Elsevier

World Neurosurgery

Volume 112, April 2018, Pages 53-56
World Neurosurgery

Case Report
Successful Use of Covered Stent for Carotid Artery Injury with Active Medial Projecting Extravasation

https://doi.org/10.1016/j.wneu.2018.01.076Get rights and content

Highlights

  • Nontraumatic carotid artery injury with active extravasation—carotid blowout syndrome (CBS) —is relatively rare and highly difficult to treat because of its anatomic factors.

  • A conventionally direct open approach was performed for CBS, which resulted in miserable morbidity and mortality.

  • Recently a covered stent has shown highly favorable results for all types of CBS.

  • The covered stent has some disadvantages: cost, risk of embolism, rebleeding due to infection, inclination for bleeding due to dual antiplatelet therapy.

  • The covered stent is especially effective for the CBS types in which the rupture point is under the clavicle and involves medially projecting extravasation.

Background

Nontraumatic carotid artery injury with active extravasation, or carotid blowout syndrome (CBS), is relatively rare and highly difficult to treat because it is difficult to approach the lesions owing to anatomic factors. It also involves quick progression and a risk of cerebral embolization caused by thrombi and carotid artery occlusion. Recently, covered stents were revealed to be effective for CBS. However, they have several disadvantages, such as their costs, rebleeding complications, or cerebral embolic risks. A firm selection method of CBS types that are appropriate for covered-stent therapy is expected.

Case Description

A 38-year-old man with esophageal cancer presented with massive hematemesis. Computed tomography revealed active extravasation from the left common carotid artery with medial projection. Initially, the open direct approach failed, which resulted in further bleeding and transient cardiopulmonary arrest. With tentative hemostasis using manual finger compression, emergency angiography was performed, and a covered stent, Fluency 8 mm × 60 mm, was placed at the rupture point. He was transferred to the rehabilitation hospital 36 days after admission with a modified Rankin score of 2 without major complications.

Conclusion

CBS cases having rupture points around the clavicle and having medial projection extravasation should be treated by covered stent placement under tentative hemostasis using manual finger pressure rather than conventional open surgical treatment.

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.

References (16)

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Cited by (3)

  • Penetrating Vertebral Artery Injuries: A Literature Review and Proposed Treatment Algorithm

    2021, World Neurosurgery
    Citation 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.

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.

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