Endovascular Carotid Reconstruction in Palliative Head and Neck Cancer Patients with Threatened Carotid Blowout Presents a Beneficial Supportive Care Measure

Endovascular Management of External Iliac Blowout Syndrome Secondary to Recurrent Sigmoid Cancer

Blowout syndrome caused by vascular invasion is a dreadful complication of late stage malignancies that carry high morbidity and poor overall prognosis in a compromised population. Endovascular management can offer minimally invasive and life-saving alternative for such acute conditions. We describe the case of a 62-year-old man with massive fresh bleeding per rectum and shock resulting from rupture of the left external iliac artery secondary to nearby infiltrative recurrent sigmoid cancer. This complication is rare, presents dramatically, and is frequently fatal. The patient was successfully treated with a stent graft deployment in order to achieve hemostasis and reinstituting the arterial integrity.

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.

A Limited Thoracocervical Approach for Accessing the Anterior Mediastinum in Retrosternal Goiters: Surgical Technique and Implications for the Management of Head and Neck Emergencies

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.

Outcomes of endovascular occlusion and stenting in the treatment of carotid blowout

BACKGROUND AND PURPOSE

Carotid blowout is a life threatening complication of invasive head and neck cancers and their treatments. This is commonly treated with endovascular embolization and carotid stenting. Using the Nationwide Inpatient Sample, we report the immediate clinical results of patients receiving embolization and/or stenting for treatment of carotid blowout associated with head and neck cancer.

MATERIALS AND METHODS

Using the Nationwide Inpatient Sample from the period 2003-2011, we defined carotid blowout patients as those with head and neck malignancies receiving carotid stenting and/or endovascular embolization without open surgery. Outcomes studied included mortality, acute ischemic stroke, hemiplegia/paresis, and other post-operative neurologic complications. Outcomes for the endovascular embolization and carotid stenting group were compared.

RESULTS

A total of 1218 patients underwent endovascular treatment for carotid blowout. Of these, 1080 patients (88.6%) underwent embolization procedures and 138 patients (11.4%) underwent carotid stenting. The mortality rate of endovascular embolization patients was similar to that of carotid stenting patients (8.0%, 95% confidence interval (CI) = 6.5%-9.7% versus 10.2%, 95% CI=6.0%-16.4%, p = 0.36). Stroke rate was similar between embolization patients and stenting patients (2.3%, 95% CI=1.6%-3.4% vs. 3.4%, 95% CI=1.3%-8.4%, p = 0.43). Hemiplegia rates were significantly higher rate in stenting patients compared with endovascular occlusion patients (3.8%, 95% CI=1.3%-8.4% vs. 1.4%, 95% CI=1.4%-2.4%, p = 0.05). The rate of post-operative neurologic complications was higher in stenting patients compared with embolization patients (6.5%, 95% CI=3.3%-12.1% vs. 1.4%, 95% CI=0.9%-2.4%, p < 0.0001).

CONCLUSIONS

Given the natural history of carotid blowout, carotid stenting and endovascular embolization are acceptable means of treating this disease. Endovascular embolization remains the most common treatment among patients with head and neck cancers with lower overall rates of post-operative neurologic complications, including hemiplegia/paresis and stroke.

The role of surgery in the palliation of head and neck cancer

PURPOSE OF REVIEW

The public demands that 'all modes of treatment' should be offered to patients who present with head and neck cancer. Up to 40% of patients present with advanced stage disease, of whom some 10% have metastatic disease and are currently deemed incurable. This review summarizes the current role and philosophy of surgical interventions in the palliation of head and neck cancer.

RECENT FINDINGS

Patients who present with advanced or recurrent head and neck cancers over the past decade have been offered nonsurgical palliative treatments of radiotherapy with or without chemotherapy, with variable responses. The aims are to achieve tumour shrinkage and gain effective relief of symptoms, such as pain, breathing and swallowing. The use of surgery in the palliation of disease and its symptoms has declined significantly since the 1980s. Within the concept of multidisciplinary clinical working as the 'gold standard' for the provision of optimum care for the head and neck patient, the place for surgery should be discussed within the many options available currently.

SUMMARY

Patients who present with advanced, incurable or recurrent head and neck cancer should be made aware of their prognosis and the potential need and benefits of palliative care. The active involvement of patients and their carers, their desires and wishes should be the prime consideration for any interventions. Careful selection of suitable patients can achieve prolonged symptom relief safely and result in an improvement in their quality of living. The ultimate goal should incorporate not only quality of life but quality of dying.

Delayed carotid blow-out syndrome: a new complication of chemoradiotherapy treatment in pharyngolaryngeal carcinoma

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.

Improving end-of-life care for head and neck cancer patients

Despite improvements in the treatment of head and neck cancer, many patients still succumb to their disease. A litany of medical, psychosocial and ethical challenges arise in managing the end-of-life experiences within this patient population. In this article, we attempt to review existing data about the end-of-life experiences of this cohort, extrapolate relevant data from other cancer patients, and suggest the most promising avenues for additional research and practice improvement for terminal head and neck cancer patients. Clinical decision-making for patients dying of head and neck cancer requires proactive consideration of quality of life, functionality, symptom control and other patient-centered objectives, and frequently benefits from palliative care team involvement. Additional research aimed toward optimizing the end of life experience of head and neck cancer patients and their families is greatly needed.

Management of vascular complications of head and neck cancer

Background:

Major vascular complications in patients with head and neck cancer have previously been thought of as terminal events. However, it is now possible to intervene in many situations, with benefits for quality of life as well as survival. Endovascular techniques have reduced morbidity and mortality in many situations, both emergency and elective.

Method:

We describe the techniques that can be employed in such situations, and present illustrative case reports. Life-threatening haemorrhage, carotid compression and radiation-induced carotid stenosis are all discussed.

Conclusion:

It is possible to predict where complications may arise, and to take prophylactic steps to allow treatment to continue. Early intervention can reduce both morbidity and mortality in this high-risk patient group.

Endovascular treatment paradigm of carotid blowout syndrome: review of 8-years experience

OBJECTIVES

Endovascular treatment is effective in treating carotid blowout syndrome (CBS). We reviewed our experience in addressing CBS over eight years and presented an account of the treatment paradigm and management algorithm.

METHOD

All cases of CBS from 2003 to 2010 with endovascular treatment performed in our center were reviewed. 15 CBS in 14 patients were recruited. Based on our management algorithm, treatment regimen was stratified into deconstructive or constructive methods. Their clinical presentations, angiographic features, angiographic and clinical outcomes were reviewed.

RESULTS

10 patients were treated with deconstructive method by means of permanent vessel occlusion (PVO) and 4 patients were treated with constructive method by means of placement of covered stent (n=3) or flow diverting device (n=1). Immediate hemostasis was achieved in all cases. 7 (50%) patients, in whom 5 treated with PVO and 2 with covered stent, had favorable outcomes and survived at a median follow-up period of 4 months (range: 1-84 months).

CONCLUSION

Permanent vessel occlusion remains the gold standard of treatment and tends to show a favorable long-term outcome. Off-label use of covered stent and flow-diverting device can produce satisfactory results should balloon occlusion test fail, but long-term follow up would be required for definitive assessment.

Carotid Blowout in Patients with Head and Neck Cancer

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.