Preoperative Protective Endovascular Stenting Followed by Surgery for Management of the Cervical Common and Internal Carotid Artery with Tumor Encasement

Background: Encasement of the common carotid artery (CCA), and/or internal carotid artery (ICA) in patients with tumors of the head and neck presents a substantial dilemma in surgical management. Encasement of greater than 180 degrees often renders the tumor unresectable leading to a substantial increase in mortality and mortality. The choice to attempt resection when encasement of the cervical ICA/CCA is present is associated with significant morbidity such as carotid rupture, and stroke. Recently, there have been multiple reports on the use of preoperative stenting in the management of vagal and tympanojugular paragangliomas with greater than 180 degree encasement of the ICA/CCA, and bilateral body tumors. The formation of a neointimal lining on the luminal surface of the stent allows for excision of the tumor and associated adventitia from the stent. The aim of this study is to report the outcomes on small cohort of patients with tumor encasement of the cervical ICA/CCA who underwent preoperative stenting prior to surgical resection.

Methods: The investigators designed a retrospective study and enrolled a sample of subjects who received preoperative stenting of the cervical ICA/CCA prior to surgical resection of head and neck tumors between April 1st, and July 31st, 2015. The outcomes assessed were final histopathological tumor margins involved by tumor, and complications after endovascular and surgical procedures.

Results: The sample was composed of 5 subjects who received preoperative stenting of the ICA/CCA prior to surgical resection. All subjects exhibited encasement of greater than 180 degrees of the ICA/CCA on preoperative imaging. The mean age was 65.2, and 3 of 5 subjects received preoperative chemotherapy and radiation. The type of tumor in all subjects was squamous cell carcinoma. Primary tumor sites include the larynx/pharynx (n = 2), pharynx (n = 1), tonsil (n = 1). One subject’s primary was unknown. Median follow-up was 3.5 months. Excision of the adventitia from the stent was performed in all subjects during tumor resection. No intraoperative complications occurred. One vascular-related complication occurred in one subject that had occlusion of the stent, suffering a mini stroke and associated motor deficit. No involvement of tumor at the deep margin (inner surface of adventitia) of the resection was seen in any of the subjects.

Conclusions: Preoperative stenting of the cervical ICA/CCA in the management of subjects with head and neck tumors who display encasement on preoperative imaging may represent a safe and effective treatment. A higher-powered study with longer follow-up needs to be performed to assess the long-term benefit and morbidity of using this technique.