Carotid Blowout Requires Life-Saving Intervention

The patient is a 57-year-old woman with a long history of tonsillar cancer, treated in the past with multiple surgical procedures including right-sided mandibular surgery and trapezius muscle flap advancement, and radiation to treat a tonsillar cancer that was then felt to be in remission.

She had been doing reasonably well, in good health, until about two months prior to the current admission when she started noticing some heavy phlegm production requiring tracheostomy placement several weeks prior to this admission.

She was admitted to Mount Sinai South Nassau Hospital with increasing mucous plugging of her tracheostomy, and then was abruptly found to be bleeding out her mouth.  Over a very short period, the patient began to have explosive, aggressive bleeding out the mouth and nose and was taken emergently to the operating room to try to stop this.

Figure 1 – Angiographic image shows external carotid artery blowout.

Figure 2- In-process treatment image illustrates packing of eroded carotid artery with coils.

All efforts at stopping the bleeding under direct observation in the operating room failed and manual compression with two large gauze sticks in the back of her throat were needed to control the bleeding.  Neurosurgery and neurointerventional emergency consultation was obtained and we decided to take the patient emergently to the angiography suite with a presumed diagnosis of a carotid blowout requiring life-saving intervention.

The first angiographic image (Figure 1) shows an external carotid artery blowout with extravasation with good filling of the internal carotid artery.  At that point, a decision was made to proceed with packing the area of eroded external carotid artery with coils, which was successful.  After quite a few coils were packed (Figure 2), the extravasation and exsanguination stopped (Figure 3) .

The patient ultimately recovered, and was found to be neurologically intact and free of cancer.

Figure 3 – Post-treatment image shows good filling of the internal carotid artery with intracranial circulation and no further extravasation of contrast, suggesting complete cessation of the bleeding.

DISCUSSION:

• Life-saving neurointervention has been used in the past and continues to be used for patients who suffer life-threatening exsanguination from blown out carotids.
• The pathophysiology of this is felt to be unrelated to any type of cancer recurrence, but rather is simply the tissues that have been weakened by radiation and prior surgeries simply blows out and takes with it a piece of the carotid artery.
• This almost always needs to be treated with emergent angiography and then embolization using various embolic materials; in this case 11 coils were used.
• Another option would have been a covered stent but given the size and shape of the carotid and the area that was blown out, a decision was made to pack this with coils, which was successful and should be long-lasting.