eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Head & Neck Surgery

Management of the Neck With Carotid Artery Involvement: Treatment

Author: Devraj Basu, MD, PhD, FACS, Assistant Professor, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System
Coauthor(s): John M Truelson, MD, FACS, Chairman, Division of Head and Neck Surgery, Associate Professor, Department of Otorhinolaryngology, University of Texas Southwestern Medical Center at Dallas; Gregory S Weinstein, MD, FACS, Professor and Vice-Chairman, Department of Otorhinolaryngology-Head and Neck Surgery, Director of Division of Head and Neck Surgery, Director of Head and Oncology Fellowship, Director of Otorhinolaryngology-Head and Neck Clinic, Co-director of The Center for Head and Neck Surgery, University of Pennsylvania School of Medicine
Contributor Information and Disclosures

Updated: Mar 5, 2009

Treatment

Surgical Therapy

Preoperative carotid occlusion

Carotid reconstruction may not technically feasible in some patients, particularly individuals with the internal carotid artery involved close to the skull base. After normal trial balloon occlusion (TBO) and flow testing results, permanent balloon occlusion is a preoperative intervention that may reduce cerebral vascular accident (CVA) incidence over simple ligation in this clinical setting.21 The underlying principle is that high embolization of the carotid eliminates the standing column of blood present after ligation that is thought to serve as a later source of stump emboli. The method involves angiographic placement of permanent balloons or coils in the carotid siphon region proximal to the ophthalmic artery. Typically, the patient is heparinized, and hemodynamics are closely monitored for 72 hours.

Carotid resection is delayed by 2 weeks to allow for fixation of the coils and to avoid adverse hemodynamic effects from surgery during the vulnerable period immediately following occlusion. Additional advantages include avoiding the need for heparinization during a period of shunting prior to reconstruction, thus reducing intraoperative blood loss. In an early study of this technique, all 8 patients who underwent preoperative permanent balloon occlusion tolerated it without sequelae.22

However, the application of this technique has still been associated with neurologic complications with protracted intraoperative hypotension; in one case, migration of a balloon was also reported.2 A further disadvantage of this technique is that it must be applied preoperatively and may thus subject a patient to unnecessary risk if the carotid artery turns out to be uninvolved at the time of surgery.

Permanent balloon occlusion may also be performed without surgery to manage impending carotid rupture. In one series, 22 patients were treated by placing 2 permanent balloons just proximal to the ophthalmic artery and embolizing the internal carotid artery (ICA) down to the level of the carotid bifurcation with liquid biological adhesive (Histoacryl). None of the 22 patients had an immediate complication from the permanent occlusion, although 2 patients developed progressive hemiplegia that began 24 hours later.23

Surgical decision making

Although the type of preoperative scanning and precise technique used may vary, patients are generally placed into 3 categories based on trial balloon occlusion (TBO) and flow scanning results, as follows:

  • High risk - Failed TBO, no cerebral blood flow (CBF) scans obtained
  • Moderate risk - Passed TBO, inadequate CBF scan
  • Low risk - Passed TBO, adequate CBF scan

Moderate- and high-risk patients usually undergo reconstruction if carotid resection is performed. Although the best management of low-risk patients is less clear, these patients may also benefit from reconstruction whenever possible. A few patients in the low-risk category undergoing carotid ligation still experience neurologic sequelae, presumptively from inadequately sensitive flow scan workups, perioperative hypotension, or carotid stump emboli. This fact has led some authors to advocate vein graft reconstruction of the artery, when feasible.24,1,2

However, although unusual, these complications may still occur in the face of vein grafting, even in low-risk patients.25,26 Such events occur despite heparinization and placement of a temporary shunt to maintain cerebral perfusion during reconstruction, an essential step in moderate- and high-risk patients. A clot in the graft may be a potential source for an embolic CVA in some cases.

