Management of the Neck With Carotid Artery Involvement Treatment & Management

Updated: Mar 02, 2022
  • Author: Devraj Basu, MD, PhD, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Surgical Therapy

Preoperative carotid occlusion

Carotid reconstruction cannot be performed in some patients, particularly individuals with the internal carotid artery resected close to the skull base, where sewing a vascular graft to the distal stump may not be feasible. 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. [6] 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.

In an early study of this technique, all 8 patients who underwent preoperative permanent occlusion tolerated it without sequelae. [28] 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. [29]

Surgical decision making

Although the type of preoperative scanning and precise technique used may vary, patients may be 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 likely 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 whenever technically feasible. [1, 2, 30]

Although unusual, neurologic complications may still occur in the face of vein grafting, even in low-risk patients. [31, 32] Such events occur despite heparinization and placement of a temporary shunt to maintain cerebral perfusion during reconstruction, an essential step in high-risk patients. A clot in the graft may be a potential source for an embolic cerebrovascular accident 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. [33, 29, 34, 18, 35, 36]

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 occlusion of the artery. 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 as necessary.



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. [33] 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. [37]

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.


Outcome and Prognosis

Long-term survival is generally poor in cases of malignant carotid involvement with squamous cell carcinoma; [38] early local recurrence and rapid failure with regional or distant metastatic disease are common. A study by Shinomiya et al reported that in patients with T4 squamous cell carcinoma of the external auditory canal and middle ear, invasion of the brain, carotid artery, and/or jugular vein indicates a poor prognosis. The investigators found that patients with at least one of these factors had a 5-year overall survival rate of 25.5%, versus 65.5% in those without these factors. [39]

However, no universal case against resection of the carotid can be made for involvement of the artery in squamous cell carcinoma, and each patient merits careful consideration within his or her broad clinical context. In fact, data show significant numbers of long-term survivors among previously untreated patients undergoing carotid resection. [7, 8, 9, 40] These favorable surgical outcomes for very biologically aggressive tumors suggest that carotid resection does still have a limited role in the management of the head and neck cancer. Patients require extensive preoperative counseling and must contemplate surgery bearing in mind substantial risks, including those of devastating neurologic sequelae. This risk can be managed significantly by carotid reconstruction whenever possible, but adverse neurologic outcomes from carotid resection cannot be preventedaltogether.