Carotid blowout syndrome: modern trends in management

Figures & data

Table 1 Postsurgical CBS

Study	No. of patients	Previous RT	No. of CBS	Mortality	Stroke	Survival >1 months
McCoy and Barsocchini^Citation6	93	3 (75%)	4 (4.3%)	1 (25%)	0	0
Joseph and Shumrick^Citation8	46	No	0
Joseph and Shumrick^Citation8	57	Yes	12 (21.1%)	8 (66.6%)	2	2
Ketcham and Hoye^Citation5	574	16 (84%)	19 (3%)	3 (15.8%)	–	16
Curutchet et al^Citation9	123	No	3 (2.4%)	1 (33.3%)	0	2
Curutchet et al^Citation9	78	Yes	11 (14.1%)	4 (36.4%)	5	2
Yim et al^Citation10	48	No	0
Yim et al^Citation10	84	Yes	4 (4.8%)	–	–	–
Martinez et al^Citation4	365	–	11 (3%)	7 (63.6%)	–	4
Shumrick^Citation3	333	10 (77%)	13 (3.8%)	8 (61.5%)	3	2
Stell^Citation11	210	No	0
Stell^Citation11	70	Yes	9 (13%)	7 (77.8%)	1	1
Leikensohn et al^Citation2	393	18 (90%)	20 (4.5%)	5 (25%)	5	10
Maran et al^Citation12	227	No	3 (1.1%)	3 (100%)	0	0
Maran et al^Citation12	167	Yes	14 (8.4%)	14 (100%)	0	0
Herranz et al^Citation15	471	No	3 (0.6%)	1 (33.3%)	0	1
Marchetta et al^Citation13	81	No	0
Marchetta et al^Citation13	83	Yes	6 (7%)	2 (33.3%)	0	4
Krause et al^Citation17	193	RT preoperatory	5 (3%)	1 (20%)	0	4
Sarkar et al^Citation14	152	No	1 (0.7%)	0	1	1
Sarkar et al^Citation14	90	Yes	4 (4.4%)	3 (75%)	0	1
Lu et al^Citation7	3,504	–	45a (1.3%)	11 (24.4%)	–	34 (76%)
Chen et al^Citation25	301	No	1 (0.3%)	–	–	–
Chen et al^Citation25	2,289	Yes	101 (4.4%)	34 (33.3%)	13	68

Note:

a Only acute CBS.

Abbreviation: CBS, carotid blowout syndrome.

Table 2 Salvage reirradiaton and CBS

Study	No. of patients	RT technique	No. of CBS	Mortality	Survival >1 months
Dawson et al^Citation31	40	3D-CRT	1 (2.5%)	0	1
Kasperts et al^Citation32	39	3D-CRT	0
Tanvetyanon et al^Citation33	103	Various ± Ch	1 (1%)	1	0
Rate et al^Citation34	47	IORT	1 (2.1%)	1	0
Stevens et al^Citation35	100	EBRT ± brachy	4 (4%)	4	0
Duprez et al^Citation36	84	IMRT	2 (2.4%)	2	0
Lee et al^Citation37	105	IMRT ± Ch	0
Sulman et al^Citation38	74	IMRT ± Ch	0
Watkins et al^Citation39	39	Ch/Rt	2 (5.1%)	1	1
De Crevoisier et al^Citation40	169	Ch/Rt	5 (2.9%)	5	0
Salama et al^Citation41	115	Ch/Rt	6 (5.2%)	5	1
Janot et al^Citation42	60	Ch/Rt	1 (1.7%)	1	0
Kramer et al^Citation43	38	Ch/Rt	1 (2.7%)	1	0
Langer et al^Citation44	83	Ch/Rt	2 (2.4%)	2	0
Spencer et al^Citation45	79	Ch/Rt	2 (2.5%)	2	0
Hehr et al^Citation46	27	Ch/Rt	2 (7%)	2	0
Iseli et al^Citation47	87	Ch/Rt	5 (5.7%)	1	3
Lartigau et al^Citation48	56	SBRT	1 (1.8%)	1	0
Cengiz et al^Citation49	46	SBRT	8 (17%)	7	1
Yamazaki et al^Citation50	381	SBRT	32 (8%)	22	10
Yazici et al^Citation51	75	SBRT	11 (14.7%)	8	3
Vargo et al^Citation52	48	SBRT	0

Abbreviations: 3D-CRT, three-dimensional conformal radiotherapy; CBS, Carotid blowout syndrome; Ch/Rt, chemoradiotherapy; EBRT, external beam radiotherapy; IMRT, intensity-modulated radiotherapy; IORT, intraoperative radiotherapy; SBRT, stereotactic body radiotherapy.

