Carotid Blowout Syndrome; an oncological emergency less discussed. Presenter: Karthik K Prasad Nagesh T Sirsath, Kiran V Naiknaware, K Sandhyarani, Manish S Bhatia M N Budhrani Cancer Institute, Pune.

INTRODUCTION Carotid blowout syndrome (CBS) is a lethal complication of head and neck cancer. Most commonly, patients have a history of radical neck surgery & radiation for HNSCC.1 Advances in interventional radiology have made management of these conditions possible. Early diagnosis and expeditious management by endovascular techniques is life-saving. 1. Powitzky R, Vasan N, Krempl G, Medina J. Carotid blowout inpatients with head and neck cancer. Ann OtolRhinolLaryngol2010;119(7):476–484

CLINICAL DETAILS A sixty-year old gentleman presented to ER with bleeding from the oral cavity. The patient was a case of recurrent carcinoma of hypopharynx & had completed induction chemotherapy followed by concurrent chemoradiation an year ago. Examination showed large clots in the oral cavity. The patient was in shock and was resuscitated.

CLINICAL DETAILS cont… Endoscopy showed a large eccentric friable mass lesion in the hypopharynx with bleeding. CBS was suspected; angiography was done. MR angiography showed the lesion completely encasing the proximal 2 cm of external carotid artery (ECA) with minimal luminal narrowing. No obvious dissection or pseudoaneurysm was seen. Interventional radiologist was consulted.

Transfemoral supra-aortic DSA showed active contrast extravasation from anterior wall of left ECA just distal to its origin. (FIGURE-A) The contrast seen tracking into pharynx, esophagus and oral cavity. Embolization using 35-3-3 coil was done, following which no active extravasation of dye was noted. A tiny stump of left ECA was seen indicating successful embolization. (FIGURE-B)

DISCUSSION CBS is involvement of the carotid artery by HNSCC with compromise of vessel integrity and rupture. Incidence – 3-4% of HNSCC, mortality & morbidity of 40% & 60% respectively. 2 CBS has been categorized by Chaloupka et al as “Threatened” -carotid artery is exposed to the oral cavity or neck “Impending” -sentinel bleeds have occurred but have been controlled. “Acute” -where there is active bleeding. Predictors of CBS on angiography include pseudoaneurysm and vessel wall damage. 3 2. Citardi MJ, Chaloupak JC, Son YH, et al. Management of carotid artery rupture by monitored endovascular therapeutic occlusion (1988 –1994). Laryngoscope1995;105:1086–92  3. Chang FC, Lirng JF, Luo CB. Carotid Blowout Syndrome in Patients with Head and Neck Cancers: Reconstructive Management by Self-Expandable Stent-Grafts. AJNR Am J Neuroradiol2007; 28:181-88.

DISCUSSION CONT… The gold standard for diagnosis CBS is digital subtraction angiography (DSA). In threatened & impending CBS, CT angiogram of head and neck is required to evaluate carotid circulation up to the circle of Willis.4 Traditional surgical ligation is technically difficult because of altered anatomy and prior radiation. Endovascular techniques (embolization or stenting) is the standard of care.5 4.Kozin E, Kapo J, Straton J, Roseille DA. Carotid blowout management #251. J Palliat Med 2012; 15(3): 360-1. 5.Cohen J, Rad I. Contemporary management of carotid blowout. CurrOpinOtolaryngol Head Neck Surg 2004; 12(2): 110-5. 

DISCUSSION CONT… Embolization is most appropriate in disease affecting vascular territory of ECA or in preoperative reduction of blood flow to a lesion. Complications of endovascular techniques (15-60%): Rebleeding, Thromboembolism, Neurological deficits. Endovascular stenting is considered in patients who are at high risk for cerebral ischemia. Clinical severity is the most significant factor affecting the hemostatic outcome of endovascular management.6 6. Chang FC, Lirng JF, Luo CB et al. Patients with head and neck cancers and associated postirradiated carotid blowout syndrome: Endovascular therapeutic methods and outcomes. J VascSurg2008;47:936-45.

CONCLUSION With increasing cases of treated HNSCCs, the oncologist must be alert to any oral bleeding or haemorrhage from an exposed neck wound. Once CBS is suspected, interventional radiologist must be contacted for expeditious management. Endovascular technique is the preferred method of management of these lesions. Early recognition of the predictors of CBS by a multidisciplinary team is crucial.