolization was performed with catheter insertion through the branches of the external carotid artery (n = 18), the external carotid artery (n = 5), or the internal carotid artery (n = 1). All patients showed dramatic clinical improvement following embolization. Patients with tongue cancer had the longest average post-transarterial embolization hospital stay (21 days) and the highest incidence of aspiration pneumonia (3/9). After two months of follow-up, five patients had experienced rebleeding. CONCLUSION Specific vessel injuries following radiation or chemotherapy require different kinds of endovascular treatment. Patients with tongue cancer should be carefully monitored for aspiration pneumonia.
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Affiliation(s)
- Yung-Fang Chen
- Department of Radiology, China Medical University Hospital, Taichung, Taiwan
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