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Carotid artery rupture is fortunately an uncommon complication of head and neck cancer treatment. Eleven episodes of carotid artery rupture following irradiation and major head and neck resection were identified over a 6-year period. We review our experience and discuss the predisposing factors that can cause this complication, important aspects of...
Context in source publication
Context 1
... common carotid artery was ligated or re- sected in two cases. Soft tissue coverage was affected using a variety of flaps (five pectoralis major, four la- tissimus dorsi, one buccal flap and one free latissimus dorsi) (Table 3). In cases of common carotid artery ligation or resection, preservation of the external carotid artery may allow satisfactory internal artery perfusion from reverse flow from the external carotid via the car- otid bifurcation. ...
Citations
... Iatrogenic carotid artery rupture has been reported to occur in 3%-5% of patients who undergo major head and neck surgery (6). In addition, it can occur during transsphenoidal surgery. ...
Common carotid artery (CCA) rupture during parathyroid cancer surgery is extremely rare and is generally
life-threatening. We present a case of successful management of a ruptured CCA following the
emergency placement of stent-graft in a 59-year-old male diagnosed with recurrent parathyroid cancer.
During recurrent parathyroid cancer surgery, his right CCA ruptured unexpectedly, and his vital signs deteriorated
rapidly despite surgical management. After stent replacement, his unstable vital signs improved
and, thereafter, he was discharged without any complications.
... Tumour recurrence and progression additionally predispose patients to CBS. Acute CBS carries a high morbidity and mortality necessitating prompt resuscitation [2,3]. Herein we present the only reported case of three consecutive carotid artery blow outs in a head and neck cancer patient. ...
Introduction and importance
Carotid artery blowout syndrome is a rare complication of head and neck cancer treatment. It defines a rupture of the carotid artery wall through vessel wall necrosis. This is typically precipitated by radiotherapy, direct tumour invasion, or a combination of these factors. We describe a rare case of three consecutive carotid artery blowouts in a head and neck cancer patient.
Case presentation
A 58-year-old man with a history of T3NO hypopharyngeal squamous cell carcinoma (SCC) treated with chemotherapy and radiation presented with a four-month history of progressive dysphagia and right sided neck pain. Flexible nasendoscopy revealed laryngeal oedema and slough. A panendoscopy and biopsy showed no evidence of tumour recurrence. The patient was discharged and represented with worsening dyspnoea. He subsequently experienced a large volume hemorrhage necessitating ligation of his right external carotid artery. He underwent pharyngolaryngectomy indicated due to the extent of laryngeal radiation necrosis. Thereafter he suffered two additional acute carotid bleeds from his right common carotid necessitating ligation in theatre.
Clinical discussion and conclusion
This case report illustrates the key issues to be considered in patients with locally advanced hypopharyngeal squamous cell carcinoma and subsequent management of acute carotid blowout syndrome, which without prompt management, can be fatal.
... The mortality rate of CBS ranges from 3% to 50% in the literature [23,24]. The recent largest cohort study on CBS from Chen et al. reported a 30-day mortality rate of 21.8% in patients undergoing emergency management [20]. ...
Background and Objectives: The purpose of the present study was to elucidate the in-hospital and long-term outcomes of patients with head and neck cancer (HNC) bleeding and to analyze the risk factors for mortality. Materials and Methods: We included patients who presented to the emergency department (ED) with HNC bleeding. Variables of patients who survived and died were compared and associated factors were investigated by logistic regression and Cox’s proportional hazard model. Results: A total of 125 patients were enrolled in the present study. Fifty-nine (52.8%) patients experienced a recurrent bleeding event. The in-hospital mortality rate was 16%. The overall survival at 1, 3 and 5 years was 48%, 41% and 34%, respectively. The median survival time was 9.2 months. Multivariate logistic regression analyses revealed that risk factors for in-hospital mortality were inotropic support (OR = 10.41; Cl 1.81–59.84; p = 0.009), hypopharyngeal cancer (OR = 4.32; Cl 1.29–14.46; p = 0.018), and M stage (OR = 5.90; Cl 1.07–32.70; p = 0.042). Multivariate Cox regression analyses indicate that heart rate >110 (beats/min) (HR = 2.02; Cl 1.16–3.51; p = 0.013), inotropic support (HR = 3.25; Cl 1.20–8.82; p = 0.021), and hypopharygneal cancer (HR = 2.22; Cl 1.21–4.06; p = 0.010) were all significant independent predictors of poorer overall survival. Conclusions: HNC bleeding commonly represents the advanced disease stage. Recognition of associated factors aids in the risk stratification of patients with HNC bleeding.
... The underlying reasons are pneumonia [87], myocardial infarction [53], or rupture of the common or external carotid artery [87]. The rare complication of carotid artery rupture is probably due to the subacute exposure of the vessel with a disorder of wound healing such as dehiscence, dislocation of the graft, fistula formation, tissue necrosis or previous radiotherapy [88]. ...