Figure 1 Management algorithm for CBS.

Abbreviations: CBS, carotid blowout syndrome; CCA, common carotid artery; ECA, external carotid artery; ICA, internal carotid artery; CTA, computed tomographic angiography; CVA, cerebrovascular accident; IR, interventional radiology.

Table 3 Treatment and outcomes of CBS

Study	No. of patients	Treatment		Compl stent		Compl embol		Mortality <1 months	Survival >1 year
		Stent	Emb	Rbl	Stroke	Rbl	Stroke
Chang et al^Citation85	8	8	0	4	1	–	–	3	3
Liu et al^Citation57	13	2	11	1	1	1	1	3	2
Chen et al^Citation25	24	0	24	–	–	11	6	8	–
Shah et al^Citation86	10	10	0	3	1	–	–	3	2
Powitzky et al^Citation20	7	1	6	0	0	0	1	2	0
Chen et al^Citation89	18	1	17	0	0	2	3	–	–
Luo et al^Citation24	14	0	14	–	–	0	1	0	11
Gaynor et al^Citation83	15	15	0	4	0	–	–	1	9
Miller et al^Citation78	5	5	0	4	0	–	–	0	1
Lee et al^Citation82	25	0	25	–	–	4	–	4	–
Chaloupka et al^Citation68	14	0	14	–	–	2	0	2	–
Chang et al^Citation69	56	18	38	7	3	5	6	–	–
Manzoor et al^Citation76	9	2	7	1	0	0	1	–	–
Zussman et al^Citation84	6	0	6	–	–	1	0	2	0
Chen et al^Citation60	13	13	0	4	0	–	–	5	2
Chang et al^Citation1	24	11	13	5	1	3	1	4	6
Patsalides et al^Citation71	8	5	3	1	0	0	1	2	2
Lesley et al^Citation80	9	9	0	3	0	–	–	1	3
Morrissey et al^Citation65	12	0	12	–	–	0	1	–	–
Roh et al^Citation66	11	5	6	2	1	2	2	2	2
Sorial et al^Citation81	4	4	0	1	0	–	–	2	0
Wan et al^Citation88	14	4	10	2	1	1	1	4	5
Zhao et al^Citation70	15	10	5	4	3	1	0	–	3
Hakime et al^Citation73	20	20	0	5	0	–	–	5	4
Liang et al^Citation22	25	11	14	3	1	3	2	12	13
Pyun et al^Citation79	7	7	0	6	0	–	–	5	0
Lu et al^Citation7	30	3	27	0	1	6	2	–	–
Hoppe et al^Citation75	13	13	0	3	0	–	–	2	4
Total	429	177 41%	252 59%	63 36%	14 8%	42 17%	29 12%	72 17%	72 17%

Abbreviations: CBS, carotid blowout syndrome; Compl stent, complications stent; Compl embol, complications embolization; Emb, embolization; Rbl, rebleeding.

McCoyGBarsocchiniLMExperiences in carotid artery occlusionLaryngoscope1968787119512105659592

 PubMed Web of Science ®Google Scholar

JosephDLShumrickDLRisks of head and neck surgery in previously irradiated patientsArch Otolaryngol19739753813844703530

 PubMedGoogle Scholar

KetchamASHoyeRCSpontaneous carotid artery hemorrhage after head and neck surgeryAm J Surg196511046496555825176

 PubMed Web of Science ®Google Scholar

CurutchetHPTerzJJLawrenceWJrThe value of the autogenous dermal graft for carotid artery protectionSurgery19727168768804555379

 PubMed Web of Science ®Google Scholar

YimDRappaportIJoseLKohutRShramekJCarotid artery and dermal graftArch Otolaryngol19749942422464594222

 PubMedGoogle Scholar

MartinezSAOllerDWGeeWde FriesHOElective carotid artery resectionArch Otolaryngol1975101127447471200922

 PubMedGoogle Scholar

ShumrickDACarotid artery ruptureLaryngoscope1973837105110614581177

 PubMed Web of Science ®Google Scholar

StellPMCatastrophic haemorrhage after major neck surgeryBr J Surg19695675255275794970

 PubMed Web of Science ®Google Scholar

LeikensohnJMilkoDCottonRCarotid artery rupture. Management and prevention of delayed neurologic sequelae with low-dose heparinArch Otolaryngol19781046307310655952

