Case ReportSuccessful Use of Covered Stent for Carotid Artery Injury with Active Medial Projecting Extravasation
Introduction
Nontraumatic carotid artery injuries with active extravasation are relatively rare and highly difficult to treat because they are difficult to approach, involve quick progression, and carry the risk of cerebral embolization caused by thrombi and carotid artery occlusion. This medical condition is also called carotid blowout syndrome (CBS), and it occurs in 2.6% of patients undergoing radiation therapy for head and neck tumors.1 It also occurs in 3% to 4% of patients with surgical neck dissections.2, 3, 4 Conventionally, direct management with open surgery was performed for these cases. However, the lesions were mostly deep and surrounded by several important vessels and nerves. These conditions led to high morbidity and mortality rates of 60% and 40%, respectively.1, 2, 5 Several studies have shown the effectiveness of the endovascular approach for the disease, although there is no standardized treatment for CBS.6, 7, 8, 9, 10, 11, 12, 13 Endovascular treatment is simpler and less invasive than the open surgical approach.
We performed covered stent placement for CBS induced by a common carotid arterioenteric fistula caused by esophageal carcinoma invasion. Recently, the covered stent has been used for the treatment of all types of CBS. Currently, only a few studies have compared the effectiveness of open surgery and endovascular approaches. Initial open surgical management failed in our case. We could not have saved the patient's life without the endovascular approach. This case revealed the proven effectiveness for certain CBS types.
Section snippets
Case Report
A 38-year-old man was experiencing fatigue and immobility. In the ambulance, his blood pressure was notably low (71/56 mm Hg), and his skin appeared sweaty and cold. He vomited a massive amount of blood just after arriving at the emergency room. Emergency computed tomography (CT) imaging with a contrast agent showed the left common carotid artery (CCA) and an enteric fistula with active extravasation (Figure 1). At first, general surgeons incised and opened the suspected site of the lesion.
Discussion
Carotid arterial injury with extravasation is extremely intractable and life-threatening because of the high blood flow through the carotid artery and the risk of infarction, embolization, or carotid artery occlusion.1, 2, 5, 14 Successful treatment with a covered stent to terminate carotid arterial extravasation revealed 2 clinically important points and valuable findings. First, the covered stent is highly effective and is a reasonable choice for addressing carotid arterial injury with active
Conclusion
CBS should be suspected when esophageal cancer patients experience massive hematochezia. Covered-stent placement should be considered an initial treatment in cases wherein the rupture point is thought to be just around the clavicle and if there is associated medial projection extravasation.
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Cited by (3)
Penetrating Vertebral Artery Injuries: A Literature Review and Proposed Treatment Algorithm
2021, World NeurosurgeryCitation Excerpt :In the case reported here, a covered stent was used without complications and continued patency on DSA at 3 months. For similar carotid artery injuries, there have been successful placement of covered stents as well.35-37 Including details on the type of stent in future reports will be beneficial to determine the ideal treatment for these unique injury patterns.
Emergent carotid artery stenting for cervical internal carotid artery injury during carotid endarterectomy: A case report
2021, Surgical Neurology International
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.