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C
17
Carotid Blowout Syndrome
Daniel Do • Claudio J. Schönholz
arotid blowout syndrome (CBS), first described in 1962, is a severe
clinical condition that usually presents in the setting of patients with
underlying head and neck cancer, specifically those with prior
radiation treatments.
1–4
Its reported incidence is 3% to 4% in patients with
neck dissection, with a 7.6-fold increased risk in the setting of additional
radiation therapy.
5,6
CBS involves compromise of the carotid artery and/or its
branches and can present as transoral or transcervical hemorrhage. When
associated with open surgical treatment, high mortality (40%) and neurologic
morbidity (60%) have been reported.
2,3
As such, multiple endovascular
options have been developed and are divided into either deconstructive or
reconstructive techniques. Deconstructive techniques have been described
involving permanent occlusion of carotid vasculature through use of coils,
liquid embolic agents, detachable balloons, and Amplatzer Vascular Plugs
(St. Jude Medical, Inc., St. Paul, Minnesota).
2–5,7,8
Deconstructive techniques
are typically used when the external carotid artery (ECA) is involved as
neurologic sequelae would be unusual and unexpected (Fig. 17.1). In the
setting of common carotid artery (CCA) or internal carotid artery (ICA)
involvement, a balloon occlusion test (BOT) is typically performed for
clinical assessment of adequate contralateral cerebral circulation. If the
patient tolerates BOT without transitional neurologic deficit, then permanent
vessel occlusion may be pursued. On the other hand, reconstructive
techniques maintain vascular patency through use of covered stent.
Depending on the institution, this may or may not represent first-line
treatment in the setting of CBS. Generally, it is the preferred treatment option
in those patients who either fail BOT, are unable to clinically undergo BOT,
or demonstrate incomplete collateral circulation through the circle of Willis.
CBS has been described to represent a clinical spectrum and categorized into
multiple groups: threatened (group 1), sentinel hemorrhage/impending
rupture (group 2), acute rupture (group 3), and recurrent CBS.
3,4
Group 1
involves patients with exposed carotid arterial segments either identified by
physical examination or imaging whose natural course is likely rupture.
Group 2 involves patients who have experienced a hemorrhagic event, which
was either self-resolved or limited with simple surgical packing. Group 3
involves patients with active, large-volume hemorrhage that cannot be
controlled with surgical packing alone. Recurrent CBS refers to the subset of
patients who have undergone initial treatment and subsequently rebleed.
CLINICAL APPLICATIONS
Timing of intervention is primarily dictated by clinical presentation. By
definition, threatened CBS patients are likely stable, whereas acute rupture
would be actively exsanguinating, necessitating immediate intervention. In
unstable patients, adequate resuscitation efforts with dedicated anesthesia
monitoring and appropriate inotrope usage are necessary before intervention.
If the patient is clinically stable, preprocedural cross-sectional imaging is
recommended. Neck computed tomographic angiography (CTA), including
the aortic arch, may be able to identify the causative lesion and assist in
prediction of vessel size and tortuosity, preprocedural supplies, expedite
methods of action and execution, and management. Pertinent CTA findings
in CBS involve necrosis, artery exposure, viable tumor, pseudoaneurysm, and
contrast extravasation.9 If the clinical presentation precludes a CTA, the
patient should be taken directly for a diagnostic arteriogram. If the CCA or
ICA is found to contain the offending lesion, reconstructive therapy is
preferred in cases where the patient fails BOT and if BOT or contralateral
collateral examination cannot be performed secondary to patient sedation,
intubation, or fragile clinical status. Additionally, reconstructive management
may be the primary treatment modality in all technically feasible cases
dependent on institution given the ability to achieve hemostasis and preserve
vascular patency. In cases of contralateral carotid occlusion, carotid
reconstruction may be the only endovascular option. Deconstructive
management is the preferred treatment option in cases involving the ECA as
neurologic sequelae from permanent vessel occlusion is minimal. Regarding
ICA and CCA lesions, if the patient has an uneventful BOT or
angiographically demonstrates adequate contralateral collateral circulation
through an intact circle of Willis, embolization may be performed. The
selection of primary treatment modality is institution dependent.
Deconstructive therapy may be a preferred option in the treatment of patients
with preexisting carotid occlusion or when vessel tortuosity precludes
adequate stent placement.
TECHNIQUE
When performing the diagnostic angiography, it is important to remember
that most patients in either group 2 or 3 will likely have complex intubations
or tracheostomies.8 Performing the study under local anesthetic and moderate
sedation is ideal, particularly in the setting of BOT. Typical standard femoral
artery access and angiographic techniques are used. If the angiogram is the
initial imaging modality, diagnostic interrogation of the entire carotid
circulation is performed, which includes an aortic arch and selective bilateral
common carotid and vertebral arteriograms. Identification of endoluminal
irregularity, pseudoaneurysm formation, disruption, or frank extravasation
within the CCA, ICA, or ECA should warrant definitive treatment.
