Recurrent Carotid Blowout Syndrome: Diagnostic and Therapeutic Challenges in a Newly RecognizedSubgroup of Patients
John C. Chaloupka,a,
Toni C. Rotha,
Christopher M. Putmana,
Sanchayeeta Mitraa,
Douglas A. Rossa,
Roger A. Lowlichta and
Clarence T. Sasakia
a From The Interventional Neuroradiology Service, Department of Diagnostic Radiology (J.C.C., T.C.R., C.M.P.), Department of Neurosurgery (J.C.C.), and Section of Otolaryngology (D.A.R., R.A.L., C.T.S.), Department of Surgery Yale University School of Medicine.
View larger version (161K):
[in a new window]
|
FIG 1. Illustrative case 1 of the spectrum of rCBS and its management.
A and B, Forty-six-year-old woman (patient TL) initially presents with CBS (Group 3). Lateral view from left common carotid injection (A) shows a pseudoaneurysm (arrow), which successfully was treated with therapeutic balloon occlusion (B).
C and D, Six years later, the patient develops a second episode of CBS. Lateral view from right external carotid injection (C) shows a hypervascular tumor of the oropharynx and hypopharynx (arrows) that is responsible for bleeding. Lateral view from superselective injection of the ascending palatine artery (D) shows significant supply to the tumor (arrows), which successfully was embolized with PVA.
E, Five days later, the patient develops a third episode of CBS, related to recurrent tumor hemorrhage. She was taken to the operating room in which, after induction of general anesthesia and oral retraction, the tumor was punctured under direct visualization and fluoroscopic guidance with a 23-gauge Chiba needle. Lateral fluoroscopic spot film shows the needle coursing through the tumor (long arrow) with extensive filling of neovasculature upon injection of absolute ethanol mixed with metrizamide (small arrows).
| |
View larger version (184K):
[in a new window]
|
FIG 2. Illustrative case 2 of the spectrum of rCBS and its management.
A and B, Sixty-six-year-old woman (patient CH) initially presents with CBS (Group 3). Lateral views from superselective injection of a facial arterial branch (short arrow) in early (A) and late arterial phases (B) show a ruptured pseudoaneurysm with extensive extravasation (long arrows). This successfully was treated with coil embolization.
C, Twenty-one days later, the patient develops a second episode of CBS (Group 1) due to a flap dehiscence. Oblique view from right CCA injection shows no evidence of pseudoaneurysm and prior ligation of the ECA. The patient failed BTO at this time, prompting a flap revision.
D, Seventeen days later, the patient develops a third episode of CBS (Group 3). Oblique view from right CCA injection shows a large pseudoaneurysm of that vessel. Acute hemorrhage initially was arrested by placement of two overlapping 8 x 20-mm Wallstents across the rent of the artery (not shown).
E and F, One day later, the patient develops a fourth episode of CBS (Group 3) due to a TF of the previously deployed stents. After inflation of a balloon occlusion catheter across the carotid rent, the pseudoaneurysm was directly punctured and embolized with cyanoacrylate. Fluoroscopic spot film (E) and subtracted-control angiography (F) from right CCA injection (oblique view) shows complete obliteration of the pseudoaneurysm with cyanoacrylate (arrow) and patency of the parent artery.
| |
