Although the incidence of carotid blowout has decreased with the advent of better reconstructive techniques, it remains a real risk after major head and neck surgery, especially in an irradiated field. A systematic, multidisciplinary approach incorporating appropriate history and physical examination, adequate resuscitation, diagnostic computed tomography, and diagnostic and therapeutic angiography can manage most of these patients in a safe and effective manner. Surgery has a limited role in acute management, although surgical techniques are useful both for prevention of this problem and for wound management after carotid blowout.
Key learning points
At the end of this article, the reader will:
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Understand the main risk factors for the development of carotid blowout syndrome.
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Understand how carotid blowout syndrome can be prevented.
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Recognize the difference between threatened and impending carotid blowout syndrome.
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Appreciate the role of computed tomography in the management of carotid blowout syndrome.
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Understand the role of angiography in the management of carotid blowout syndrome.
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Define the role of surgery in the management of carotid blowout syndrome.
Carotid blowout syndrome (CBS) remains one of the most serious and dramatic complications of head and neck surgery. Prevention of the syndrome is paramount and is primarily accomplished by prophylactic coverage of the major vasculature with well-vascularized tissue, especially in an irradiated field. Modern reconstructive techniques have therefore significantly decreased its occurrence and the development of endovascular techniques has significantly altered its management, with an associated decrease in short-term morbidity and mortality. However, the long-term mortality of patients experiencing this complication remains essentially unchanged because it usually occurs in the setting of recurrent and/or uncontrolled tumors in the head and neck region.
This article outlines a practical and rational approach to this problem, incorporating modern diagnostic and therapeutic techniques that can be applied to any patient in whom this possible complication is considered.
The most effective management of CBS is preventing it from developing in the first place. Although some cases are inevitable, recognition of the long-term risk of CBS at the time of patients’ primary or salvage surgery may steer surgeons toward the use of various reconstructive techniques that may prevent CBS from developing. As mentioned previously, the incidence of CBS has been decreasing with the development of more modern surgical techniques. The shift from true radical neck dissection to selective neck dissection with preservation of the internal jugular vein (IJV) and/or the sternocleidomastoid muscle (SCM) over the past few decades has resulted in fewer patients with the carotid artery covered only by the skin and platysma muscle. When a radical neck dissection is needed and both the IJV and SCM are sacrificed, placement of a pectoralis flap or a fasciocutaneous free flap into the neck may provide coverage of the carotid with healthy vascularized tissue and prevent the development of CBS. Similarly, it has been shown that use of either a pectoralis overlay flap or an interposed fasciocutaneous free flap for pharyngeal closure after salvage laryngectomy is superior to primary closure in reducing fistula formation, which is a key risk factor for the development of CBS. Thus, every effort should be made at the time of surgery to provide well-vascularized tissue coverage of the carotid artery, particularly in previously irradiated patients. Despite this, there is a subset of patients who inevitably develop CBS ( Table 1 ).
| Category | Definition |
|---|---|
| Threatened carotid blowout | Exposed carotid artery, no evidence of bleeding |
| Impending carotid blowout | Exposed carotid artery with self-limited sentinel bleed |
| Active carotid blowout | Massive hemorrhage from exposed carotid artery |
Patients facing this potential complication generally present in one of 3 different categories. Perhaps most common are patients who have an exposed carotid artery in the neck, from prior surgery, wound breakdown, or tumor, but no history of bleeding. This condition has been termed threatened carotid blowout. The second group, termed impending carotid blowout, are patients with the same physical findings as group 1 but who have also experienced a self-limited bleeding event (sentinel bleed) thought to have arisen from the carotid artery system. The third group is the patients who present with active carotid bleed or carotid rupture. With this group, diagnosis is straightforward and clinicians proceed directly to active management (discussed later). In the threatened and impending groups, decision making can be more difficult because the likelihood that carotid bleeding will occur or has occurred and the degree to which further diagnostic and therapeutic strategies are needed must be determined.
