Rapid Endovascular Control of Hemorrhage Secondary to Malignant Carotid Erosion with Airway Compromise
- Volume 9 - Issue 5 - May 2012
- Posted on: 5/1/12
- 1 Comments
- 8137 reads
Pamela M. Zimmerman, MD, Alexandre d’Audiffret, MD, Lakshmikumar Pillai, MD
ABSTRACT: Purpose. Two cases of exsanguinating cervical hemorrhage with sudden airway compromise secondary to recurrent tumor erosion into the left common carotid artery treated expeditiously (<30 minutes) with covered stent placement are presented. Materials and methods. A 41-year-old male patient with previous history of chemoradiation therapy followed by transhiatal esophagectomy for squamous cell cancer approximately 6 months prior presented with massive pharyngeal and left cervical hemorrhage from the site of a previously closed cutaneous fistula. He was intubated and taken to the OR where an iCast covered stent (Atrium Medical) was placed across the common carotid fistula at the thoracic inlet, controlling the hemorrhage. He was discharged home neurologically intact with arrangements to receive adjuvant radiotherapy 5 days later. A 65-year-old female patient with a prior history of treated laryngeal cancer including laryngectomy and radical neck dissection followed by radiation in February 2005 and partial glossectomy for recurrence in February 2007, presented to the ER with acute onset massive pharyngeal hemorrhage. Her airway was secured by intubation and she underwent placement of an iCast covered stent through a percutaneous transfemoral approach across the carotid fistula (low cervical), achieving control of the hemorrhage. She was then discharged home the following day neurologically intact with arrangements for adjuvant therapy. Results. Successful control of exsanguinating cervical hemorrhage with airway compromise from malignant carotid erosion was accomplished rapidly using covered stents placed percutaneously with excellent short-term recovery and no morbidity and mortality. Conclusion. Percutaneous endovascular placement of a covered stent across the carotid fistula is the preferred method for rapid control of exsanguinating hemorrhage with airway compromise in these cases of low cervical or intrathoracic malignant carotid erosion. Surgical approaches to the low cervical and intrathoracic carotid artery for emergency hemorrhage control remains a challenge fraught with significant morbidity.
VASCULAR DISEASE MANAGEMENT 2012;9(5):E71-E75
Key words: carotid artery, head and neck cancer, hemorrhage, carotid blowout, endovascular, palliative care, stenting
Although rare, carotid blowout is a dramatic and devastating complication for head and neck cancer patients and their families. Patients at risks are those with large tumor masses or metastases of the head and neck region, or those who have had previous disease treatment with major flap and/or neck dissection or radiation or chemotherapy. Clinical presentation can range from acute hemorrhage versus asymptomatic exposure of the carotid artery with threatened or impending blowout.1
Some patients with acute blowout do not survive long enough to receive treatment. Of those who make it to the hospital, the traditional surgical treatment is technically difficult and associated with high morbidity and mortality. Historically, emergency treatment has consisted of flow removal from the carotid. Open surgical techniques usually consist of ligation of the common carotid or internal carotid artery and endovascular techniques usually involve carotid occlusion. Both of these techniques can cause major neurologic comorbidities in approximately 60% of patients and mortality rates of 40%.2
Reconstructive endovascular therapy may offer a better option for treatment of impending or acute carotid blowout syndrome in patients who might not otherwise be a surgical candidate due to comorbidities. Two cases of exsanguinating hemorrhage with sudden airway compromise secondary to recurrent tumor erosion into the left common carotid artery treated expeditiously (<30 minutes) with covered stent placement are presented. The particular challenges of treating hemorrhage secondary to malignant carotid erosion are discussed and the clear superiority of endovascular repair emphasized.
Case Report 1. A 41-year-old male patient presented to the emergency department with massive pharyngeal and left neck hemorrhage. Approximately 6 months earlier, the patient had previously undergone chemoradiation therapy followed by transhiatal esophagectomy for squamous cell cancer. Now there was bleeding from the site of a previously closed cutaneous fistula. He was intubated in the emergency department and taken directly to the operating room.
Case Report 2. A 65-year-old female patient presented to the emergency department with acute onset of massive pharyngeal hemorrhage. Her history was remarkable for prior treatment of laryngeal cancer. She had a laryngectomy and radical neck dissection followed by radiation in February 2005 and then partial glossectomy for recurrence in February 2007. Her airway was secured by intubation in the emergency department. She was taken emergently to the operating room.