Stenting for Prevention of Carotid Blowout Syndrome in High-Risk Head and Neck Cancer Patients

Background: Carotid blowout syndrome is a surgical emergency caused by structural compromise of the extracranial carotid artery either due to local invasion from head and neck malignancies or to secondary effects from radiotherapy, resulting in uncontrolled hemorrhage. Patients with newly diagnosed nonresectable head and neck cancers with involvement of the carotid artery may benefit from prophylactic stenting to prevent carotid blowout. Prophylactic carotid stenting may also benefit patients already treated for advanced head and neck cancer presenting with newly observed disease progression or threatened carotid blowout.

Objective: The study aims to report outcomes from a single institution experience with prophylactic endovascular stent-reconstruction of the extracranial carotid artery in head and neck cancer patients with at high risk for carotid blowout syndrome.

Methods: A retrospective review of the electronic medical record was conducted to identify patient characteristics, laboratory findings, devices used, complications, imaging, and clinical follow-up data for patients with head and neck cancers undergoing prophylactic stenting of the extracranial carotid artery at Rush University Medical Center between 2012 and 2019.

Results: Twelve patients underwent prophylactic carotid artery stent placement, with average age 59 (range = 32–71). All twelve patients (100%) had invasive squamous cell carcinoma of the head or neck judged to be advanced based on clinical staging. Eight patients (66%) had locally advanced stage II or III disease, while four (33%) had metastatic stage IV disease. Two (17%) patients received prophylactic stenting prior to any other treatment, while two (17%) patients received radiation therapy, but no surgery prior to stenting. The remaining eight (66%) patients all received surgical resection and radiotherapy prior to stenting. One patient was unable to receive proper stent placement due to anatomic tortuosity. This patient was also the only of the twelve to experience intraoperative complications. One patient died 4 days following stent placement from nonprocedure-related causes. One was lost to follow-up. Of the remaining nine patients, mean length of follow-up was 11.6 months (range = 1–43 months). All nine received postoperative imaging that demonstrated patent stents. Three patients (25%) received radiation postprocedure. One patient experienced hemorrhage from the stented artery 31 months after placement and 30 months after radiation therapy, which was treated with the placement of additional covered stents.

Conclusion: Endovascular stent reconstruction of the extracranial carotid artery represents a safe and effective method for preventing carotid artery blowout in patients with advanced head and neck cancers.

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