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Extracranial/Intracranial Vascular Bypass in the Treatment of Head
and Neck Cancer - Related Carotid Blowout Syndrome
Ping-An Wu, MD, PhD ; Guo-Yan Yuan, MD; Ru-Ming Zhou, MD; Wilson Wai-Shing Ho, MD;
Zhao-Qun Lu, MD; Ji-Fu Cai, MD; Si-Yi Yang, MD; Raymond King-Yin Tsang, MD ;
Jimmy Yu-Wai Chan, MD, PhD
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 endo-
vascular 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 endo-
vascular 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.
Key Words: Carotid blowout syndrome, endovascular, embolization, covered stent, vascular bypass.
Level of Evidence: 4
Laryngoscope, 00:1–9, 2021
INTRODUCTION
The rupture of the extracranial carotid artery or its
major branches is called carotid blowout syndrome (CBS).
With the prolongation of survival after treatment in
patients with head and neck cancer, carotid blowout
bleeding has become a clinically uncommon but often
fatal clinical emergency. The prevalence of CBS in
patients with advanced head and neck cancer was 3.9%.
Risk factors include malnutrition, wound rupture, pha-
ryngeal fistula, history of radical neck dissection, cervical
radiotherapy dose greater than 70Gy, and recurrent head
and neck cancer patients receiving re-radiotherapy.
1,2
CBS includes three different clinical subtypes: threat-
ened, impending, and acute carotid blowout.
3
Type 1
(threatened) CBS represents vascular exposure, no signs
of bleeding, type 2 (impending) CBS Refers to self-
limiting or sentinel bleeding, while type 3 (acute) CBS
refers to significant arterial bleeding. The mortality rate
of CBS is very high, usually over 50%. The management
of patients with CBS is extremely challenging, and it is
necessary to make clinical diagnosis and treatment deci-
sions through a multidisciplinary diagnosis and treat-
ment model. Current treatment methods include open
arterial ligation, different endovascular interventions,
and extracranial/intracranial (EC/IC) vascular bypass,
but the immediate and delayed complications of these
treatments still exist. In this study, we collected data
from patients with head and neck cancer-related CBS
treated in a single institution, detailing patient manage-
ment patterns, analyzing perioperative stroke and mor-
tality, short- and medium-term mortality, and rebleeding.
From the Department of Surgery, Division of Otolaryngology,
Head and Neck Surgery (P.-A.W., Z.-Q.L., S.-Y.Y., R.K.-Y.T., J.Y.-W.C.), The
University of Hong Kong-Shenzhen Hospital, Shenzhen, P.R. China;
Department of Surgery, Division of Neurosurgery (G.-Y.Y., W.W.-S.H.), The
University of Hong Kong-Shenzhen Hospital, Shenzhen, P.R. China;
Department of Interventional Radiology (R.-M.Z.), The University of Hong
Kong-Shenzhen Hospital, Shenzhen, P.R. China; and the Department of
Neurology (J.-F.C.), The University of Hong Kong-Shenzhen Hospital,
Shenzhen, P.R. China
Editor’s Note: This Manuscript was accepted for publication on
January 12, 2021.
This work was supported by High-Level Hospital Program, Health
Commission of Guangdong Province, China (No. HKUSZH201901033;
No. HKUSZH201901039) and National Natural Science Foundation of
China (No. 82072738).
The authors have no other funding, financial relationships, or con-
flicts of interest to disclose.
Send correspondence to Jimmy Yu-Wai Chan, MD, PhD, Depart-
ment of Surgery, Division of Otolaryngology, Head and Neck Surgery, the
University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong,
P.R. China. E-mail: jywchan1@hku.hk
DOI: 10.1002/lary.29427
Laryngoscope 00: 2021 Wu et al.: EC/IC Bypass in Carotid Blowout Syndrome
1
The Laryngoscope
© 2021 The American Laryngological,
Rhinological and Otological Society, Inc.
To investigate the therapeutic effects of EC/IC vascular
bypass and endovascular intervention in patients with
head and neck cancer-related CBS.
