Abstract
Patients undergoing free tissue reconstruction are at risk for development of an anastomotic pseudoaneurysm, which may present as delayed neck hemorrhage or a pulsatile neck mass. Diagnosis may be achieved by noninvasive imaging, angiography, and exploration. Management strategies for head and neck pseudoaneurysms have included open vessel ligation, open direct vessel repair, endovascular parent vessel embolization, and, most recently, endovascular pseudoaneurysm embolization. In patients with anastomotic pseudoaneurysms where adequate flap inosculation is doubted, endovascular pseudoaneurysm embolization with pedicle preservation may be an appropriate primary treatment approach. We discuss the successful endovascular coiling of an external carotid artery branch anastomotic pseudoaneurysm in a patient one month after free tissue reconstruction of a total laryngopharyngectomy and partial glossectomy defect.
1
Introduction
Pseudoaneurysm (PA) formation results from arterial wall disruption with extravasation of blood into the surrounding tissues. High-pressure extraluminal circulating blood leads to creation of a cavity that expands until contained by adjacent tissue, thrombus, and fibrous material. Predisposing factors include trauma, infection, radiotherapy, systemic hypertension, malignancy, and vascular anastomosis . Anastomotic PAs are a well-known complication of large vessel reconstruction ; however, their formation after microvascular free tissue transfer is rare. Only a handful of case reports have been published describing microvascular anastomotic PAs and their presentation and management have been highly variable.
Presenting symptoms of PA often include an enlarging mass with or without pulsatility at the anastomotic site or hemorrhage from the surgical site . Additionally, infection is often present and frequently cited as a primary etiologic factor . Management depends on severity of the initial presentation. Unstable or ruptured aneurysms may require urgent surgical exploration, while stable PAs may be amenable to less invasive or endovascular approaches . Of course, a primary consideration during this process is maintaining perfusion to the flap. In this report, we describe a ruptured anastomotic PA managed by endovascular coiling of the PA with pedicle preservation and complete flap survival.
2
Case report
Our patient is a 70-year-old male with an active 50-pack year history of tobacco use and early stage squamous cell carcinoma of the supraglottic larynx. He was treated at an outside hospital with definitive radiation therapy 10 years prior to presentation. He presented to our system with left-sided otalgia and hoarseness and was found to have a second primary T4N0M0 squamous cell carcinoma of the glottic larynx with extension into the tongue base and intrinsic tongue musculature. He underwent salvage total laryngopharyngectomy, subtotal base of tongue glossectomy, bilateral neck dissections, and tubed anterolateral thigh flap reconstruction. The lateral circumflex femoral artery was anastomosed to the right facial artery using conventional suture technique. The patient’s postoperative course was complicated by necrosis of his left native tongue base remnant, which resulted in a left neck pharyngocutaneous salivary fistula, as well as pneumonia ultimately resulting in a three-week hospitalization. The salivary fistula was treated with wound packing performed twice daily. On postoperative day 30, he developed sudden bright red bleeding from his right neck while straining during a bowel movement. The hemorrhage had ceased when he arrived at the hospital and he ultimately underwent conventional angiography revealing a 5.4 × 8.0 mm multilobular PA arising just distal to the arterial anastomosis (see Fig. 1 ). Due to concerns of inadequate flap inosculation due to previous radiation, active smoking history, left tongue base necrosis, and pharyngocutaneous fistula, endovascular PA management with pedicle preservation was pursued. Cannulation of the distal portion of the complex PA was unsuccessful due to the multiple 180-degree turns that would have been required and risk of further rupture. The proximal portion of the PA was tightly packed with platinum detachable coils without complication, leading to angiographic eradication of the lesion (see Fig. 2 ). Neck exploration and washout were performed immediately following embolization and his postoperative course was unremarkable. Six weeks after surgery, he received postoperative re-irradiation to the surgical site and tolerated it well. Six months after coiling, he is doing well, his flap remains viable, and he is taking food by mouth (see Fig. 3 ). Other cases of PA management after free tissue transfer are described in Table 1 .
| First author | Year | Type of free flap | Recipient site | Recipient arterial anastomosis | Presenting sign | Time from surgery | Etiologic factors | Management | Outcome |
|---|---|---|---|---|---|---|---|---|---|
| Islam | 2014 | Radial forearm | Oral cavity | End-to-end proximal ECA | Enlarging mass | 4 weeks | None identified | Percutaneous thrombin injection, thrombosis of PA only | Complete survival |
| Smelt | 2012 | Jejunum | Pharynx and cervical esophagus | End-to-end, superior thyroid | Hemorrhage | 2 months | Chemoradiation, infection | EV coiling of PA and distal ECA | Complete survival |
| Lykoudis | 2009 | Fibula | Mandible | End-to-end, facial | Hemorrhage | 7 days | Uncontrolled hypertension | Excision of anastomotic segment, vein graft repair of anastomosis | Complete survival |
| Baynosa | 2007 | Radial forearm | Scalp | End-to-side, proximal ECA | Pulsatile mass | 2 weeks | Suture pulled out of donor artery | Resection of sac, direct repair of anastomosis | Complete survival |
| Goddard | 2004 | Jejunum | Pharynx | End-to-end, lingual-facial trunk | Hemorrhage | 2 weeks | Radiation, infection | EV coiling of PA and ECA (failed), common carotid ligation | Complete loss |
| Ceulemans | 2001 | Thoracodorsal artery perforator | Dorsal foot | End-to-side, anterior tibial | Pulsatile mass | 18 days | Infection, flap congestion | Antibiotic therapy, leeches | Complete survival |
| Yuen | 2000 | Rectus | Nasopharynx and skull base | End-to-side, ECA | Enlarging mass | 5 weeks | Chemoradiation | EV coiling of PA only (failed), EV coiling of ECA | Complete survival |
| Kalainov | 1998 | Gracilis | Lower leg | End-to-side, posterior tibial | Enlarging mass | 7 days | Infection | Direct suture repair of defect | Complete loss |
| Harashina | 1988 | Lateral thoracic | Not reported | Not reported | Hemorrhage | 10 days | Not reported | Ligation of recipient artery | Complete loss |
| Rath | 1986 | Latissimus dorsi | Lower leg | End-to-end, posterior tibial | Hemorrhage | 17 days | Infection | Ligation of recipient artery | Near-complete survival |
| Serafin | 1977 | Groin | Lower leg | Not reported | Hemorrhage | 10 days | Infection | Ligation of recipient artery | 30% survival a |
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