Introduction Carotid blowout syndrome (CBS) refers to the acute rupture of any segment of the common carotid artery, including both the external and extracranial internal carotid arteries (ICA). CBS often results in life threatening hemorrhage and acute upper airway obstruction. CBS is a well-known phenomenon in patients with head and neck cancer and typically occurs via direct extension of tumor into the arterial wall or iatrogenically during surgical manipulation. With a reported incidence of 4.3% following radical neck dissection and mortality rates as high as 60%, CBS must always be considered in any patient with head or neck cancer and acute hemorrhage in the oro- or nasopharynx of unknown origin. Accepted management strategies for CBS include open surgical ligation or endovascular treatment via parent vessel sacrifice or intraluminal stent placement. One of the more feared complications associated with endovascular parent vessel sacrifice is distal migration of embolic material, which can lead to ischemic stroke. Delayed migration of embolic material into the oro- or nasopharynx is extremely uncommon. We present a case of a coil migration into the nasopharynx one year following endovascular treatment of CBS that occurred during nasopharyngeal carcinoma resection.
Methods A 41-year-old female presented with brisk oral cavity hemorrhage after undergoing surgical resection of nasopharyngeal carcinoma seven weeks prior.
Results Computed tomography angiography (CTA) revealed a small 0.2×0.2×0.3 cm pseudoaneurysm arising from the medial aspect of the right ICA at the level of C1-C2 vertebrae that abutted the nasopharynx. After radiographically passing a balloon test occlusion (BTO), the decision was made to endovascularly sacrifice the right ICA. With the balloon inflated, embolization with coils and onyx was performed in the petrous segment of the ICA. Angiography and CTA confirmed pseudoaneurysm obliteration and complete vessel occlusion. Three-month follow-up CTA demonstrated stable vessel occlusion. Eleven months following ICA sacrifice, she started to complain of throat irritation and difficulty swallowing. During a scheduled sinus debridement, exposed coils were visualized in the right nasopharynx. CTA revealed vessel wall dehiscence with extrusion of coils into the nasopharynx but continued occlusion of the vessel. The exposed coils were clipped and extracted endoscopically for symptomatic relief. Three-month follow-up angiogram confirmed stable vessel occlusion and patient has remained asymptomatic.
Conclusion CBS can be a rare and devastating complication of head and neck surgery, often requiring immediate endovascular treatment. Coil migration is a rare complication following cerebral pseudoaneurysm obliteration via endovascular vessel sacrifice. When a patient has a partially extruding coil, it is imperative to obtain imaging and treat as soon as possible to avoid further coil migration and possible airway compromise.
Disclosures D. Sheinberg: None. D. McCarthy: None. E. Luther: None. S. Chen: None. R. Starke: None.
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