MATERIALS AND METHODS
Data Collection
After the ethics review committee approval at the Univer-
sity of Hong Kong-Shenzhen Hospital, this study collected the
data of patients with head and neck cancer who experienced
carotid blowout bleeding from 2014 to 2020. Patients with no his-
tory of head neck cancer or non-carotid artery hemorrhage were
excluded from the study. Collect detailed information about
patient demographics, treatment, and prognosis.
Treatment
A multidisciplinary treatment meeting is held with the par-
ticipation of a surgeon (head and neck surgeon, neurosurgeon),
radiologist, neurointerventional surgeon, and patients and their
relatives to determine treatment options. Endovascular interven-
tions include endovascular stenting and endovascular emboliza-
tion. The former is applied to the common carotid artery (CCA)
or internal carotid artery (ICA), and the latter is selected for any
carotid artery bleeding. Vascular bypass surgery includes EC/IC
vascular bypass and ligation of proximal and distal hemorrhagic
arterial stumps. EC/IC vascular bypass is divided into two types:
the lesion vascular ipsilateral middle cerebral artery and the
ipsilateral carotid artery anastomosis (ipsilateral bypass) or con-
tralateral carotid artery anastomosis (trans-cranial bypass), and
the application is selected according to the bleeding site, the
extent of the tumor, and the relationship between the tumor and
the carotid artery.
Embolization and Stenting
If bleeding is limited to the external carotid artery (ECA)
truck or its branches, polyvinyl alcohol particles (PVA, Cook
Incorporated, Bloomington, IN, U.S.A.), coils(Boston Scientific,
Marlborough, MA, U.S.A.), Embosphere microspheres (Biosphere
Medical, Parc Des Nations, Roissy En, France), or a combination
of these materials are used to control bleeding. If bleeding is in
ICA/CCA, a balloon occlusion test (BOT) is required in stable
patients to assess collateral cerebral circulation before occlusion
of the ICA/CCA. However, BOT is not possible in patients with
intubation, sedation, or instability. In this case, angiography of
the bilateral ICA and vertebral artery with Matas test is per-
formed to assess the adequacy of the Willis circle to estimate
potential collateral blood flow through the anterior or posterior
communicating artery. Endovascular occlusion is performed
using a pushable and/or detachable coil (MicroVention, Tustin,
CA, U.S.A.).
4,5
A self-expanding Viabahn covered stent (W. L. Gore &
Associates Inc, Flagstaff, AZ, U.S.A.) that preserves blood flow is
used in selected cases of bleeding of ICA, CCA, or ECA stem,
which is too near CCA to be embolized. The length of the carotid
artery to be covered is determined by cervical CT or MRI and
angiographic results. The stent was selected based on the mea-
sured maximum diameter of the internal and common carotid
arteries. The covered stent was then directed to the proposed
landing zone and released. Neck and cerebral angiography before
and after stent placement were performed to assess thromboem-
bolism and stent position. Postoperative antiplatelet agents were
used to prevent thrombosis. All patients received 300 mg of
aspirin and 75 mg of clopidogrel for 6 weeks daily, followed by
daily maintenance doses of 300 mg of aspirin.
6
EC/IC Vascular Bypass
This operation is performed by two teams. Through craniot-
omy, the neurosurgeon prepares the middle cerebral artery M2
portion (MCA) on the same side as the lesion.
7
At the same time,
the head and neck surgeon performs neck preparation, and can
choose the ipsilateral (ipsilateral bypass) or contralateral neck
(trans-cranial bypass) for selective neck dissection to remove
lymphoid tissues from I to III and V level. Dissect the CCA,
ECA, and ICA. Autologous radial artery is often used as graft. If
a longer graft is required, or if the Allen test fails on both sides,
a long saphenous vein graft can be used instead.
Subsequently, a subcutaneous tunnel is formed in pre-
auricular area between the craniotomy and the neck wound to
avoid damage to the facial nerves. The graft is then passed
through the subcutaneous tunnel to ensure that the graft is not
distorted. For transcranial bypass surgery using the saphenous
vein as a graft, a high-speed electrosurgical drill must be used to
drill a long groove in the skull to place the graft and prevent
compression. Vascular anastomosis between the graft and the
M2 portion of the MCA, between the graft and the ECA or CCA
of the neck were performed end-to-side under a surgical micro-
scope. Postoperative patients were transferred to the intensive
care unit (ICU) for monitoring. Once the surgical wound is sta-
ble, start taking aspirin 100 mg daily. The patency of the bypass
graft was periodically checked using a portable Doppler ultra-
sound machine. CT angiography and CT cerebral perfusion scans
were performed on the 5th day after surgery.