Evaluation of an intact circle of Willis and posterior collateral circulation via
the vertebral arteries is mandatory if permanent CCA or ICA occlusion is
considered. Additional interrogation of the subclavian artery, thyrocervical
trunk, and costocervical branches should be considered in cases of lower
neck hemorrhage.8 Selection of the supra-aortic arch vessels can be
performed with standard reverse curve (Simmons types 1 to 3) or angled tip
catheters (Vertebral, Headhunter).
Deconstructive endovascular techniques involve the use of permanent
arterial occlusion through coils, liquid embolic agents, and Amplatzer
Vascular Plugs. Detachable balloons were previously used but are no longer
available in North America. Embolization of the ECA is typically achieved
through use of coils and/or liquid embolic agents. If used in conjunction,
primary placement of coils followed by liquid embolic introduction is
preferred for formation of a matrix.
8
Coverage distal and proximal to the
hemorrhagic lesion is crucial in achieving hemostasis, eliminating the
possibility of continued filling via collateralization. Particles can be used to
achieve small vessel occlusion in distal ECA branches. Embolization of the
ECA and the selection of the embolic agent should be done knowing that
there are multiple collateral circulation pathways between branches of the
ECA and ICA that could be the source of nontarget embolization leading to
stroke complications.
If embolization of the CCA or ICA is considered, a BOT is performed to
demonstrate patient’s tolerance without increased neurologic sequelae. BOT
is only used in a stable, cooperative patient. Following a baseline neurologic
examination, a microcatheter with distal nondetachable Hyperform balloon
(Covidien, Irvine, California) is placed proximally within the culprit vessel.
After adequate systemic heparinization, the balloon is carefully insufflated
with occlusion confirmed with hand contrast injection through the catheter.
Continuous neurologic monitoring is then performed for a 15- to 20-minute
period. If there is no change from the patient’s neurologic baseline, occlusion
of the ICA or CCA can be considered. If new neurologic symptoms are
experienced, the balloon should immediately be deflated to prevent
permanent ischemic injury. If the BOT cannot be performed due to patient
instability or intubation and reconstructive techniques are unachievable, the
examination of the contralateral collateral circulation can be performed
during balloon insufflation for evaluation. The ICA occlusion can be
achieved through use of coils and self-expandable occlusion devices.
Optimally, embolization would begin intracranially, specifically at the level
of the petrous or cavernous ICA segment. This reduces potential
thromboembolic phenomenon often associated with proximal embolization
caused by residual large-volume blood stagnation. Sparing of the ophthalmic
segment is beneficial, allowing for reversed collateral supply into the
remainder of the intracranial ICA.
8
Endovascular reconstruction of the carotid artery employs use of
covered stent placed across the offending lesion, achieving both hemostasis
and preservation of blood flow (Fig. 17.2). However, as covered stents are
known to serve as a thrombogenic nidus, an antiplatelet regimen with
acetylsalicylic acid or clopidogrel should be incorporated.
10,11
Varying
treatment patterns have been reported but commonly involve preprocedural
antiplatelet administration and intraprocedural systemic heparinization, with
the goal of having the activated clotting time two to three times the baseline.
Again, antiplatelet regimen ad infinitum should follow the stent graft
placement.
8,10,12–18
Additional use of intravenous glycoprotein IIb/IIIa
inhibitors in conjunction with heparin has also been described, especially in
cases where preprocedural antiplatelet treatment is not feasible.13 If the
anticipated stent placement crosses the carotid bifurcation, embolization of
the ECA is recommended to prevent rebleeding through collateral filling.
Due to the natural anatomic configuration of the carotid bulb, type I
endoleaks may be encountered, producing a potential source for persistent or
recurrent hemorrhage. Maldonado et al.19 and Chen et al.20 described the use
of N-butyl cyanoacrylate (NBCA) to assist in sealing the endoleak. This is
achieved through use of an additional access with placement of a
microcatheter across the lesion before stent deployment. Following stent
deployment, the microcatheter is positioned with NBCA administered in
appropriate placement. Immediate microcatheter withdrawal is followed upon
completion of injection. Embolization with liquid embolic agents like
cyanoacrylate and Onyx (Covidien, Irvine, California) should be reserved for
interventionists with extensive experience using these embolic agents.
Additionally, broader stent graft coverage of the lesion has been suggested
given natural disease progression in possible prevention of rebleeding
complications.
21
COMPLICATIONS
The results and complications involving the endovascular treatment of CBS
have varied in the literature. Overall technical success rates with immediate
hemostatic control have been reported to be very high. Zussman et al.
22
published a review of endovascular deconstructive management and showed
that immediate hemostasis was achieved in 100% of the patients. Rebleeding
rates for deconstructive management ranged from 13% to 27%. The overall
pooled complication rate was reported as 12%, identified as significant
unintentional morbidity unrelated to the primary disease process.22 Delayed
transient ischemia with neurologic sequelae related to the permanent vessel