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Carotid Blowout Syndrome of an Infected Pseudoaneurysm after Radiation Therapy of Parotid Cancer: Successful Multidisciplinary Treatment with Coiling, Pseudoaneurysm Excision, Debridement, and Plastic Reconstruction
Vasc Specialist Int 2020;36:268-269
Published online December 31, 2020;  https://doi.org/10.5758/vsi.200082
© 2020 The Korean Society for Vascular Surgery.

Hyunmin Ko1, Ahram Han1, Hak Chang2, and Seung-Kee Min1

Departments of 1Surgery and 2Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul, Korea
Correspondence to: Seung-Kee Min
Division of Vascular Surgery, Rm 5313, Biomedical Research Institute, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea
Tel: 82-2-2072-0297
Fax: 82-2-766-3975
E-mail: skminmd@snuh.org
http://orcid.org/0000-0002-1433-2562
Received December 21, 2020; Accepted December 27, 2020.
Body

A 73-year-old man visited emergency room due to recurrent bleeding from the neck wound. Nineteen years ago, he was performed resection and radiation therapy of right parotid cancer. One year ago, he developed osteoradionecrosis of right mandibular angle, and multiple operations were performed; debridement, skin grafts and flaps, and partial mandibulectomy. However, 9 months ago, a pustule developed at the operation site and conservatively managed by dressing. From two weeks earlier, three massive herald bleedings developed from the wound, which was controlled by compression. Physical examination revealed the crusted wound with hematoma over the exposed carotid artery and another wound with mandibular bone exposure (Fig. 1). The neck was tightly fibrotic and fixed due to the previous radiation therapy. Computed tomography (Fig. 2) showed a pseudoaneurysm from the right carotid bifurcation, and occluded right internal carotid artery. Because of the high risk of rebleeding, emergent coil embolization was performed (Fig. 3). After 6-day antibiotic therapy, the wound was explored under general anesthesia. After removing the crust with hematoma, ruptured carotid artery and the coils inside the pseudoaneurysm were exposed (Fig. 4). After debridement, the both ends of the carotid artery were sutured with polypropylene. The wound was reconstructed with pedicled pectoralis major myocutaneous flap and split thickness skin graft (Fig. 5). He survived more than 3 years until lost to follow-up due to pneumonia.

Figure 1. Initial presentation at the emergency room. The crusted wound with hematoma was located just over the carotid pulsation (arrow), and another small wound showed exposed mandible (arrow head).

Figure 2. Computed tomography angiography showed a pseudoaneurysm (arrow) at the right carotid bifurcation connecting to the skin, occluded internal carotid artery, and severely stenotic external carotid artery.

Figure 3. Coil embolization of the carotid artery and the pseudoaneurysm was performed.

Figure 4. After removing the crust, ruptured carotid artery and coils inside were exposed.

Figure 5. Wound was reconstructed with a myocutaneous flap and skin graft.

Carotid blowout syndrome is a rupture of the carotid artery and a life-threatening complication [1]. It is mainly developed by radiation and surgery of head and neck cancer. Treatment includes coil embolization, covered stent graft, and surgical treatment [2]. Because of the previous radiation therapy and multiple operations in this case, surgical approach to ensure proximal and distal control of the carotid artery was almost impossible. Moreover, the infected wound prohibited covered stent graft. A multidisciplinary approach with vascular surgeons, interventional radiologists, plastic surgeons and oncologic surgeons of maxillofacial surgery is particularly important in the management of carotid blowout syndrome to prevent a disaster [3].

References
  1. Kim M, Hong JH, Park SK, Kim SJ, Lee JH, Byun JH, et al. Rupture of carotid artery pseudoaneurysm in the modern era of definitive chemoradiation for head and neck cancer: two case reports. World J Clin Cases 2020;8:4858-4865.
    Pubmed KoreaMed CrossRef
  2. Bond KM, Brinjikji W, Murad MH, Cloft HJ, Lanzino G. Endovascular treatment of carotid blowout syndrome. J Vasc Surg 2017;65:883-888.
    Pubmed CrossRef
  3. Sallustro M, Abualhin M, Faggioli G, Pilato A, Dall'Olio D, Simonetti L, et al. Multistep and multidisciplinary management for post-irradiated carotid blowout syndrome in a young patient with oropharyngeal carcinoma: a case report. Ann Vasc Surg 2020;67:565.e1-565.e5.
    Pubmed CrossRef


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