Statistical analysis: analysis of patient demographics, peri-
operative stroke incidence, and mortality after primary bleeding
intervention, survival rate, rebleeding rate; Fisher’s exact, two-
tailed t-test, analysis of variance and Kruskal-Wallis test for
inter-group Comparison. The Kaplan–Meier survival method
was used to analyze time-event data for death and rebleeding.
The SPSS 13.0 software package (SPSS, Inc., Chicago, IL,
U.S.A.) were used for statistics and Pvalues of <.05 were consid-
ered to be statistically significant.
RESULTS
Patient Baseline Characteristics and Bleeding
Thirty-seven patients were eligible for inclusion in
the study. The majority of patients were male (23/37
[62.2%]) with a median age of 53 years (range,
6–71 years). All patients were diagnosed with advanced
malignant tumors of the head and neck; the most com-
mon sites were the nasopharynx and neck. Among the
bleeding events in these 37 patients, 28 patients (28/37,
75.7%) had acute hemorrhage, 4 patients (4/37, 10.8%)
had threatened hemorrhage, and five patients had
impending hemorrhage (5/37, 13.5%). There were 25 cases
(25/37, 67.6%) associated with ECA trunk and branch
bleeding, all of which used endovascular embolization to
control bleeding. There were 12 cases (12/37, 32.4%) with
ICA/CCA-related bleeding, nine cases (9/12, 75.0%)
underwent EC/IC bypass surgery, three cases (3/12,
25.0%) underwent stenting, and one patient (1/12, 8.3%)
received embolization (Table I).
Laryngoscope 00: 2021 Wu et al.: EC/IC Bypass in Carotid Blowout Syndrome
2
Perioperative Stroke and Mortality
The overall perioperative stroke and mortality were
0 and 13.5% (4/37), respectively. The ICA/CCA-related
CBS subgroup perioperative stroke and mortality were
0 and 8.3% (1/12), respectively. Four patients died during
the perioperative period. Among them, 1 ICA/CCA-
related CBS patient died of rebleeding due to rupture of
the distal carotid artery of the stent graft 22 days after
the treatment of nasal bleeding with stenting; three
patients with ECA-related CBS, one of whom did not
bleed again after vascular embolization, and died of
tumor progression 4 days later; two of them had persis-
tent bleeding after endovascular embolization and both
died 2 days after the bleeding (Table II).
Survival Rate
Patients were followed up for an average of
9.1 months (range, 2 days–55.3 months).
According to Kaplan–Meier analysis, the median
overall survival time of ECA-related CBS patients and
ICA/CCA-related CBS patients were 6.2 months
(186.0 days, range, 2–1,658 days; 95% confidence interval
[CI], 63.6–308.4) and 22.5 months (675.0 days, range,
22-923 days; 95% CI, 395.6–954.4), respectively. ECA-
related CBS patients 90-day, 1-year, and 2-year survival
rates were 67.1%, 44.7%, and 33.6%, respectively;
ICA/CCA-related CBS patients 90-day, 1-year, and 2-year
survival rates were 92.3%, 71.8%, and 41.0%, respectively
(Fig. 1A).
TABLE I.
Cohort Characteristics at Baseline and by Rebleeding Status and Survival Status.
