Endovascular intervention for carotid blowout syndrome and predictors of recurrence: A retrospective and multicenter cohort study

Joshua H Weinberg; Kevin Liu; Ashlee M Asada; Mara Bahri; Kareem El Naamani; Amanda Zakeri; Jessica Zakeri; Stavropoula Tjoumakaris; Pascal Jabbour; James W Rocco; Kyle VanKoevering; Stephen Yang; Matthew Old; Ciaran Powers; Shahid Nimjee; Patrick Youssef

doi:10.1016/j.clineuro.2024.108584

Endovascular intervention for carotid blowout syndrome and predictors of recurrence: A retrospective and multicenter cohort study

Clin Neurol Neurosurg. 2024 Nov:246:108584. doi: 10.1016/j.clineuro.2024.108584. Epub 2024 Oct 3.

Authors

Joshua H Weinberg¹, Kevin Liu², Ashlee M Asada³, Mara Bahri⁴, Kareem El Naamani⁵, Amanda Zakeri⁶, Jessica Zakeri⁷, Stavropoula Tjoumakaris⁸, Pascal Jabbour⁹, James W Rocco¹⁰, Kyle VanKoevering¹¹, Stephen Yang¹², Matthew Old¹³, Ciaran Powers¹⁴, Shahid Nimjee¹⁵, Patrick Youssef¹⁶

Affiliations

¹ Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA. Electronic address: Joshua.weinberg@osumc.edu.
² Department of Otolaryngology, The Ohio State University Wexner Medical Center, Columbus, OH, USA. Electronic address: kevin.liu@osumc.edu.
³ Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA. Electronic address: ashlee.asada@osumc.edu.
⁴ Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA. Electronic address: mara.bahri@osumc.edu.
⁵ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA. Electronic address: kareem.elnaamani@jefferson.edu.
⁶ Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA. Electronic address: amanda.zakeri@osumc.edu.
⁷ Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA. Electronic address: jessica.zakeri@osumc.edu.
⁸ Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA. Electronic address: stavropoula.tjoumakaris@jefferson.edu.
⁹ Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA. Electronic address: pascal.jabbour@jefferson.edu.
¹⁰ Department of Otolaryngology, The Ohio State University Wexner Medical Center, Columbus, OH, USA. Electronic address: james.rocco@osumc.edu.
¹¹ Department of Otolaryngology, The Ohio State University Wexner Medical Center, Columbus, OH, USA. Electronic address: kyle.vankoevering@osumc.edu.
¹² Department of Otolaryngology, The Ohio State University Wexner Medical Center, Columbus, OH, USA. Electronic address: stephen.yang@osumc.edu.
¹³ Department of Otolaryngology, The Ohio State University Wexner Medical Center, Columbus, OH, USA. Electronic address: matthew.old@osumc.edu.
¹⁴ Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA. Electronic address: ciaran.powers@osumc.edu.
¹⁵ Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA. Electronic address: shahid.nimjee@osumc.edu.
¹⁶ Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA. Electronic address: patrick.youssef@osumc.edu.

PMID: 39368393
DOI: 10.1016/j.clineuro.2024.108584

Abstract

Introduction: Carotid blowout syndrome (CBS) is a potentially life-threatening complication of head and neck cancer and associated treatment. In this study, we assess the safety and efficacy of deconstructive and reconstructive procedures with a focus on CBS recurrence.

Methods: We conducted a multicenter retrospective analysis of a prospectively maintained database and identified 80 consecutive neurointerventions for CBS from 2016 to 2020. Patients were divided into 2 groups: deconstructive embolization (68 patients) and reconstructive stenting (12 patients). A comparative analysis was performed between the two groups.

Results: The CBS recurrence rate was 23.8 % with 84.2 % of recurrences occurring within 90 days of the primary event. The median time to rebleeding was 8.0 days (IQR: 2.0 - 28.5) with a mortality rate of 26.3 %. There was no significant difference in rates of peri-operative ischemic stroke (1.5 % vs. 0 %, p=0.672) or peri-operative mortality (1.5 % vs. 0 %, p=0.670). CBS recurrence was significantly higher in the reconstructive group (58.3 % vs. 17.6 %, p=0.002). On multivariate analysis, reconstructive stenting independently predicted rebleeding (adjusted hazard ratio 8.31, 95 % CI: 2.34-29.59, p=0.001). There was no significant association between CBS recurrence and pre-operative (p=0.600) or post-operative (p=0.275) anticoagulant/antiplatelet use.

Conclusion: CBS remains a challenging and potentially catastrophic complication of head and neck cancers. Reconstructive procedures, including stenting, predicted CBS recurrence independent of bleeding site or tumor invasion. Postoperative surveillance based on time intervals to CBS recurrence and engineering advancements including improved vessel reconstruction devices have the potential to reduce rehemorrhage rates and improve patient outcomes. Further clinical investigations amongst larger cohorts are needed.

Keywords: Carotid blowout; Covered stent; Deconstruction; Embolization; Endovascular; Head and neck cancer; Reconstruction.

Publication types

Multicenter Study

MeSH terms

Aged
Carotid Artery Diseases* / surgery
Cohort Studies
Embolization, Therapeutic* / methods
Endovascular Procedures* / methods
Female
Head and Neck Neoplasms / surgery
Humans
Male
Middle Aged
Recurrence*
Retrospective Studies
Stents*
Treatment Outcome