Simple Summary
Complete removal of the larynx (total laryngectomy) offers a curative approach for advanced laryngeal and pharyngeal cancer. If the operation is performed after radiotherapy wound healing problems have to be taken into account which can be managed by adapted reconstructive techniques. Laryngectomy results in the loss of voice which can be managed e.g., by using a voice prosthesis with a significant increase in quality of life. Total laryngectomy still represents a relevant surgical procedure in modern head and neck oncology.
Abstract
Surgical removal of the larynx (total laryngectomy) offers a curative approach to patients with advanced laryngeal and hypopharyngeal (squamous cell) cancer without distant metastases. Particularly in T4a carcinoma, laryngectomy seems prognostically superior to primary radio(chemo)therapy. Further relevant indications for laryngectomy include massive laryngeal dysfunction associated with aspiration and recurrence after radio(chemo)therapy, resulting in salvage surgery. The surgical procedure including neck dissection is highly standardised and safe. The resulting aphonia can be compensated by functional rehabilitation (e.g., voice prosthesis) associated with a significant quality of life improvement. This article presents an overview of indications, preoperative diagnostics, surgical procedures, including new developments (robotics), possible complications, the choice of adjuvant treatment, alternative therapeutic approaches, rehabilitation and prognosis. In summary, total laryngectomy still represents a relevant surgical procedure in modern head and neck oncology.
... However, surgical techniques that remove or weaken the carotid adventitia during resection of head and neck cancers have been critiqued as increasing the likelihood of carotid artery rupture, especially if the patient receives radiation. [16][17][18] Pseudoaneurysm may also be a complication of the weakening of the carotid artery wall. 19 Subadventitial dissection would potentially have a higher likelihood of leading to pseudoaneurysm and rupture. ...
... 20,21 Radiation has been shown to induce aneurysm and carotid artery rupture. 17,22,23 Radiation has also been linked to adverse effects including mucositis, xerostomia, dysphagia, dysphonia, nerve paralysis, coronary artery disease, carotid artery stenosis, cerebrovascular accident, and radiation-induced cancer. [24][25][26][27][28][29][30] However, radiotherapy is used for head and neck paraganglioma when the risk of morbidity from resection is high, particularly in non-CBT paraganglioma. ...
This study examines whether surgical resection of carotid body tumors (CBTs) is acceptable in light of potential significant neurologic complications. This IRB-approved retrospective study analyzed data from 24 patients undergoing surgical treatment for CBTs between April 1998 and April 2017 at Mayo Clinic (Florida campus only). For patients who underwent multiple CBT resections, only data from the first surgery was used in this analysis. CBT resection occurred in 24 patients with the following demographics: fourteen patients (58.3%) were female, median age was 56.5 years, median BMI was 29. A prior history of neoplasm was found in ten patients (41.7%). A known family history of paraganglioma was present in five patients (20.8%). Two patients were positive for succinate dehydrogenase mutation (8.3%). Multiple paragangliomas were present in seven patients (29.2%). There was nerve sacrifice in three patients (12.5%) during resection. Carotid artery reconstruction and patch angioplasty occurred in one patient (4.2%). Complete resection occurred in 24 patients (100.0%). Postoperatively, one patient (4.2%) suffered stroke. No mortalities occurred within or beyond 30 days of surgery. Persistent cranial nerve injury occurred in two patients (8.3%) with vocal cord paralysis. There was no recurrence of CBT through last follow-up. Five patients (20.8%) were diagnosed with other neoplasms after resection, including basal cell carcinoma, contralateral carotid body tumor, glomus vagale, and glomus jugulare. There was 100% survival at 1 year in patients followed for that time ( n = 17). Surgical treatment remains the first-line curative treatment to relieve symptoms and ensure non-recurrence. While acceptable, neurologic complications are significant and therefore detailed preoperative informed consent is mandatory.
... In addition, the re-bleeding rate was 27% after treatment. With respect to adverse effects, permanent vessel occlusion results in immediately higher cerebral ischemia, and stenting induces potentially delayed complications [8,9] . There are no randomized prospective studies evaluating differences in survival outcomes between coil embolization and stenting. ...
Background:
Carotid blowout syndrome (CBS) is a rupture of the carotid artery and is mainly caused by radiation and resection of head and neck cancers or direct tumor invasion of the carotid artery wall. It is a life-threatening clinical situation. There is no established and effective mode of management of CBS. Furthermore, there is no established preceding sign or symptom; therefore, preventive efforts are not clinically meaningful.