Characteristic
Total
Cohort (n = 37
*
)
Rebleeding Survive
No
Rebleeding (n = 30)
Rebleeding
(n = 7)
P
Value
Survivor
(n = 20)
Nonsurvivor
(n = 17)
P
Value
Age, years 52.81 ± 14.44 52.55 ± 15.60 53.88 ± 8.81 .819 49.83 ± 11.34 57.00 ± 17.45 .119
Male sex, n (%) 23 (62.16) 18 (60.00) 4 (57.14) 1.000 14 (70.00) 9 (52.94) .42
Diabetes mellitus, n (%) 2 (5.4) 2 (6.67) 0 (0) 1 (5.00) 1 (5.88)
Hypertension disease, n (%) 4 (10.81) 3 (10.00) 1 (14.29) 3 (15.00) 1 (5.88)
Cerebrospinal fluid (CSF) leak,
n (%)
1 (2.70) 1 (3.33) 0 (0) 0 (0) 1 (5.88)
Chronic kidney disease (stage V) 1 (2.70) 0 (0) 1 (14.29) 0 (0) 1 (5.88)
Cancer characteristics, n (%)
Location .457 .875
Oral cavity 4 (10.81) 4 (13.33) 0 (0) 2 (10.00) 2 (11.76)
Nasopharynx 24 (64.86) 19 (63.33) 5 (71.42) 13 (65.00) 11 (64.71)
Larynx 2 (5.41) 2 (6.67) 0 (0) 1 (5.00) 1 (5.88)
Neck soft tissue 7 (18.92) 5 (16.67) 2 (28.57) 4 (20.00) 3 (17.65)
Initial cancer treatment, n (%) .586 .053
No treatment 10 (27.03) 9 (30.00) 1 (14.29) 7 (35.00) 3 (17.63)
Operative resection 3 (8.11) 2 (6.67) 1 (14.29) 1 (5.00) 2 (11.76)
Radiotherapy/
chemoradiation
22 (59.46) 16 (53.33) 5 (71.42) 10 (50.00) 12 (70.59)
Operation
+chemoradiotherapy
2 (5.41) 2 (6.67) 0 2 (10.00) 0
Cancer recurrence, n (%) 25 (67.5 7) 18 (60.00) 6 (85.71) .399 12 (60.00) 13 (76.47) .767
Blowout characteristics
Bleed type, n (%) .145 .752
Threatened 4 (10.81) 4 (13.33) 0 (0) 2 (10.00) 2 (9.09)
Impending 5 (13.51) 5 (16.67) 0 (0) 3 (15.00) 2 (18.18)
Acute hemorrhage 28 (75.68) 21 (70.00) 7 (100.00) 15 (75.00) 13 (76.47)
Blowout site, n (%) 1.000 .575
Common carotid/Internal
carotid
12 (32.43) 10 (33.33) 2 (28.58) 8 (40.00) 4 (23.53)
External carotid 25 (67.57) 20 (66.67) 5 (71.42) 12 (60.00) 13 (76.47)
Blowout treatment, n (%) .030 .662
Covered stent
*
3 (7.89) 1 (3.23) 2 (28.58) 2 (10.00) 1 (5.88)
Coil embolization 26 (68.42) 21 (67.74) 5 (71.42) 15 (70.00) 11 (64.71)
Bypass grafting 9 (23.68) 9 (29.03) 0 (0) 4 (20.00) 5 (29.41)
*
One of the patients with covered stent underwent bypass treatment again.
Laryngoscope 00: 2021 Wu et al.: EC/IC Bypass in Carotid Blowout Syndrome
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Among the 12 patients with ICA/CCA-related CBS
bleeding, one patient was negative for BOT and under-
went endovascular embolization and survived. In the
three stenting patients, one patient died of rebleeding
within 22 days after surgery; one patient’s stent was
exposed to the neck 55 days after the stenting, and
the EC/IC bypass surgery was done to prevent rebleeding;
The third patient’s stent was exposed to the oral cavity,
because the carotid artery was occluded without
rebleeding, still following up. In the 9 EC/IC bypass
patients, five people died of end-stage tumor cachexia
187 to 662 days after surgery, the remaining cases are
still alive. The median overall survival time of ICA/CCA-
related CBS patients undergoing bypass was 22.1 months
(662.0 days, range, 96–858 days; 95% confidence interval
[CI], 215.5–1,108.5) (Fig. 1B).
TABLE II.
Cohort and Outcomes by Treatment Type.