 PubMedGoogle Scholar

MaranAGAminMWilsonJARadical neck dissection: a 19-year experienceJ Laryngol Otol198910387607642769046

 PubMed Web of Science ®Google Scholar

HerranzJSarandesesAFernándezMFBarroCVVidalJMGavilánJComplications after total laryngectomy in nonradiated laryngeal and hypopharyngeal carcinomasOtolaryngol Head Neck Surg2000122689289810828805

 PubMed Web of Science ®Google Scholar

MarchettaFCSakoKMaxwellWComplications after radical head and neck surgery performed through previously irradiated tissuesAm J Surg196711468358386060759

 PubMed Web of Science ®Google Scholar

KrauseCJSmitsRGMcCabeBFComplications associated with combined therapy of oral and pharyngeal neoplasmsAnn Otol Rhinol Laryngol19728144965005055082

 PubMed Web of Science ®Google Scholar

SarkarSMehtaSATiwariJMehtaARMehtaMSComplications following surgery for cancer of the larynx and pyriform fossaJ Surg Oncol19904342452492325423

 PubMed Web of Science ®Google Scholar

LuHJChenKWChenMHPredisposing factors, management, and prognostic evaluation of acute carotid blowout syndromeJ Vasc Surg20135851226123523958069

 PubMed Web of Science ®Google Scholar

ChenYJWangCPWangCCJiangRSLinJCLiuSACarotid blowout in patients with head and neck cancer: associated factors and treatment outcomesHead Neck201537226527224375817

 PubMed Web of Science ®Google Scholar

DawsonLAMyersLLBradfordCRConformal re-irradiation of recurrent and new primary head-and-neck cancerInt J Radiat Oncol Biol Phys200150237738511380224

 PubMed Web of Science ®Google Scholar

KaspertsNSlotmanBJLeemansCRde BreeRDoornaertPLangendijkJAResults of postoperative reirradiation for recurrent or second primary head and neck carcinomaCancer200610671536154716518815

 PubMed Web of Science ®Google Scholar

TanvetyanonTPadhyaTMcCaffreyJPrognostic factors for survival after salvage reirradiation of head and neck cancerJ Clin Oncol200927121983199119289616

 PubMed Web of Science ®Google Scholar

RateWRGarrettPHamakerRIntraoperative radiation therapy for recurrent head and neck cancerCancer19916711273827402025836

 PubMed Web of Science ®Google Scholar

StevensKRJrBritschAMossWTHigh-dose reirradiation of head and neck cancer with curative intentInt J Radiat Oncol Biol Phys19942946876988040014

 PubMed Web of Science ®Google Scholar

DuprezFMadaniIBonteKIntensity-modulated radiotherapy for recurrent and second primary head and neck cancer in previously irradiated territoryRadiother Oncol200993356356919919885

 PubMed Web of Science ®Google Scholar

LeeNChanKBekelmanJESalvage re-irradiation for recurrent head and neck cancerInt J Radiat Oncol Biol Phys200768373174017379449

 PubMed Web of Science ®Google Scholar

SulmanEPSchwartzDLLeTTIMRT reirradiation of head and neck cancer-disease control and morbidity outcomesInt J Radiat Oncol Biol Phys200973239940918556144

 PubMed Web of Science ®Google Scholar

WatkinsJMShiraiKSWahlquistAEToxicity and survival outcomes of hyperfractionated split-course reirradiation and daily concurrent chemotherapy in locoregionally recurrent, previously irradiated head and neck cancersHead Neck200931449350219156831

 PubMed Web of Science ®Google Scholar

De CrevoisierRBourhisJDomengeCFull-dose reirradiation for unresectable head and neck carcinoma: experience at the Gustave-Roussy Institute in a series of 169 patientsJ Clin Oncol19981611355635629817275

 PubMed Web of Science ®Google Scholar

SalamaJKVokesEEChmuraSJLong-term outcome of concurrent chemotherapy and reirradiation for recurrent and second primary head-and-neck squamous cell carcinomaInt J Radiat Oncol Biol Phys200664238239116213104

 PubMed Web of Science ®Google Scholar

JanotFde RaucourtDBenhamouERandomized trial of postoperative reirradiation combined with chemotherapy after salvage surgery compared with salvage surgery alone in head and neck carcinomaJ Clin Oncol200826345518552318936479

