Coronaric stent-graft deployment in the treatment of carotid blowout

backgroun and purpose: some reports of reconstructive management of carotid blowout syndrome (CBS) with stent-grafts are promising, but some are unfavorable. this study sought to evaluate the hemostatic efficacy, safety, and outcome of reconstructive, endovascular stent-graft placement in patients with head-and-neck cancers in association with CBS. methods: eight patients with head-and-neck cancers with CBS were treated with self-expandable stent-grafts. we evaluated the initial hemostatic results, complications, and outcomes by assessing the clinical and imaging findings. results: Immediate hemostasis was achieved in all patients. Initial complications included stroke in 1 patient and asymptomatic thrombosis of the carotid artery in 2 patients. delayed complications included rebleeding, delayed carotid thrombosis, and brain abscess formation. Rebleeding was noted in 4 patients and was successfully managed with a second stent-graft and embolization in 2 of them. delayed carotid thrombosis with follow-up after 3 months was found in 3 patients, 1 of whom had associated brain abscesses. conclusion: although stent-grafts achieved immediate and initial hemostasis in patients with head-and-neck cancers and CBS, long-term safety, stent patency, and permanency of hemostasis appeared unfavorable. this treatment may be for temporary or emergency purposes rather than serving as a permanent measure. we suggest its applications in patients with acute CBS that precludes performance of an occlusion test, as well as when carotid occlusion poses an unusually high risk of neurologic morbidity. we also propose prophylactic antibiotic treatment and combined embolization of pathologic vascular feeders to improve outcomes. carotid blowout refers to rupture of the carotid artery and its branches.1–4 It is one of the most devastating complications associated with therapy for head-and-neck cancers. the clinical signs and symptoms related to rupture of the carotid artery have been referred to as carotid blowout syndrome (CBS). carotid blowout tends to occur in patients with head-and-neck cancers and radiation-induced necrosis, recurrent tumors, or pharyngocutaneous fistulas.2 the reported neurologic morbidity and mortality rates associated with this complication are 40% and 60%, respectively.3 surgical management of carotid blowout is usually technically difficult because exploration and repair of the previously irradiated field are difficult. endovascular therapy with either permanent balloon occlusion or stent deployment is reportedly a good alternative to surgery.1–5 as many as 15%–20% of patients with CBS who are treated with permanent balloon occlusion have immediate or delayed cerebral ischemia.1,6 a balloon occlusion test may be performed before threatened CBS is treated definitively, but this test is usually not possible in acute cases. additionally, test occlusion may not help identify the small subset of patients in whom delayed hemodynamic ischemia develops after the internal carotid artery (ICA) is permanently occluded.1–3 reconstructive endovascular management of CBS seems reasonable to achieve hemostasis and to prevent neurologic morbidity. however, some reports of limited cases show unfavorable long-term outcomes after the deployment of foreign bodies into a field with ongoing contamination.5,7 such studies suggest preserving flow in the artery adjacent to ongoing cancer and infection can leave the patient at a higher risk of delayed complications (eg, subsequent bleeding or stent occlusion) than with carotid sacrifice. the purpose of this study, therefore, was to evaluate the hemostatic efficacy, safety, and outcome of endovascular reconstruction with self-expandable stent-grafts to manage carotid blowout in patients with head-and-neck cancer.