Characteristic Total Cohort (n = 37
*
) Bypass Grafting (n = 9) Covered Stent (n = 3) Embolization (n = 26) PValue
Age, years, mean ± SD 52.81 ± 14.44 45.89 ± 17.85 58.67 ± 6.66 54.35 ± 13.50 .241
Male sex, n (%) 23 (62.16) 5 (55.56) 2 (66.67) 16 (61.54) .89
Initial cancer treatment, n (%)
No treatment 10 (27.03) 0 (0) 0 (0) 10 (38.46) .073
Operative resection 3 (8.11) 0 (0) 0 (0) 3 (11.54)
Radiotherapy/chemoradiation 22 (59.46) 9 (100.00) 3 (100.00) 11 (42.31)
Operation+chemoradiotherapy 2 (5.41) 0 (0) 0 (0) 2 (7.69)
Blowout characteristics
Blowout type, n (%) .009*
Threatened 4 (10.81) 3 (33.33) 0 (0) 1 (4.00)
Impending 5 (13.51) 2 (22.22) 0 (0) 3 (12.00)
Acute hemorrhage 28 (75.68) 4 (44.44) 3 (100.00) 21 (84.00)
Blowout site, n (%) 0
Common carotid/Internal carotid 12 (32.43) 9 (100.00) 3 (100.00) 1 (3.85)
External carotid 25 (67.57) 0 (0) 0 (0) 25 (96.15)
Outcomes, n (%)
Perioperative stroke 0 (0) 0 (0) 0 (0) 0 (0)
Perioperative death 4 (10.81) 0 (0) 1 (33.33) 3 (15.38) .033*
Rebleeding 7 (18.92) 0 (0) 2 (66.67) 5 (19.23) .026*
*
One of the patients with covered stent underwent bypass treatment again.
Fig. 1. (A) Overall survival of ECA and ICA/ CCA CBS patients (X
2
= 1.462, P = 0.227). (B) Overall survival of ICA/ CCA CBS patients undergo-
ing bypass. The median overall survival length of ECA CBS patients and ICA/ CCA CBS patients were 186.00(range, 2–1,658; 95% confidence
interval [CI], 63.61–308.39) and 675.00 (range,22-923 days; 95% CI, 395.58–954.42) days, respectively. The median survival time of ICA/
CCA-related CBS patients undergoing bypass was 662.00 days (range, 96-858 days; 95% confidence interval [CI], 215.47–1,108.53). [Color
figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Laryngoscope 00: 2021 Wu et al.: EC/IC Bypass in Carotid Blowout Syndrome
4
Rebleeding
Seven patients (7/37, 18.9%) experienced at least one
rebleeding event after initial intervention in CBS, five
patients died after rebleeding. In the ECA-related CBS
patients, the rebleeding rate was 20.0% (5/25), and the
expected freedom of rebleeding at 1-month, 6-month, and
2-year was 92.9%, 80.0%, and 68.4%, respectively; In the
ICA/CCA-related CBS patients, the rebleeding rate was
16.7% (2/12), and the expected freedom of rebleeding at
1-month, 6-month, and 2-year was 92.3%, 84.6%, and
84.6% (Fig. 2A). The expected freedom of rebleeding for
the ICA/CCA-related CBS patients undergoing bypass at
1-month, 6-month and 2-year was 100.0%, 100.0%, and
100.0%, respectively (Fig. 2B).
Patency Rates of Bypass Treatment
A total of 9 EC/IC bypasses were performed, two
with long saphenous vein graft (transcranial bypass) and
seven with radial artery graft (ipsilateral bypass).
The Kaplan–Meier curve was used to analyze the
patency rate of the bypass (Fig. 2C). The mean patency
time of bypass surgery patients was 21.2 months
(635.14 days, range, 96–858 days; 95% confidence interval
[CI], 380.80–889.49).