 PubMed Web of Science ®Google Scholar

KramerNMHorwitzEMChengJToxicity and outcome analysis of patients with recurrent head and neck cancer treated with hyperfractionated split-course reirradiation and concurrent cisplatin and paclitaxel chemotherapy from two prospective phase I and II studiesHead Neck200527540641415719391

 PubMed Web of Science ®Google Scholar

LangerCJHarrisJHorwitzEMPhase II study of low-dose paclitaxel and cisplatin in combination with split-course concomitant twice-daily reirradiation in recurrent squamous cell carcinoma of the head and neck: results of Radiation Therapy Oncology Group Protocol 9911J Clin Oncol200725304800480517947728

 PubMed Web of Science ®Google Scholar

SpencerSAHarrisJWheelerRHFinal report of RTOG 9610, a multi-institutional trial of reirradiation and chemotherapy for unresectable recurrent squamous cell carcinoma of the head and neckHead Neck200830328128817764087

 PubMed Web of Science ®Google Scholar

HehrTClassenJBelkaCReirradiation alternating with docetaxel and cisplatin in inoperable recurrence of head-and-neck cancer: a prospective phase I/II trialInt J Radiat Oncol Biol Phys20056151423143115817346

 PubMed Web of Science ®Google Scholar

IseliTAIseliCERosenthalELPostoperative reirradiation for mucosal head and neck squamous cell carcinomasArch Otolaryngol Head Neck Surg2009135111158116419917931

 PubMedGoogle Scholar

LartigauEFTreschEThariatJMulti institutional phase II study of concomitant stereotactic reirradiation and cetuximab for recurrent head and neck cancerRadiother Oncol2013109228128524262821

 PubMed Web of Science ®Google Scholar

CengizMÖzyiğitGYaziciGSalvage reirradiaton with stereo-tactic body radiotherapy for locally recurrent head-and-neck tumorsInt J Radiat Oncol Biol Phys201181110410920675075

 PubMed Web of Science ®Google Scholar

YamazakiHOgitaMKodaniNFrequency, outcome and prognostic factors of carotid blowout syndrome after hypofractionated re-irradiation of head and neck cancer using CyberKnife: a multi-institutional studyRadiother Oncol2013107330530923751378

 PubMed Web of Science ®Google Scholar

YaziciGSanlıTYCengizMA simple strategy to decrease fatal carotid blowout syndrome after stereotactic body reirradiaton for recurrent head and neck cancersRadiat Oncol2013824224139288

 PubMed Web of Science ®Google Scholar

VargoJAFerrisRLOhrJA prospective phase 2 trial of reirradiation with stereotactic body radiation therapy plus cetuximab in patients with previously irradiated recurrent squamous cell carcinoma of the head and neckInt J Radiat Oncol Biol Phys201591348048825680594

 PubMed Web of Science ®Google Scholar

ChangFCLirngJFLuoCBCarotid blowout syndrome in patients with head-and-neck cancers: reconstructive management by self-expandable stent-graftsAJNR Am J Neuroradiol200728118118817213454

 PubMed Web of Science ®Google Scholar

LiuHMYangCYLeeCWWangYHChenYFRapid, sequential bilateral acute carotid blowout syndromeNeuroradiology201355447548123388889

 PubMed Web of Science ®Google Scholar

ShahHGemmeteJJChaudharyNPandeyASAnsariSAAcute life-threatening hemorrhage in patients with head and neck cancer presenting with carotid blowout syndrome: follow-up results after initial hemostasis with covered-stent placementAJNR Am J Neuroradiol201132474374721436338

 PubMed Web of Science ®Google Scholar

PowitzkyRVasanNKremplGMedinaJCarotid blowout in patients with head and neck cancerAnn Otol Rhinol Laryngol2010119747648420734970

 PubMed Web of Science ®Google Scholar

ChenKCYenTTHsiehYLPostirradiated carotid blowout syndrome in patients with nasopharyngeal carcinoma: a case-control studyHead Neck201537679479924604752

 PubMed Web of Science ®Google Scholar

LuoCBTengMMChangFCChangCYGuoWYRadiation carotid blowout syndrome in nasopharyngeal carcinoma: angiographic features and endovascular managementOtolaryngol Head Neck Surg20081381869118164999

 PubMed Web of Science ®Google Scholar

GaynorBGHaussenDCAmbekarSPetersonECYavagalDRElhammadyMSCovered stents for the prevention and treatment of carotid blowout syndromeNeurosurgery201577216416725790070