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Prior radiotherapy
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Prior radical neck dissection
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Mucocutaneous fistula
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Flap necrosis
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Wound infection
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Poor nutrition or compromised wound healing
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Recurrent tumor
Carotid blowout is almost exclusively associated with patients who have undergone prior radiation therapy, although prior neck dissection, mucocutaneous fistula, flap necrosis, wound infection, poor nutrition/unhealthy supporting tissue, and recurrent tumor are also strongly associated. Therefore, when evaluating a patient with suspected CBS, the presence or absence of these risk factors must be evaluated. The amount of prior radiation (risk is proportional to dose), the radiation ports (was the carotid artery in the port?), and the period of time since irradiation (risk is higher with a longer period of time after irradiation because tissue devascularization increases with time) should be determined. If there has been a prior neck dissection, knowledge of whether the carotid sheath was opened (risk increased ), whether the IJV was taken (if present, the IJV is a possible source of bleeding ), and whether there was close proximity of the tumor to the carotid wall helps determine risk and what vessels are most likely involved. If the patient has had prior removal of an upper aerodigestive tract malignancy, knowledge of the primary site and whether there was/is a postoperative mucocutaneous fistula or wound breakdown is important. History of a prior tracheotomy raises the possibility that a tracheoinnominate fistula exists. If recurrent tumor is present, its location is important in determining the possible site of bleeding and the tumor prognosis is important as a context for future decision making about the aggressiveness of management ( Table 2 ).
| History | Physical Examination |
|---|---|
| Chronology of bleeding? | Vital signs/hemodynamic stability? |
| Amount of bleeding? | Presence and location of fistula? |
| Blood in saliva/tracheal secretions/neck wound? | External wound breakdown? |
| Presence of fistula? | Carotid exposure? |
| Previous neck dissection? Vessels preserved? | Tumor recurrence? |
| Previous radiation? Dose and elapsed time? | Status of tracheal mucosa/blood in the airway? |
| Presence of tracheostomy? | Blood or clot present in neck wound? |
| Previous microvascular reconstruction? | — |
| Oncologic prognosis and comorbidities? | — |
It can be challenging to determine whether or not a sentinel bleed has occurred. Patients often report small amounts of blood in their saliva/tracheal secretions or wound drainage and these may or may not be significant. Questioning the patient as to the chronology and amount of bleeding, whether it was pulsatile, and whether the bleeding was in their mouth, airway, or both is important in determining the likelihood that a bleed from the head and neck vasculature has occurred. It must be differentiated from other sources such as wound granulation tissue, ulcerated tumor, tracheal mucosa, or gastrointestinal mucosa that could be responsible for the bleeding. If a tracheotomy is present, the clinician should try to ascertain whether bleeding has come through or around the tube. In addition, if a microvascular free flap reconstruction has been performed, it is important to know the vessel that was used in the anastomosis and whether it is viable, because this may influence subsequent decisions to sacrifice or stent vasculature.
Physical examination is directed toward ascertaining hemodynamic stability, the status of the patient’s airway, the presence of tumor, the presence of a mucocutaneous fistula and its proximity to the carotid vasculature, and any wound breakdown. The presence or absence of blood in the neck wound, oral cavity, pharynx, or airway should be noted to determine the possible site of the bleeding. If significant clot is present in the neck it should not be disrupted before subsequent investigations. If a tracheostomy exists, the presence of blood in the airway and the status of the tracheal mucosa are important. Particular attention should be paid to the anterior tracheal mucosa at the site of the innominate artery. Flexible endoscopy through the nose, tracheostomy, and/or fistula should be performed as indicated.
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Is the patient at high risk for carotid blowout based on the history and examination?
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Has a sentinel bleed occurred?
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If so, which vessel is most likely involved?
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Can this vessel be sacrificed?
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Is the patient’s airway secure or easily secured?
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What is the patient’s overall prognosis from the cancer and comorbidities?
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