The primary patency rate of the bypass is 77.78%
(7/9) with an average follow-up of 16.7 months (186–-
948 days), and the overall expected patency rates at
6 months, 1 year, and 2 years are 85.7%, 64.3%, and
64.3%, respectively. Primary patency at 1 year was 100%
Fig. 2. (A) Estimated freedom from rebleeding of ECA and ICA/ CCA CBS patients (X
2
= 0.553, p = 0.457). (B) Estimated freedom from
rebleeding of ICA/ CCA CBS patients undergoing bypass. (C) Patency rate for patients undergoing bypass treatment. The expected free-
dom of rebleeding for ECA-related CBS at 1-month, 6-month, and 2-year was 92.9%, 80.0%, and 68.4%, respectively; The expected free-
dom of rebleeding for the ICA/CCA-related CBS at 1-month, 6-month, and 2-year was 92.3%, 84.6%, and 84.6%, respectively. The
expected freedom of rebleeding for the ICA/CCA-related CBS patients undergoing bypass at 1-month, 6-month, and 2-year was 100.0%,
100.0%, and 100.0%, respectively. The overall patency rate of the bypass is 77.78% (7/9), and the overall expected patency rates at
6 months, 1 year and 2 years are 85.7%, 64.3%, and 64.3%, respectively. Primary patency at 1 year was 100% and 0% for ipsilateral
bypass and trans-cranial bypass patients, respectively. [Color figure can be viewed in the online issue, which is available at www.
laryngoscope.com.]
Laryngoscope 00: 2021 Wu et al.: EC/IC Bypass in Carotid Blowout Syndrome
5
and 0% for ipsilateral bypass and transcranial patients,
respectively. Two ICA/CCA-related CBS patients with
transcranial EC/IC bypass were occluded within 1 year,
and both were asymptomatic.
Typical Case: Management of Acute CBS with
Insufficient Contralateral Collateral Circulation
The patient was a 55-year-old male who was admit-
ted to the hospital for recurrence of right neck cancer
4 years after radiotherapy for nasopharyngeal carcinoma.
The right neck ulcer had a sudden massive hemorrhage
and the amount of bleeding was about 1,000 ml. Com-
pression hemostasis, blood transfusion, and DSA angiog-
raphy were performed. DSA found bleeding at the
bifurcation of the right common carotid artery, and the
right internal carotid artery stent graft was placed.
The patient did not rebleed after the operation. Due to
the gradual exposure of the right neck blood vessel and
vascular stent, the risk of rebleeding and death is
extremely high (Fig. 3). Under general anesthesia, the
left common carotid artery-right middle cerebral artery
bypass graft and the right common carotid artery ligation
were performed on the 55th day after placing the vascu-
lar stent. The left saphenous vein is used as a bypass
material for the transcranial bypass. Intraoperative angi-
ography showed smooth blood flow. Clamp the right
intracranial internal carotid artery with a permanent
aneurysm clip, and ligate the proximal end of the right
common carotid artery, internal carotid artery, and exter-
nal carotid artery (Figs. 4 and 5). Two weeks after the
first operation, the extended resection of right neck mass,
right pectoralis major myocutaneous flap repair, and ICA
stent resection were performed, and the patient’s condi-
tion was stable (Fig. 6).
DISCUSSION
The diagnosis and treatment of CBS is extremely
challenging. Historically, surgical ligation of the carotid
artery to treat CBS has a high mortality rate (40%) and a
major neurological disease incidence (60%). Over the past
two decades, the use of endovascular intervention tech-
niques has greatly changed the treatment of CBS,
thereby greatly reducing the mortality and the incidence
of neurological diseases. However, the application of
EC/IC in CBS is rarely reported.
8,9
The basic principles of
acute CBS treatment involving resuscitation, establish
airway, nasal packing or neck wound compression to con-
trol bleeding, use blood products for rapid resuscitation.
Fig. 3. (A). DSA showed right neck CCA bleeding before initial treatment.(B) DSA after covered stenting showed ECA was embolized and ICA
was placed stent.(C)This picture and (D)CT showed Stent exposure after 55 days of stent implantation. [Color figure can be viewed in the
online issue, which is available at www.laryngoscope.com.]
Laryngoscope 00: 2021 Wu et al.: EC/IC Bypass in Carotid Blowout Syndrome
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CTA can be used in patients with hemodynamic stability
to determine possible bleeding sites and to assess the
patency of the Willis ring.
