Pathophysiology
Radiotherapy:
- Obliteration of vaso vasorum
- adventitial fibrosis
- premature atherosclerosis
- weakening of arterial wall
- subendothelial vacuolization & oedema
- fragmentation of the media elastic fibres
Aetiology
Epidemiology
- Tumours
- involvement of carotid
- Surgery
- neck dissection
- salvage surgery
- Blunt or penetrating trauma
- Radiotherapy
- increases risk x 7
- total radiation dose
most imporant factor
- >70Gy --> 14 times
- Wound breakdown
- Necrosis
- Infection
- thrombosis of v.v.
- Pharyngocutaneous fistula
- including salivary leak
- tryptic enzyme activity of saliva
Other factors
- Mobile foreign bodies
- 4 x increase with wet gauze dressings to wound dehiscence
- Poor nutrition (BMI <22 --> x 2 risk)
- 10 - 15% loss of body weight
- Diabetes mellitus
- Prolonged corticosteroid use
1) Threatened Carotid Blowout
2) Impending Carotid Blowout
3) Acute Carotid Blowout
- reported rate of 3 to 4% of patients with Head and Neck cancer
- newer literature suggests less frequent
- Historical data:
- 40% mortality
- 60% neurological morbidity
- recent studies suggest morbidity and mortality between 0 - 8%
Type 1: Threatened rupture
Type III: Acute rupture
Type II: Impending
rupture
- Patients with exposed carotid arteries
- wound dehisence
- flap necrosis/breakdown
- infection
- recurrence/residual tumour
Grade 0: No evidence of vascular disruption
Grade 1: Focal weakening/irregularity of vascular wall
Grade 2: Pseudoaneurysm formation
Grade 3: Evidence of extravasation from carotid
- Sudden rupture of vessel
- Haemorrhage that cannot be stopped with pressure or packing
- rapid deterioration
- temporary/poor/no response to resuscitation
- Mortality of 50 - 100%
- exsanguination
- aspiration
- Sentinel haemorrhage
- short, spontaneousy resolving bleed
- usually transoral, transcervical, trans-stomal
- through wound/fistula
- Resolves with pressure or packing
Anatomy
Management Options
Endovascular
Surgical
Deconstruction
Vessel balloons, or coils
Advantages:
- takes less time
- avoids manipulation of irradiated neck
- GA not required
Disadvantages:
- Horner syndrome (8%)
- Cerebral ischaemia (20%)
- Thromboembolic events
Vessel occlusion
(deconstruction)
Vessel stent
(reconstruction)
Ligation of artery
usually done in acute setting
provides rapid securing of bleeding
less demanding than endovascular technique
Significant neurological morbidity
CVA - early or late
recurrent bleed
Vessel Stenting
Stent placement through injured area
Advantages:
- Stops bleed with lowered risk of CVA
- less time
- GA not required
- Disadvantages
- foreign body - risk of infection
- occlusion, re-haemorrhage
- Temporary solution
- until reconstruction
Definition
Vascular Anatomy
- Uncommon complication typically of head and neck cancer patients
- Syndrome with clinical manifestations ranging from:
- asymptomatic exposure of artery wall
- acute haemorrhage
Definition
"rupture of extracranial carotid arteries, or its major branches"
one of the most feared complications of head and neck cancer treatment
Questions
Management
Carotid Blowout Syndrome
Open, honest approach
Decision on advanced directive
- palliation
- active resuscitation
Education of patient/family
Ward Care
Active resuscitation
Ensure alway G&S 4 units
Resuscitation:
- Airway
- Breathing
- Circulation
- large bore cannulas
- volume replacement
Specific measures
- compression on bleeding point
- packing
- haemostatic material
- decision on management
- surgical
- endovascular
Palliation
Nursed in a single room
Equipment:
- call bell
- suction
- syringes for cuff inflation
- bowl
- PPE: gloves/gown/eyes
- Dark towels
- IV access at all times
- Syringes: morphine/midazolam
Decision for comfort care/palliation
stay with patient
call calmly for assistance
apply dark towels around the bleeding
inflate tracheostomy cuff if appropriate
gentle suctioning as required
administer midazolam IV
administer morphine for pain/breathlessness
family assistance