We herein report a case of carotid artery pseudoaneurysm following intensive treatment for hypopharyngeal carcinoma. An81-year-old male had undergone surgery and concurrent chemoradiotherapy to treat hypopharyngeal carcinoma (T4aN1M0).This treatment led to a complete response, but pseudoaneurysms were formed at the external carotid artery in a contaminatedwound. One of the pseudoaneurysms was located close to the bifurcation and thus caused intractable hemorrhaging. We performedendovascular treatment to achieve hemostasis. One year after the embolization, surgical removal of the endovasculardevices from the infected area was performed. Three years have passed since the removal, and the patient is still alive withoutany complications. Primary endovascular treatment of an infected pseudoaneurysm could be an effective option for the treatmentof acute lethal hemorrhaging

Iwanaga Tetsu

Kaneko Kenichi

Komuro Satoru

Takahashi Haruo

Yamaguchi Nimpei

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IntroductionThe formation of a carotid artery pseudoaneurysm is arare, potentially lethal complication after intensive treat-ment for head and neck cancer. A pseudoaneurysm withoutinfection is currently treated by endovascular interventionwith a stent and detachable coils. To date, few reports onthe endovascular management of infected carotid arterypseudoaneurysm have been documented.In this article, we describe a rare case that was success-fully treated by transcatheter arterial embolization of an in-fected carotid artery pseudoaneurysm.Case ReportAn 81-year-old male had undergone a right neck dissectionto treat hypopharyngeal carcinoma (T4aN1M0). Concurrentchemoradiotherapy (total dose of 60 Gy and 100 mg ofdocetaxel) had been performed after the surgery, which hadled to complete response. However, the tumor recurred in thehypopharynx. The patient consequently underwent a totalpharyngolaryngectomy and reconstruction with a microvascularjejunal graft. After the surgery, the anterior skin of neckhad become necrotic. Therefore, reconstruction with a leftpectoral major musculocutaneous flap (PMMF) was per-formed. Postoperatively, a minor salivary fistula had formedaround the PMMF. It took 2 months to close the fistula bymeans of local conservative treatment, and thereafter heActa Med. Nagasaki 57: 65－68Address correspondence: Nimpei Yamaguchi, Department of Otolaryngology - Head and Neck Surgery, Nagasaki UniversityGraduate School of Biomedical Sciences 1-7-1, Sakamoto, Nagasaki 852-8501, JapanPhone: +81-95-819-7349, Fax: +81-95-819-7352, E-mail: y-nimpei@nagasaki-u.ac.jpReceived March 15, 2012; Accepted April 3, 2012MS#AMN 07110Case ReportEndovascular Treatment of a Carotid Artery Pseudoaneurysm in aContaminated Wound: Report of a CaseNimpei YAMAGUCHI,1 Kenichi KANEKO,1 Tetsu IWANAGA,2 Satoru KOMURO,3 Haruo TAKAHASHI11 Department of Otolaryngology - Head and Neck Surgery, Nagasaki University Graduate School of Biomedical Sciences2 Department of Otorhinolaryngology Head and Neck Surgery, Nagasaki Municipal Hospital3 Komuro Otorhinolaryngology ClinicWe herein report a case of carotid artery pseudoaneurysm following intensive treatment for hypopharyngeal carcinoma. An81-year-old male had undergone surgery and concurrent chemoradiotherapy to treat hypopharyngeal carcinoma (T4aN1M0).This treatment led to a complete response, but pseudoaneurysms were formed at the external carotid artery in a contaminatedwound. One of the pseudoaneurysms was located close to the bifurcation and thus caused intractable hemorrhaging. We per-formed endovascular treatment to achieve hemostasis. One year after the embolization, surgical removal of the endovasculardevices from the infected area was performed. Three years have passed since the removal, and the patient is still alive withoutany complications. Primary endovascular treatment of an infected pseudoaneurysm could be an effective option for the treat-ment of acute lethal hemorrhaging.ACTA MEDICA NAGASAKIENSIA 57: 65－68, 2012Keywords: Pseudoaneurysm; carotid arteryNimpei Yamaguchi et al.: Endovascular treatment of a carotid artery pseudoaneurysmwas successfully discharged.One week after leaving the hospital, the patient was