Abstract
Cervical radiotherapy for treatment of head and neck cancer can result in the delayed carotid vasculopathy. Surgical management for an ensuing hemorrhage is challenging due to the associated high mortality and morbidity. We present a case of a relative rapid formation of common carotid pseudoaneurysm formation with subsequent carotid blowout syndrome in previously irradiated neck. Successful treatment in our patient is highlighted by the fact that multiple, contiguous endovascular stents were placed emergently to obtain control of pseudoaneurysm rupture.
1
Introduction
Carotid pseudoaneurysm is a rare entity with catastrophic potential that poses therapeutic challenges. It is most commonly a result of neck trauma or carotid vascular intervention . Among head and neck cancer patients, its formation and the progression to a carotid blowout syndrome are the most feared complications with a small but significant 4% rate . Moreover, with current treatment protocols stressing organ preservation, primary radiation therapy is implicated in an increase in iatrogenic arterioapathy .
Surgical intervention is recommended for pseudoaneurysm treatment. Open repair has been the standard of care however is hazardous in a previously operated or irradiated neck . Endovascular stent placement of a carotid artery pseudoaneurysm offers a minimally invasive technique however its role in emergent management or long-term control has not been established . We present a case of life threatening hemorrhage secondary to common carotid pseudoaneurysmal rupture in the setting of a previously treated laryngeal carcinoma with emphasis on definitive endovascular control.
2
Case report
Eighty-year-old male with a history of a T1N2b left piriform sinus squamous cell carcinoma s/p primary chemoradiation therapy completed in November of 2006 was referred to our head and neck oncology clinic by his primary care physician for 2 day history of hematemesis. Briefly, after primary therapy, he developed complete pharyngeal and upper esophageal stenosis along with a left neck recurrence; therefore he underwent total laryngectomy and partial pharyngectomy with left modified radical neck dissection in 3/2008. He later developed a pharyngocutaneous fistula shortly after surgery and underwent neck exploration with pectoralis major myocutaneous flap reconstruction. Patient did not undergo reirradiation due to prolonged healing issues. The patient’s history was also significant for atrial fibrillation for which he was treated with digoxin. He quit tobacco 15 years prior.
Physical examination showed normal oral cavity and oropharynx clear of any old or active bleeding. He displayed expected postradiation fibrosis and postsurgical changes consistent with his salvage surgery and regional reconstruction. The stoma site was clear and patent with minimal granulation tissue in the trachea. Flexible tracheoscopy showed patent trachea without any origin of bleeding. Flexible nasopharyngoesophagoscopy was performed showing no mass, ulceration, lesion, or blood. However the scope could not be passed into the thoracic esophagus.
After evaluation in the clinic, the patient underwent computed tomography (CT) of the neck with intravenous contrast. This revealed a 2.6 × 2.8 cm pseudoaneurysm in the left distal common carotid artery just proximal to bifurcation with active bleeding into the cavity ( Fig. 1 ). The patient was immediately admitted to the hospital and the neurointerventionalist was consulted. Upon initial interview and examination, the patient developed profuse arterial hemorrhage from his upper airway signifying rupture. The patient was emergently transferred to the neurointerventional suite and diagnostic angiogram was obtained of the left carotid artery, confirming the presence and location of the pseudoaneurysm. Heparin was infused and once an activated clotting time (ACT) > 300 was achieved, an Atrium iCast covered 7 × 22 mm stent was deployed using a transfemoral percutaneous technique. The stent was placed across the aneurysm occluding it from the remainder circulation and bleeding was controlled. Once the stent was deployed, 650 mg of aspirin and 450 mg of plavix was given by gastrostomy tube. The patient was observed in the neurointensive care unit. However, the following day, the patient redeveloped bleeding. The patient was then again transferred to the neurointerventional suite. After confirming persistent leak ( Fig. 2 ), a second covered stent was placed adjacent to the previous stent ( Fig. 3 ), definitively controlling the pseudoaneurysm ( Fig. 4 ). The patient remained on short-term anticoagulation therapy with plavix and lifelong aspirin therapy. The patient was ultimately discharged home on hospital day 12 clear any further events or infection.
On follow up, the patient is currently doing well without any recurrence of bleeding. A follow up CT of the neck 8 months post treatment shows patent common carotid artery without evidence of extravasation ( Fig. 5 ).