Other operative considerations include attention to the possibility of preserving the external carotid artery, which often requires resection in patients with head and neck cancer. Backflow from an intact external carotid can, in principle, both augment cerebral perfusion and prevent the development of stump emboli. Preservation of the external carotid is, not surprisingly, associated with an approximately 50% decrease in the CVA rate, as apparent from multiple reports.27,23,28,10

Lastly, whether or not to reconstruct the carotid must be decided in the larger context of the total resection and reconstruction to be performed. In previously irradiated patients, postoperative exposure of a carotid reconstruction from wound breakdown or contact with fistula drainage may risk lethal hemorrhage and instead bias one's management toward preoperative balloon occlusion. When reconstruction is performed, attention must be given to adequate protection of the carotid from pharyngeal secretions and coverage with well-vascularized tissue, using pedicled or free tissue transfer to accomplish these ends when necessary.

Complications

Neurologic complications

The early cerebral vascular accident (CVA) risk is well described and guides much of the perioperative evaluation and management efforts when carotid resection is considered. However, reports of long-term follow-up in patients with occluded carotid arteries demonstrate a delayed CVA rate as high as 25 times that of the general population. In a report of 814 cases of carotid occlusion performed for intracranial aneurysm, 233 patients developed ischemic symptoms after occlusion.27 Of these, 79% occurred within the first 48 hours and 10% occurred in the second 48 hours. However, 5 patients had ischemic symptoms at 6 months, 11 months, 12 months, 18 months, and 4 years, respectively. Late ischemic complications have also been confirmed in other reports.29

Nerve deficits

Resection of malignant disease that involves the carotid wall typically requires an en bloc resection of other adjacent involved structures, which often include the vagus nerve, the hypoglossal nerve, the spinal accessory nerve, and the cervical sympathetic chain. Particularly when compounded with other deficits, combined vagus and hypoglossal palsies may produce lasting postoperative dysphagia and aspiration, and patients must be apprised of the risks of such disabilities before surgery.

More on Management of the Neck With Carotid Artery Involvement

Overview: Management of the Neck With Carotid Artery Involvement
Workup: Management of the Neck With Carotid Artery Involvement
Treatment: Management of the Neck With Carotid Artery Involvement
Follow-up: Management of the Neck With Carotid Artery Involvement
References
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References

  1. Wright JG, Nicholson R, Schuller DE, Smead WL. Resection of the internal carotid artery and replacement with greater saphenous vein: a safe procedure for en bloc cancer resections with carotid involvement. J Vasc Surg. May 1996;23(5):775-80; discussion 781-2. [Medline].

  2. Freeman SB, Hamaker RC, Borrowdale RB, Huntley TC. Management of neck metastasis with carotid artery involvement. Laryngoscope. Jan 2004;114(1):20-4. [Medline].

  3. Huvos AG, Leaming RH, Moore OS. Clinicopathologic study of the resected carotid artery. Analysis of sixty-four cases. Am J Surg. Oct 1973;126(4):570-4. [Medline].

  4. McCready RA, Miller SK, Hamaker RC, Singer MI, Herod GT. What is the role of carotid arterial resection in the management of advanced cervical cancer?. J Vasc Surg. Sep 1989;10(3):274-80. [Medline].

  5. Sanna M, Piazza P, Ditrapani G, Agarwal M. Management of the internal carotid artery in tumors of the lateral skull base: preoperative permanent balloon occlusion without reconstruction. Otol Neurotol. Nov 2004;25(6):998-1005. [Medline].

  6. Ozer E, Agrawal A, Ozer HG, Schuller DE. The impact of surgery in the management of the head and neck carcinoma involving the carotid artery. Laryngoscope. Oct 2008;118(10):1771-4. [Medline].

  7. Roh JL, Kim MR, Choi SH, et al. Can patients with head and neck cancers invading carotid artery gain survival benefit from surgery?. Acta Otolaryngol. 2008;128(12):1370-4. [Medline].

  8. Yoo GH, Hocwald E, Korkmaz H, et al. Assessment of carotid artery invasion in patients with head and neck cancer. Laryngoscope. Mar 2000;110(3 Pt 1):386-90. [Medline].

