Acute common carotid artery blowout despite endovascular treatment of pseudoaneurysm





Abstract


Carotid blowouts are a low-incidence complication of head and neck tumors. We present the case of a 56-year-old man with squamous cell carcinoma of the supraglottic larynx causing acute hemoptysis. Pseudoaneurysm was discovered on the left distal carotid artery and subsequently, a stent was placed. Despite treatment, re-hemorrhage occurred distal to the covered stent leading to irreversible brain damage and death. We provide striking images of active extravasation and propose liberal deployment of long stent constructs in treating this pathology. It may be beneficial for the interventionalist to place a stent covering the area affected by the tumor rather than the area of the pseudoaneurysm.


Introduction


Carotid blowout is an uncommon but frequently fatal complication of erosive head and neck tumors [ ]. Prior radiation and surgical resection are risk factors [ ]. Prophylactic endovascular stent placement can be performed to reinforce the carotid artery. In this report, we present a case of carotid blowout that occurred despite endovascular treatment. In addition, we provide angiographic images of an active carotid blowout.


Case presentation


A 56-year-old man with a history of squamous cell carcinoma of the supraglottic larynx presented with hemoptysis. His oncological history included left tonsil squamous cell carcinoma treated by chemoradiotherapy and radical neck dissection 20 years earlier. Six months prior to presentation, he developed new left aryepiglottic fold squamous cell carcinoma. Endoscopic excision was attempted but aborted due to severe trismus; therefore, additional radiation therapy (6600 cGy in 30 fractions) was performed.


Computed tomography (CT) of the neck showed ulceration of the left oropharynx encroaching on the left common carotid artery ( Fig. 1 ). A diagnostic carotid angiogram revealed a pseudoaneurysm of the distal left common carotid artery without extravasation ( Fig. 2 ). Two hours later, his hemoptysis increased such that an emergency bedside tracheostomy was performed. We placed a 7 mm × 40 mm covered stent (Viabahn, Gore, Newark, Delaware, United States) across the pseudoaneurysm. ( Fig. 3 a). After stent placement, there was no angiographic or clinical evidence of bleeding.




Fig. 1


Radiographic Imaging of the Neck: CT neck showing an ulcerative cavity filled with gas and extending around the superior horn of the left side of the thyroid cartilage. The medial surface of the distal left common carotid artery (arrow) is suggestive of ulceration. There is no extravasation seen on CT.



Fig. 2


CT Angiogram: Initial axial view of CT angiogram performed on patient with hemoptysis. Below, at the medial wall of the left common carotid, proximal to the carotid bifurcation a pseudoaneurysm (arrow) is visualized.

Jul 5, 2021 | Posted by in OTOLARYNGOLOGY | Comments Off on Acute common carotid artery blowout despite endovascular treatment of pseudoaneurysm
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