read-mitted with occult hemorrhaging in the mouth. Pharyngo-esophagoscopy revealed a pharyngeal hemorrhage from anunknown origin. A pulsatile mass was recognized throughthe thick PMMF. Three-dimensional CT demonstrated twopseudoaneurysms of the right external carotid artery (ECA)that measured 3 cm and 1.5cm in diameter (Figure 1). Theproximal one was located close to the bifurcation.After the CT, the patient suddenly developed intractablehemorrhaging from the hypopharynx and went into hypovolemicshock. An angiographic examination revealed that the proximallarger pseudoaneurysm had ruptured into the hypopharynx.A 9 × 35 mm wire braided stent (Wallstent RP) was placedbetween the right internal carotid artery (ICA) and commoncarotid artery (CCA) to prevent migration of the coils to theright ICA. 41 detachable coils (Vortex 3 × 5~40 mm,Tornade 4~8 mm, IDC 7~20 × 20 mm, GDC 7~8 × 30mm, Nestor 6 × 14 mm) were then inserted into the aneu-rysm sac and the right ECA through the stent. A part of thecoil remained in the ICA. A 10 × 20 mm wire braidedstent (Wallstent RP) was placed in the former stent to ex-clude the remaining part of the coil. After this series of pro-cedures, the ECA and pseudoaneurysm were completelyembolized. The arterial flow in the right ICA was well pre-served (Figure 2).One day after the embolization, minor hemorrhage to theneck appeared again. Compression hemostasis was not ef-fective. Three days after the embolization, a balloon carotidocclusion test was performed and showed that he couldtolerate permanent carotid occlusion. Because of the severetissue adhesion due to previous irradiation and surgery, weattempted a transcatheter embolization of the right CCAand ICA instead of their surgical ligation. 25 detachable coils(Trufill 6~7 mm, Nestor 6 × 14 mm, Vortex 3 × 5~7 mm,Tornade 4~8 mm) were then placed from the right CCA tothe ICA (Figure 3). Finally, complete hemostasis was achievedwithout any neurological deficits. As the pseudoaneurysmhad already ruptured into the hypopharynx, there was sig-nificant potential for a secondary infection to develop aroundany endovascular devices. The patient therefore receivedintravenous injection of 4.5g/day of sultamicillin tosilate and1200 mg/day of clindamycin for two weeks to control sec-ondary infections. Three months after being readmitted tothe hospital, he was discharged without any complications.However, a cervical infection subsequent to transcatheter66Figure 1. A three-dimensional CT image of two pseudoaneurysms(asterisk) located in the right external carotid artery (ECA).Figure 2. An angiographic image of the right carotid system. (a)Unsubtracted view shows a mesh stent was placed between thecommon carotid artery (CCA) and the internal carotid artery(ICA). Detachable coils were placed at the aneurysm sac (aster-isk), the external carotid artery (ECA). (b) Subtracted view showsthe arterial flow in the right ICA was well preserved.Figure 3. An angiographic image of the post-occluded right ca-rotid system. Detachable coils were placed at the aneurysm sac,the external carotid artery, the common carotid artery (CCA) andthe internal carotid artery (ICA).Nimpei Yamaguchi et al.: Endovascular treatment of a carotid artery pseudoaneurysmembolization could not be controlled, and recurred. Ten monthsafter leaving the hospital, secretion of the pus from the for-mer bleeding point of the neck appeared. MRI revealed ab-scess formation around the endovascular devices (Figure4). Culture of the pus showed Pseudomonas aeruginosa.Antibiotic therapy was not effective. We performed surgi-cal removal of infected devices and ligation of the rightCCA, ICA and ECA. We could not remove the distal partand proximal part of the stent because of a high risk of re-bleeding. Surgical wound healing was prevented by the tis-sue ischemia produced from the previous irradiation. Weused hyperbaric oxygen therapy for two weeks to activatethe healing process, but failed to induce sufficient healing.Therefore, reconstruction surgery with a right PMMF wasperformed one month after the surgery. Finally, the woundhealed after the operation. As of the three year follow-upexamination, the patient has remained tumor free withoutany further