  9. Yousem DM, Hatabu H, Hurst RW, et al. Carotid artery invasion by head and neck masses: prediction with MR imaging. Radiology. Jun 1995;195(3):715-20. [Medline].

  10. Konno A, Togawa K, Iizuka K. Analysis of factors affecting complications of carotid ligation. Ann Otol Rhinol Laryngol. May-Jun 1981;90(3 Pt 1):222-6. [Medline].

  11. Maves MD, Bruns MD, Keenan MJ. Carotid artery resection for head and neck cancer. Ann Otol Rhinol Laryngol. Sep 1992;101(9):778-81. [Medline].

  12. Razack MS, Sako K. Carotid artery hemorrhage and ligation in head and neck cancer. J Surg Oncol. Apr 1982;19(4):189-92. [Medline].

  13. Jones TH, Morawetz RB, Crowell RM, et al. Thresholds of focal cerebral ischemia in awake monkeys. J Neurosurg. Jun 1981;54(6):773-82. [Medline].

  14. Ehrnefeld WK, Stoney RJ, Wylie EJ. Relation of carotid stump pressure to safety of carotid artery ligation. Surgery. Feb 1983;93(2):299-305. [Medline].

  15. Kelly JJ, Callow AD, O'Donnell TF, et al. Failure of carotid stump pressures. Its incidence as a predictor for a temporary shunt during carotid endarterectomy. Arch Surg. Dec 1979;114(12):1361-6. [Medline].

  16. James NJ, Stuteville OH, Tasche C. Elective carotid artery ligation in the treatment of advanced cancer of the head and neck. Plast Reconstr Surg. Mar 1971;47(3):243-5. [Medline].

  17. Standard SC, Ahuja A, Guterman LR, et al. Balloon test occlusion of the internal carotid artery with hypotensive challenge. AJNR Am J Neuroradiol. Aug 1995;16(7):1453-8. [Medline].

  18. Andersen AR, Friberg HH, Schmidt JF, Hasselbalch SG. Quantitative measurements of cerebral blood flow using SPECT and [99mTc]-d,l-HM-PAO compared to xenon-133. J Cereb Blood Flow Metab. Dec 1988;8(6):S69-81. [Medline].

  19. Erba SM, Horton JA, Latchaw RE, et al. Balloon test occlusion of the internal carotid artery with stable xenon/CT cerebral blood flow imaging. AJNR Am J Neuroradiol. May-Jun 1988;9(3):533-8. [Medline].

  20. Witt JP, Yonas H, Jungreis C. Cerebral blood flow response pattern during balloon test occlusion of the internal carotid artery. AJNR Am J Neuroradiol. May 1994;15(5):847-56. [Medline].

  21. Adams GL, Madison M, Remley K, Gapany M. Preoperative permanent balloon occlusion of internal carotid artery in patients with advanced head and neck squamous cell carcinoma. Laryngoscope. Mar 1999;109(3):460-6. [Medline].

  22. Eckard DA, Purdy PD, Bonte FJ. Temporary balloon occlusion of the carotid artery combined with brain blood flow imaging as a test to predict tolerance prior to permanent carotid sacrifice. AJNR Am J Neuroradiol. Nov-Dec 1992;13(6):1565-9. [Medline].

  23. Gonzalez CF, Moret J. Balloon occlusion of the carotid artery prior to surgery for neck tumors. AJNR Am J Neuroradiol. Jul-Aug 1990;11(4):649-52. [Medline].

  24. Meleca RJ, Marks SC. Carotid artery resection for cancer of the head and neck. Arch Otolaryngol Head Neck Surg. Sep 1994;120(9):974-8. [Medline].

  25. de Vries EJ, Sekhar LN, Horton JA, et al. A new method to predict safe resection of the internal carotid artery. Laryngoscope. Jan 1990;100(1):85-8. [Medline].

  26. Segal DH, Sen C, Bederson JB, Catalano P, Sacher M, Stollman AL. Predictive value of balloon test occlusion of the internal carotid artery. Skull Base Surg. 1995;5(2):97-107. [Medline].