Case summary:
We described two cases of CBS that occurred in patients with head and neck cancer after definitive chemoradiotherapy (CRT) using three-dimensional conformal intensity-modulated radiation therapy. Two men aged 61 and 56 years with locally advanced head and neck cancer were treated with definitive CRT. After completing CRT, both of them achieved complete remission. Subsequently, they had persistent severe pain in the oropharyngeal mucosal region and the irradiated neck despite the use of opioid analgesics and rehabilitation for relief of contracted skin. However, continuous follow-up imaging studies showed no evidence of cancer recurrence. Eleven to twelve months after completing CRT, the patients visited the emergency room complaining about massive oronasal bleeding. Angiograms showed rupture of carotid artery pseudoaneurysms on the irradiated side. Despite attempting to secure hemostasis with carotid arterial stent insertion and coil embolization, both patients died because of repeated bleeding from the pseudoaneurysms.
Conclusion:
In patients with persistent pain in irradiated sites, clinicians should be suspicious of progressing or impending CBS, even in the three-dimensional conformal intensity-modulated radiation therapy era.
... The average mortality and morbidity rate in recent meta-analysis depicted that the average mortality after re-radiation of recurrent head and neck cancer reached up to 76%, and the neurological sequel of patients surviving an acute episode of CBS was found to be ranging from 16% to 50% [48]. ...
... In a huge study made by Chen et al. [18] on 3876 patients in a period of 10 years it has been shown to have the following results: 46% of the patients who had CBS and underwent endovascular procedures developed rebleeding and 14.9% had neurological squeal after emergency management. The rate of death within 30 days after emergency management of CBS was 28.1% which was almost in coherence with previous studies [4,11,21,22,48]. ...
Carotid blowout syndrome (CBS) is one of the most dreaded complications of neck dissection. CBS was once shown to have a high morbidity and mortality rates in all of its three types; however, with recent advancement in the medical field these rates decreased considerably. Surgeons and medical practitioners must have a thorough knowledge about this serious condition and the different ways of managing it. This paper is an overview of the syndrome discussing all that has been published about its methods of diagnosis, known risk factors and its numerous management techniques.
... It can be very serious in that it prevents wound healing, prolonged dependence on tube feeding and can cause serious complications. A study by Upile et al. concluded that salivary fistula may involve the carotid sheath causing degradation by the salivary enzyme resulting in devastating carotid blowout [12]. Many have suggested ways to deal with postoperative salivary fistula after head and neck surgery; some suggested aggressive surgical intervention such as debridement of all devitalized tissues, and closure by re-elevation of previously used flaps or with additional flaps [11,13,14]. ...
Orocutaneous fistula is not an uncommon complication of neck dissection. It has been stated to have an incidence of 13.5-29% in local or regional flap. It can be a serious complication due to delay in wound healing, prolonged dependence on nasogastric tube and sometimes carotid sheath rupture. Many approaches have been proposed in the management of orocutaneous fistula and surgery was almost always advocated. Here we present a case of squamous cell carcinoma (SCC) of the tongue that underwent an operation of partial glossotomy and modified radical neck dissection that developed orocutaneous fistula postoperatively. We managed the case by conservative approach that had shown great success.
... In some patients, the hemorrhage may be delayed more than 2-3 months after resection. 19,23 The rupture site often occurs in a segment of arteriosclerotic change with stenosis. 24 Bilateral, CBS is extremely rare, and encountered in only 2% of a cohort of 140 patients who experienced CBS. ...
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.
... This pooled saliva may precipitate fistula formation in patients with poor oral hygiene and exacerbate surgical site infection, causing the wound healing process to deteriorate further. Moreover, salivary leakage through the fistula tract during the postoperative period exposes the carotid to the enzymatic action of saliva and increases the risk of devastating carotid blowout [19]. ...
Background:
Although previous studies have focused on determining prognostic and causative variables associated with fistula-related complications after head and neck reconstructive surgery, only a few studies have addressed preventive measures. Noting that pooled saliva complicates wound healing and precipitates fistula-related complications, we devised a continuous suction system to remove saliva during early postoperative recovery.
Methods:
A continuous suction system was implemented in 20 patients after head and neck reconstructive surgery between January 2012 and October 2017. This group was compared to a control group of 16 patients at the same institution. The system was placed orally when the lesion was on the anterior side of the retromolar trigone area, and when glossectomy or resection of the mouth floor was performed. When the orohypopharynx and/or larynx were eradicated, the irrigation system was placed in the pharyngeal area.
Results:
The mean follow-up period was 9.2±2.4 months. The Hemovac system was applied for an average of 7.5 days. On average, 6.5 days were needed for the net drain output to fall below 10 mL. Complications were analyzed according to their causes and rates. A fistula occurred in two cases in the suction group. Compared to the control group, a significant difference was noted in the surgical site infection rate (P<0.031).
Conclusions:
Clinical observations showed reduced saliva pooling and a reduction in the infection rate. This resulted in improved wound healing through the application of a continuous suction system.