 PubMed Web of Science ®Google Scholar

MillerTBurnsJFarinhasJCovered stents safely utilized to prevent catastrophic hemorrhage in patients with advanced head and neck malignancyJ Neurointerv Surg20124642643421990527

 PubMed Web of Science ®Google Scholar

LeeCWYangCYChenYFHuangAWangYHLiuHMCT angiography findings in carotid blowout syndrome and its role as a predictor of 1-year survivalAJNR Am J Neuroradiol201435356256723969344

 PubMed Web of Science ®Google Scholar

ChaloupkaJCPutmanCMCitardiMJRossDASasakiCTEndo-vascular therapy for the carotid blowout syndrome in head and neck surgical patients: diagnostic and managerial considerationsAJNR Am J Neuroradiol19961758438528733956

 PubMed Web of Science ®Google Scholar

ChangFCLuoCBLirngJFEndovascular management of post-irradiated carotid blowout syndromePLoS One20151010e013982126439632

 PubMed Web of Science ®Google Scholar

ManzoorNFRezaeeRPRayAContemporary management of carotid blowout syndrome utilizing endovascular techniquesLaryngoscope2017127238339027900766

 PubMed Web of Science ®Google Scholar

ZussmanBGonzalezLFDumontAEndovascular management of carotid blowoutWorld Neurosurg2012781–210911422120297

 PubMed Web of Science ®Google Scholar

ChenYLWongHFKuYKWongAMWaiYYNgSHEndovascular covered stent reconstruction improved the outcomes of acute carotid blowout syndrome. Experiences at a single instituteInterv Neuroradiol200814Suppl 22327

 PubMedGoogle Scholar

ChangFCLirngJFLuoCBPatients with head and neck cancers and associated postirradiated carotid blowout syndrome: endovascular therapeutic methods and outcomesJ Vasc Surg200847593694518328665

 PubMed Web of Science ®Google Scholar

PatsalidesAFraserJFSmithMJKrausDGobinYPRiinaHAEndovascular treatment of carotid blowout syndrome: who and how to treatJ Neurointerv Surg201021879321990567

 PubMed Web of Science ®Google Scholar

LesleyWSChaloupkaJCWeigeleJBManglaSDogarMAPreliminary experience with endovascular reconstruction for the management of carotid blowout syndromeAJNR Am J Neuroradiol200324597598112748106

 PubMed Web of Science ®Google Scholar

MorrisseyDDAndersenPENesbitGMBarnwellSLEvertsECCohenJIEndovascular management of hemorrhage in patients with head and neck cancerArch Otolaryngol Head Neck Surg1997123115199006498

 PubMedGoogle Scholar

RohJLSuhDCKimMREndovascular management of carotid blowout syndrome in patients with head and neck cancersOral Oncol200844984485018218333

 PubMed Web of Science ®Google Scholar

SorialEValentinoJGivenCAEndeanEDMinionDJThe emergency use of endografts in the carotid circulation to control hemorrhage in potentially contaminated fieldsJ Vasc Surg200746479279817903657

 PubMed Web of Science ®Google Scholar

WanWSLaiVLauHYWongYCPoonWLTanCBEndovascular treatment paradigm of carotid blowout syndrome: review of 8-years experienceEur J Radiol2013821959921310571

 PubMed Web of Science ®Google Scholar

ZhaoLBShiHBParkSAcute bleeding in the head and neck: angiographic findings and endovascular managementAJNR Am J Neuroradiol201435236036624136646

 PubMed Web of Science ®Google Scholar

HakimeAKhouryEHamegAPolytetrafluoroethylene-covered nitinol stent graft for treatment of carotid artery blowout syndrome in head and neck cancer patientsLaryngoscope201312371670167523483533

 PubMed Web of Science ®Google Scholar

LiangNLGuedesBDDuvvuriUOutcomes of interventions for carotid blowout syndrome in patients with head and neck cancerJ Vasc Surg20166361525153026926937

 PubMed Web of Science ®Google Scholar

PyunHWLeeDHYooHMPlacement of covered stents for carotid blowout in patients with head and neck cancer: follow-up results after rescue treatmentsAJNR Am J Neuroradiol20072881594159817846218

 PubMed Web of Science ®Google Scholar

HoppeHBarnwellSLNesbitGMPetersenBDStent-grafts in the treatment of emergent or urgent carotid artery disease: review of 25 casesJ Vasc Interv Radiol2008191314118192465

 PubMed Web of Science ®Google Scholar