  27. Nishioka H. Results of the treatment of intracranial aneurysms by occlusion of the carotid artery in the neck. J Neurosurg. Dec 1966;25(6):660-704. [Medline].

  28. Youmans JR, Kindt GW, Mitchell OC. Extended studies of direction of flow and pressure in the internal carotid artery following common carotid artery ligation. J Neurosurg. Sep 1967;27(3):250-4. [Medline].

  29. Barnett HJ. Delayed cerebral ischemic episodes distal to occlusion of major cerebral arteries. Neurology. Aug 1978;28(8):769-74. [Medline].

  30. Berenstein A, Ransohoff J, Kupersmith M, Flamm E, Graeb D. Transvascular treatment of giant aneurysms of the cavernous carotid and vertebral arteries. Functional investigation and embolization. Surg Neurol. Jan 1984;21(1):3-12. [Medline].

  31. Freeman SB, Hamaker RC, Borrowdale RB, Huntley TC. Management of neck metastasis with carotid artery involvement. Laryngoscope. Jan 2004;114(1):20-4. [Medline].

  32. German WJ, Black SP. Cervical ligation for internal carotid aneurysms. An extended follow-up. J Neurosurg. Dec 1965;23(6):572-7. [Medline].

  33. Wright JG, Nicholson R, Schuller DE, Smead WL. Resection of the internal carotid artery and replacement with greater saphenous vein: a safe procedure for en bloc cancer resections with carotid involvement. J Vasc Surg. May 1996;23(5):775-80; discussion 781-2. [Medline].

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Further Reading

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Keywords

management of the neck with carotid artery involvement, carotid artery, carotid involvement, malignant carotid invasion, malignant carotid involvement, carotid reconstruction, carotid artery reconstruction, carotid weakness, arterial wall weakness, arterial wall rupture, carotid artery rupture, carotid rupture, herald bleed, carotid ligation, sudden carotid rupture, carotid occlusion, CVA, cardiovascular accident, TBO, total balloon occlusion, xenon, Xe, carotid resection

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Contributor Information and Disclosures

Author

Devraj Basu, MD, PhD, FACS, Assistant Professor, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System
Devraj Basu, MD, PhD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Association for Cancer Research, American College of Surgeons, and American Head and Neck Society
Disclosure: Nothing to disclose.

Coauthor(s)

John M Truelson, MD, FACS, Chairman, Division of Head and Neck Surgery, Associate Professor, Department of Otorhinolaryngology, University of Texas Southwestern Medical Center at Dallas
John M Truelson, MD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society for Head and Neck Surgery, Phi Beta Kappa, and Texas Medical Association
Disclosure: Nothing to disclose.

Gregory S Weinstein, MD, FACS, Professor and Vice-Chairman, Department of Otorhinolaryngology-Head and Neck Surgery, Director of Division of Head and Neck Surgery, Director of Head and Oncology Fellowship, Director of Otorhinolaryngology-Head and Neck Clinic, Co-director of The Center for Head and Neck Surgery, University of Pennsylvania School of Medicine
Gregory S Weinstein, MD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Laryngological Association, American Laryngological Rhinological and Otological Society, American Medical Association, American Radium Society, American Society for Head and Neck Surgery, Pennsylvania Medical Society, Philadelphia County Medical Society, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Richard V Smith, MD, Director of Clinical Affairs, Associate Professor, Department of Otolaryngology, Division of Head and Neck Surgery, Einstein College of Medicine, Montefiore Medical Center
Richard V Smith, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Laryngological Rhinological and Otological Society, American Medical Association, American Medical Student Association/Foundation, Medical Society of the District of Columbia, New York Academy of Medicine, and Vermont State Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Nader Sadeghi, MD, FRCS(C), Associate Professor of Surgery, Director of Head and Neck Surgery, Division of Otolaryngology, George Washington University
Nader Sadeghi, MD, FRCS(C) is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society, Federation of Medical Specialists in Quebec, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
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