complications.DiscussionA pseudoaneurysm of the carotid artery is one of the se-rious complications of intensive treatment for head andneck cancers, including chemoradiotherapy and surgery.Since such intensive measures have recently become one ofthe established treatments for advanced head and neck car-cinomas, mainly since they allow for organ preservation,the incidence of such pseudoaneurysms of carotid artery havethus been observed to occur with an increasing frequency.Radiation therapy induces vascular injury and damages theability of the tissue to heal from injury spontanelusly.1 Asendovascular treatment is effective for controlling acute le-thal bleeding of pseudoaneurysms without sacrificing theinternal carotid artery, it is therefore sometimes utilized totreat non-infected carotid aneurysms. However, no general-ized strategy has yet been established to treat infected ca-rotid artery aneurysms. The major problem associated withthese aneurysms is the difficulty in controlling the infectionaround the endovascular devices, and the presence of suchinfection is a risk factor for re-bleeding.2 It is known that theparent artery of the aneurysm has to be isolated to preventrebleeding. However, performing the primary embolizationof the common or internal carotid artery without evaluatingthe collateral cerebral circulation can result in major neurologicmorbidity and mortality.In the current case, the pseudoaneurysm was thought tohave developed as a result of infection through the minorsalivary fistula formed after the previous surgery. For the ini-tial endovascular treatment, we could not select embolizationof the CCA and ICA without performing the balloon ca-rotid occlusion test. We achieved hemostasis, however, bycarrying out two staged endovascular treatments.We judged a surgical reconstruction of the carotid sys-tem to be extremely hazardous and thus instead choseendovascular occlusion. Another method to stop bleedingwithout interruption of the carotid artery (CA) flow is toplace a covered stent on the diseased CA. However, Changet al reported that the mean duration of stent graft patencywas just 3.0 ± 2.6 months.3 In the current case, we couldnot use a covered stent because it was not approved by theJapanese Health Insurance System and there was no avail-able device.The infection around the endovascular devices was notcontrolled by the antibiotic therapy. We had performedhyperbaric oxygen therapy and reconstruction by a well-vascularized flap following the removal of the infected de-vices. Goddard et al. recommended direct surgery ratherthan endovascular treatment of infected pseudoaneurysm.4However, in the current case, treatments that were per-formed on infected pseudoaneurysms, including primaryendovascular management, were able to prevent carotidblow out. Primary endovascular treatment of an infectedpseudoaneurysm may therefore be an effective optiontherapeutic modality in cases of acute lethal hemorrhaging.AcknowledgementsNothing67Figure 4. A contrast-enhanced MRI image fourteen months afterthe embolization shows abscess formation (asterisk) with ring-enhancement.Nimpei Yamaguchi et al.: Endovascular treatment of a carotid artery pseudoaneurysmReferences1. Okamura H, Kamiyama R, Takiguchi R, et al. Histopathological ex-amination of ruptured carotid artery after irradiation. ORL 64: 226-228, 20022. James C, Lonel R. Contemporary management of carotid blowout. CurrOpin Otolaryngol Head Neck Surg 12: 110-115, 20043. Chang FC, Lirng JF, Luo CB, et al. Patients with head and neck cancersand associated postirradiated carotid blowout syndrome: Endovasculartherapeutic methods and outcomes. J Vasc Surg 47: 936-945, 20084. Goddard AJ, Lenthall RK, Bradley PJ. Endovascular management ofinfected carotid artery pseudoaneurysm complicating pharyngolaryngectomy:complete occlusion followed by early recurrence and rebleeding. JLaryngol Otol 118: 991-995, 200468

Endovascular Treatment of a Carotid Artery Pseudoaneurysm in a Contaminated Wound: Report of a Case

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Endovascular Treatment of a Carotid Artery Pseudoaneurysm in a Contaminated Wound: Report of a Case

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