9
For bleeding from the ECA trunk or its branches,
endovascular embolization is feasible. After endovascular
embolization of ECA, the incidence of surgical stroke
is less than 2%, and the rebleeding rate is 30–35%. The
underlying causes of rebleeding may be related to the
lack of recognition of the target vessel, the reflux caused
by the ECA-rich collateral circulation, the regeneration
Fig. 4. (A-C) showed the incision Left CCA-right MCA transcranial bypass was done. (D) Long saphenous vein as graft. [Color figure can be
viewed in the online issue, which is available at www.laryngoscope.com.]
Fig. 5. Intraoperative photo of the contralateral common carotid artery - middle cerebral artery bypass. (A) End-to-side anastomosis between
the graft vessel and the right middle cerebral artery. (B) End-to-side anastomosis between the left common carotid artery and the graft vessel.
(C) Microscopic anastomosis of the middle cerebral artery under the microscope. (D) Microscopic anastomosis of the left carotid artery. [Color
figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Laryngoscope 00: 2021 Wu et al.: EC/IC Bypass in Carotid Blowout Syndrome
7
of the tumor vascular bed, and the new ECA branch
disease.
10–12
For ICA/CCA bleeding, it is usually treated by endo-
vascular embolization and flow-preserving endovascular
stent placement or EC/IC bypass surgery. Before plan-
ning to sacrifice the patient’s ICA or CCA through endo-
vascular embolization, BOT should be performed to
assess collateral cerebral blood flow. However, although
asymptomatic test occlusion of 15 to 30 minutes can be
tolerated, 10% of patients will experience perioperative
stroke; 10% to 30% of patients will experience delayed
neurological sequelae after permanent occlusion, which
may be due to incomplete Willis circle, thromboembolism
caused by acute carotid occlusion and/or delayed collat-
eral failure. Endovascular embolization has a relatively
low 9.1% to 13% risk of rebleeding.
10,11,13
To reduce the incidence of neurological morbidity
associated with carotid artery occlusion, the endovascular
occlusion of the ICA and CCA should be carefully
selected. EC/IC bypass surgery and endovascular
stent placement to maintain blood flow to the brain are
Preferred.
Literature studies have shown that the efficiency of
endovascular stent grafts in controlling acute hemorrhage
is 95% to 100%, but the risk of rebleeding and stent occlu-
sion is high. The indications for endovascular stent place-
ment are mainly for patients at risk of permanent carotid
occlusion, such as incomplete Willis circle, severe steno-
sis, or complete occlusion of the contralateral carotid
artery, intolerance of BOT, or emergency status of BOT
cannot be performed. A review of 119 ICA/CCA patients
underwent carotid stent placement, which found that
there was a 2.5% procedural stroke, 31.9% rebleeding
rate, 10.1% delayed neurological morbidity rate, and
15.1% stent thrombosis rate after stent placement. Other
authors have also observed similar rebleeding rates
(34%–44%), post-operative neurologic complications
(6.5–30%), and stent thrombosis rate (15.1%–50%) in ste-
nting patients.
6,10,11,13–15
The potential causes of high
rebleeding after stent placement include endoluminal
leakage of the stent graft, tumor invasion of the proximal
and distal arteries of the stent, and infection.
16,17
The
causes of high stent thrombosis after stent placement
include the thrombotic properties of the stent itself, distal
edges stenosis of the stent, and irregular use of dual anti-
platelet therapy. Most (two-thirds) of stent thrombosis is
asymptomatic, and the delayed incidence of neurological
morbidity increases in patients with acute blood loss-
related hypovolemia and malnutrition.
Although endovascular stent placement techniques
may be effective for acute hemostasis, their effects are
usually only as temporary treatments due to their high
rebleeding and stent thrombosis rate.
4,13,16–18
Therefore, in our institution, for bleeding from the
ECA trunk or its branches, endovascular embolization is
preferred; For ICA/CCA bleeding, if the ICA/CCA-related
CBS patients have a long expected survival period, the
bypass with the definitive therapeutic effect is preferred;
and if the ICA/CCA-related CBS patients have a short
expected survival period or the patient’s hemodynamics is
unstable, Stent placement or endovascular embolization
is preferred.
