Experiences in carotid artery occlusion

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.

Carotid artery erosion in a 4-year child

The carotid erosion occurs most commonly in patients receiving radiotherapy for head and neck cancer and is associated with high mortality. We report a case of carotid blow out in a 4-year-old child who presented with massive parapharyngeal space abscess. The common carotid artery (CCA) was ligated and child recovered without any neurological sequel.

Surgical palliation of head and neck cancer

Palliative care in head and neck cancer has not been studied systematically. Patients with incurable head and neck tumors may live months and even years. Ideal palliation should enable them to engage in a normal life before death ensues. It is likely that our improving ability to treat these tumors without achieving cures will cause people to live longer with their cancer. Hence, the need for palliation will probably increase. Also, treatments that cure patients produce conditions that require palliation. Achievement of the best possible function is the major consideration in dealing with head and neck tumors. Difficulty with speech, swallowing, oral hygiene, and laodorous tumors are all common. Depression too should be addressed in a comprehensive fashion by the "head and neck team". The surgeon, radiotherapist, and medical oncologist will need help from dentists, prosthodontists, dental hygienists, psychiatrists, physiatrists, occupational and physical therapists, visiting nurses, nutritionists, and social workers. Palliative care in the hospital is the least desirable, although often unavoidable. Proper hospice support will benefit patients and their families.

Emergency management of carotid artery rupture

Rupture of the carotid artery has been one of the most feared postoperative complications in head and neck cancer patients. Traditional management of carotid artery rupture has been disappointing, and morbidity and mortality have been high. Experience with carotid artery rupture at the authors' institution over the past 20 years has been reviewed. The current method of management seems to result in a decreased number of neurologic sequelae and episodes of rebleeding. Of the last 23 carotid ruptures encountered, four occurred while the patient was at home. Two patients had neurologic complications, and there were two deaths. Only one episode of rebleeding occurred. All patients except one were discharged from the hospital. These patients were managed according to an established protocol, and the results of the authors' experience are reported and analyzed. Preoperative preparation prior to ligation is explained, and prognostic indicators and risk factors are reviewed.

Resection and reconstruction of the carotid artery in metastatic squamous cell carcinoma

Although it is uncommon to consider resection of the common and internal carotid arteries for involvement by carcinoma, nevertheless, if this is the only significant finding precluding an adequate ablative procedure, this operation is worthy of consideration. Ten procedures were performed in nine such patients; the carotid bifurcation was resected and continuity reestablished using Teflon or autogenous saphenous vein grafts. In attempting to predict the efficiency of the collateral cerebral cross-flow, arteriography, oculopneumoplethysmography and intraoperative measurement of carotid stump pressure were used in some patients. There was no operative mortality. The postoperative mortality rate was 20 percent and cerebrovascular complications occurred in 20 percent of the cases. Seven patients survived 19 months to 4 1/4 years. Teflon grafts appeared to have a higher patency rate than saphenous vein autogenous grafts. Although this series is very small, it is an evaluation of a procedure of last resort which appears worthwhile in carefully selected patients.

Analysis of factors affecting complications of carotid ligation

A study of 156 patients subjected to common carotid ligation in the treatment of head and neck carcinoma was made to investigate the influence of selected factors on cerebral complications. In the analysis complications were grouped as death or coma; death, coma, hemiplegia or monoplegia; and transitory cerebral symptoms. Primary independent variables included method of occlusion (abrupt, gradual); duration of occlusion; and collateral circulation via the external carotid artery (intact, ligated external carotid artery). Death or coma occurred in 24 cases (15.4%) and complications including death, coma, hemiplegia or monoplegia occurred in 47 cases (30.1%). Although no statistically significant difference between abrupt and gradual occlusion cases was noted, the incidence of cerebral complications was significantly lower for the group with gradual carotid occlusions performed over 13 days (6.3%) than for those with abrupt occlusions or gradual occlusions performed in less than five days. The incidence of death or coma following carotid artery occlusion was 10.5% in cases with an intact external carotid artery, as against 25.5% in those with a ligated external carotid artery, a statistically significant difference. Cerebral complications occurred within 48 hours after carotid occlusion in 35 of 47 cases (74.5%) in which complications developed. In the remaining 12 cases (25.5%) complications developed after 48 hours. There was no difference between abrupt and gradual occlusion cases in the incidence of complications after 48 hours.

Carotid arterial hemorrhage after radical head and neck surgery

From 1960 to 1974, 63 patients treated by the Head and Neck Service of Memorial Hospital underwent carotid arterial ligation for control of actual or threatened carotid rupture. Twenty-one of these patients died without leaving the hospital. Fourteen of these deaths were the direct result of carotid ligation or hemorrhage. Five of the surviving patients suffered permanent neurologic damage. Factors predisposing to carotid rupture included a history of radiation, advanced disease, the presence of an oral or pharyngeal suture line in continuity with a dissected neck, and the postoperative development of skin necrosis or fistulas. Because elective carotid ligation did not prevent the consequences of carotid rupture and because reestablishment of vascular continuity is almost never possible, all attempts should be made to avoid the conditions that are precursors to this most serious complication of radical head and neck surgery.

The importance of tumor attachment to the carotid artery

The records of 508 patients who had undergone radical neck dissection were reviewed. Twenty-eight of these patients (5.5%) were found to have tumor attached to the carotide arterial system. Twenty-four patients (86%) died with tumor, the mean survival time being 16.9 months. Local recurrence of tumor in the neck occurred in 46% of the patients and distant metastases in 67%. Eighteen percent of those who developed local recurrence did so in the absence of distant metastases and might have benefited from a more aggressive approach toward the tumor.

Recognizing and treating deep neck infection

Deep neck infection has ominous implications if not detected and treated in an early stage. The anatomic relationships of head and neck spaces encourage spread of infection. Immediate hospitalization and constant monitoring of the patient after diagnosis are mandatory.