Article Figures & Data
Figures
- Fig 1.
Patient 5.
A, Left carotid angiogram shows a pseudoaneurysm in the bifurcation (arrow).
B, After 3 fiber coils (arrowheads) were placed in the main trunk of the ECA, an 8 × 50-mm stent was deployed in the left carotid artery.
C, Reconstructive CT angiography (curved multiplanar, reformatted images) of left carotid artery 2 months later shows complete obliteration of the pseudoaneurysm. Retained fiber coils in the thrombosed ECA with metallic artifact were also found (arrows).
D and E, Contrast-enhanced axial CT scans of the head and neck 4 months later show septic thrombosis of the stent-graft with gas collection (arrow in panel D) and several brain abscesses (arrowheads in panel E).
- Fig 2.
Patient 1.
A, Right carotid angiogram shows a ruptured carotid artery in the bifurcation (vertical arrows) and an active jet of extravasation (arrowheads) through a focal skin defect on the right side of the neck during the injection of contrast medium. Obvious long-segmental stenosis of the cervical ICA was also found (horizontal arrows).
B, After the deployment of an 8 × 50-mm stent from the ICA to the CCA, acute thrombosis with total occlusion of the carotid artery occurred immediately.
- Fig 3.
Patient 3. Left carotid angiograms. A, Pseudoaneurysm in the cervical ICA (arrow). B, Soon after a 7 × 30-mm stent was deployed in the cervical ICA, acute thrombosis was noted in the stent and its distal end (arrowheads). C, Acute thrombosis was lysed in 10 minutes by using an intravenous antiplatelet agent. D, Rebleeding due to a pseudoaneurysm in the carotid bulb was found 3 weeks later; the lesion (arrow) was just proximal to the first stent. E, A 9 × 50-mm stent was deployed in the carotid artery, which stopped the bleeding. F, Follow-up left carotid angiogram shows preserved carotid artery and complete obliteration of the pathologic lesion 1 week later. G, Six months later, axial contrast-enhanced CT scan of the neck shows thrombosis of the left carotid artery (arrow).
- Fig 4.
Patient 6.
A, Right carotid angiogram shows a pseudoaneurysm in the right distal CCA (arrow).
B, An 8 × 50-mm stent was deployed from the right carotid bulb to the right CCA.
C, Another pseudoaneurysm in the right carotid bulb just distal to the distal end of the stent (arrow) was noted 2 months later.
D, A second 8 × 50-mm stent was deployed in the right cervical ICA to overlap the first stent. Mottled gas collection (arrowheads) in the soft tissue indicates radiation necrosis.
E, Right subclavian angiogram shows a pseudoaneurysm (arrow) in a branch of the right superior thyroid artery reconstituted from branches of the ipsilateral costocervical trunk via the ipsilateral ECA. The stent occludes the orifice of the right ECA.
F, Direct percutaneous puncture of the main trunk of the right ECA with a spinal needle (arrowheads) was done by using a roadmap image. The needle contacted the right superior thyroid artery and showed the small pseudoaneurysm (arrow). The pseudoaneurysm was successfully embolized with a slow injection of a mixture of liquid adhesives (n-butyl cyanoacrylate and lipiodol).
Tables
Summary of patients with carotid blowout syndrome treated with self-expandable stent-grafts
Patient No./Age (y)/Sex Cancer and Treatment History Presentation Blowout Stent-Graft (mm)* Initial Complication† Follow-Up Outcome Onset (y) Group Location 1/35/M Mixed, submandibular gland; wide excision, R/T, C/T Recurrence, RN; lung, kidney metastasis 5 Acute CBF 8 × 50 Asymptomatic acute ICA thrombosis and occlusion Not applicable 19 d: rebleed; died 2/43/M Tonsillar; wide excision, R/T, C/T Recurrence, RN 1 Acute CCA 8 × 30 None Not applicable 2 d: rebleed; died 3/52/M Laryngeal; total laryngectomy, R/T, C/T Recurrence, RN, PCF 4 Acute ICA 7 × 30, 9 × 50 Asymptomatic transient in-stent thrombosis Rebleed wk 3, second stent-graft; patency on 1-mo CTA & 3-mo angiogram 6-mo CT: asymptomatic carotid thrombosis; lived 20 mo 4/49/M Nasopharyngeal, R/T; second primary hypopharyngeal, R/T, C/T Recurrent hypopharyngeal cancer, RN 12, 1 Impending CBF 8 × 50‡ Embolic infarct, MCA territory Stent patency on 1-mo CT, sonography 2-mo: died from progression 5/52/M Hypopharyngeal; R/T, C/T Slightly swollen soft tissue of neck 1 Impending CBF 8 × 50‡ None Stent patency on 2-mo CTA 4-mo: septic carotid thrombosis, brain, abscess; lived 14 mo 6/65/M Laryngeal; R/T RN, PCF 4 Acute CCA, CBF 8 × 50, 8 × 50 None Rebleed at 2-mo, second stent-graft; rebleed at 3-mo, direct percutaneous ECA puncture for embolization; stent patency at 3-mo CT 5-mo CT: asymptomatic carotid thrombosis; lived 13 mo 7/44/M Hypopharyngeal; total laryngopharyngectomy, C/T, R/T Recurrence, RN, PCF, lung metastasis 1/2 Threatened CCA 9 × 70 None Stent patency on 2-wk sonography 1-mo: died from lung metastasis 8/54/M Lower esophageal, primary hypopharyngeal; esophagectomy, laryngectomy, C/T, R/T Recurrence, RN, PCF 1 Threatened CCA 9 × 70 None Stent patency on 2-wk CTA 1.5-mo: died from progression, mediastinitis Note.—CBF indicates carotid bifurcation; CCA, common carotid artery; C/T, chemotherapy; CTA, CT angiography; ECA, external carotid artery; MCA, middle cerebral artery; PCF, pharyngocutaneous fistula; RN, radiation necrosis; R/T, radiotherapy.
* Wallgraft; Boston Scientific Corporation.
† Immediate hemostasis was achieved in all patients.
‡ Plus 3 fiber coils in the ECA
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