All treatments are technically successful for immedi-
ate hemostasis in patients with acute bleeding, and there
is a risk of perioperative stroke. The incidence of stroke
in different studies is different, about 0% to 15%,
1,2,6
and
the incidence of stroke in our study is 0. Endovascular
occlusion of the ICA and CCA is usually not performed in
Fig. 6. (A) CTA of the contralateral common carotid artery - middle cerebral artery bypass (B) Tumor extended resection and pectoralis major
flap repair. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Laryngoscope 00: 2021 Wu et al.: EC/IC Bypass in Carotid Blowout Syndrome
8
our institution, and endovascular stenting or EC/IC vas-
cular bypass with preservation blood flow is the preferred
treatment for ICA/CCA-related CBS patients.
The perioperative mortality rate in our study was
very low, about 13.51%. The perioperative survival rate
was similar to that reported by others.
12
However, the
overall mid-term survival rate is still very low. In our
cohort, the median survival of patients with ECA-related
CBS is 6 months, and their 90-day, 1-year, and 2-year sur-
vival rates are 67.1%, 44.7%, and 33.6%, respectively, simi-
lar to previous reports; The median survival time of
patients with ICA/CCA-related CBS is 22.5 months, and
their 90-day, 1-year, and 2-year survival rates are 92.3%,
71.8%, and 41.0%, respectively, significantly higher than
previous reports. May be related to more use of EC/IC vas-
cular bypass surgery as a definite treatment. The median
survival of ICA/CCA-related CBS patients reported in the
literature was 6.5 to 10.7 months.
12,19
The high mortality
rate after discharge may be more related to the overall
poor condition of the patient’s advanced-stage tumor.
Therefore, if bleeding is controlled in a timely manner,
carotid blowout may be more of a sign of a poor prognosis
for serious advanced disease, rather than a fatal event.
Our overall rebleeding rate was as high as 18.9%
(7/37). In the ECA-related CBS patients, the estimated
recurrent bleeding risk at 1-month, 6-month, and 2-year
was 7.1%, 20.0%, and 31.6%, respectively, similar to pre-
vious reports
10,11,13;
. In the ICA/CCA-related CBS
patients, the estimated recurrent bleeding risk at
1-month, 6-month, and 2-year was 7.7%, 15.4%, and
15.4%, respectively, significantly lower than previous
reports and may be related to more use of EC/IC vascular
bypass surgery as a definite treatment. The rebleeding
rate of ICA/CCA-related CBS patients reported in the lit-
erature was 31.9% to 44%,
2,10,11,13,20,21
and rebleeding
demonstrates the temporary nature of many treatments
on CBS despite the initial success rate of controlled bleed-
ing. In this study, because of the small sample size and
other confounding factors, no further risk factors for
rebleeding were analyzed.
The primary patency rate of the bypass is 77.78%
(7/9) with an average follow-up of 16.7 months. Two
ICA/CCA-related CBS patients with transcranial EC/IC
bypass (long saphenous vein graft) were occluded within
1 year, and both patients were asymptomatic. The high
graft occlusion rate of transcranial bypass may be due to
the excessive length vein, thin vein wall, and the presence
of venous valves, which may cause the blood vessels to be
easily compressed, the blood flow rate slows down, and
thrombosis is easy to form. However, because graft occlu-
sion is a slowly progressing process, it is conducive to the
formation of the contralateral cerebral collateral circula-
tion, and will not cause cranial nerve complications.
CONCLUSION
Head and neck cancer-related CBS has a signifi-
cantly high mortality and complication rate. Rational use
of EC/IC vascular bypass surgery and endovascular inter-
vention for the treatment of head and neck cancer-related
CBS can achieve ideal bleeding control and short-term
survival. However, patients with poor prognosis in the
medium and long-term survival may be more related to
the advanced state of tumor disease, rather than carotid
artery involvement, and CBS may be a sign of poor prog-
nosis of advanced tumor disease rather than a fatal
event, which should be actively managed. For ICA/CCA-
related CBS, the use of an endovascular stenting helps to
achieve rapid hemostasis while preserving cerebral blood
flow, but in most cases, stenting should be considered a
temporary measure requiring definitive vascular Recon-
struction or bypass surgery.
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