External carotid artery stenosis in patients with head and neck squamous cell carcinoma--a prospective study

Vascular disease, which can be asymptomatic until arterial stenosis is severe, is common in head and neck cancer patients as the risk factors for both cancer and atherosclerosis are similar. Although studies of common and internal carotid artery stenosis in head and neck patients have been reported, none have specifically assessed the external carotid system, especially in asymptomatic patients undergoing major microvascular free flap reconstructive surgery. A prospective study of 44 patients using pre-operative duplex scanning to assess the common, external and internal carotid arteries bilaterally. Eighteen patients (41%) had no obvious carotid disease in any vessel. Although the remaining 26 patients (59%) had some carotid tree stenosis, only nine patients (20% of study group) had disease affecting the external carotid artery, with significant stenosis (greater than 50%) of this vessel being found in only three patients (7%). A correlation was found between the degree of carotid stenosis and hypertension (P<0.05). No correlation was found between carotid artery stenosis and flap failure (t=5.4; P=1). Significant stenosis of the external carotid artery, even in the presence of atherosclerosis elsewhere in the carotid tree, is uncommon. The screening of the external carotid artery in head and neck patients requiring microvascular reconstruction should be considered when there are significant risk factors for carotid stenosis, including hypertension.     

Incidence of carotid stenosis in nasopharyngeal carcinoma patients after radiotherapy.

BACKGROUND: Radiation-induced carotid stenosis in patients with head and neck tumors can cause significant mortality and morbidity. This study examined the incidence of stenosis in the extracranial carotid arteries of nasopharyngeal carcinoma patients after radiotherapy. METHODS: The extracranial carotid arteries of 71 (53 male and 18 female; mean age of 53.6 years) postradiation patients with nasopharyngeal carcinoma were examined with color Doppler ultrasound. The distribution of the arterial stenosis and the degree of stenosis were documented. The results were compared with the control group, which comprised 51 newly diagnosed nasopharyngeal carcinoma patients (35 male and 16 female, mean age of 48.8 years) before radiotherapy. Incidences of risk factors for arterial stenosis such as hypertension, smoking, and hypercholesterolemia also were studied in these two groups. RESULTS: There was no significant difference in the incidence of risk factors between the two groups. Arterial stenosis was, however, more common in the postradiation group than the preradiation group (56 of 71 vs. 11 of 51). The common/internal carotid arteries (CCA/ICA) were most commonly involved (55 of 71 vs. 11 of 51; P < 0.01), followed by the external carotid artery (ECA) (32 of 71 vs. 1 of 51; P < 0.01) and vertebral artery (VA; 5 of 71 vs. 0; P = 0.069). Significant stenosis (> 50% reduction of luminal diameter) was only found in the postradiation group (21 of 71 in CCA/ICA, 11 of 71 in ECA, 4 of 71 in VA). CONCLUSIONS: This study showed that radiation could cause significant carotid stenosis. Ultrasound examinations for these patients therefore are necessary for early detection and possible intervention of this late radiation-induced complication.     

A historical prospective cohort study of carotid artery stenosis after radiotherapy for head and neck malignancies

PURPOSE: To determine carotid artery stenosis incidence after radiotherapy for head-and-neck neoplasms. METHODS AND MATERIALS: This historical prospective cohort study comprised 44 head-and-neck cancer survivors who received unilateral neck radiotherapy between 1974 and 1999. They underwent bilateral carotid duplex ultrasonography to detect carotid artery stenosis. RESULTS: The incidence of significant carotid stenosis (8 of 44 [18%]) in the irradiated neck was higher than that in the contralateral unirradiated neck (3 of 44 [7%]), although this difference was not statistically significant (p = 0.13). The rate of significant carotid stenosis events increased as the time after radiotherapy increased. The risk of ipsilateral carotid artery stenosis was higher in patients who had undergone a neck dissection vs. those who had not. Patients with significant ipsilateral stenosis also tended to be older than those without significant stenosis. No other patient or treatment variables correlated with risk of carotid artery stenosis. CONCLUSIONS: For long-term survivors after neck dissection and irradiation, especially those who are symptomatic, ultrasonographic carotid artery screening should be considered.     

Comparison of Duplex Ultrasound with Angiography in Assessment of Carotid Bifurcation Disease

This is a study comparing duplex ultrasound against the “gold standard” of angiography in assessing atherosclerotic disease of the carotid bifurcation, prior to prospective endarterectomy surgery. Thirty-nine patients were studied with both sonography and angiography studies being performed within one month of each other. Plaques were described by sonography as being “smooth” or “irregular” in surface and “homogeneous” or “heterogeneous” in composition. Ultrasound showed an overall 92% sensitivity, against the standard of angiography, in its ability to assess the degree of internal carotid stenosis. There was only a 63% sensitivity with the common carotid arteries and only a 65% sensitivity with the external carotid arteries. Ultrasound did not show a high accuracy in detecting plaque ulceration when compared against angio-graphy.     

Pseudoaneurysm of the external carotid artery branch following radiotherapy for nasopharyngeal carcinoma

Rupture of irradiated arteries in patients with head and neck cancer is an uncommon complication. We present the first case of a pseudoaneurysm of the external carotid artery branch that developed after irradiation of nasopharyngeal carcinoma and was successfully treated by microcoil embolization therapy. Clinicians should be aware of this unusual complication to avoid a potentially erroneous management.     

Neck irradiation, carotid injury and its consequences

Carotid stenosis is a major sequela of head and neck irradiation that has not received the attention it deserves. Its impact on the quality of life of patients can be substantial. This review discusses the incidence, pathogenesis and consequences of radiation-induced carotid stenosis following head and neck irradiation. This review is based on literature search (Medline and Pub Med) and cross-referencing. The incidence of significant carotid stenosis following head and neck irradiation range from 30% to 50%. Patients with carotid stenosis are at increased risk for stroke. Factors such as hypertension, diabetes, smoking and obesity increase the risk. Increased attention to the clinical signs of carotid stenosis and evaluation of these patients with appropriate imaging studies, together with strict implementation of management of hypertension and diabetes and, counseling on obesity and smoking have the potential to reduce the incidence of this sequela of head and neck irradiation. Those patients with severe carotid stenosis can be managed with endarterectomy or carotid artery stenting.     

An anatomical study of the arteries for intraarterial chemotherapy of head and neck cancer

Background. The intraarterial approach is one of the most important routes for the administration of anticancer drugs for head and neck cancer. A profound knowledge of the anatomical characteristics and variations of the carotid artery, such as its branching pattern, length, and inner diameter, is essential to avoid complications with catheter insertion. Methods. We conducted a morphometric investigation of head and neck arteries in 29 Japanese cadavers (58 sites). Results. The branching pattern of the external carotid artery showed variations. In 65.5% of the cadavers, the lingual, facial, and superior thyroid arteries arose separately. However, in 31.0% of the cadavers, the lingual artery formed a common trunk with the facial artery, and in 3.5%, the lingual artery formed a common trunk with the superior thyroid artery. The transverse facial artery arose from the superficial temporal artery in 53.4% of the specimens, from the maxillary artery in 27.6%, and from a site central to the maxillary artery in 19.0%. The posterior auricular artery arose from the external carotid artery at the same level as the maxillary artery in 37.9% of specimens, and from a site central to the maxillary artery in 62.1%. The occipital artery arose from the external carotid artery at the same level as the maxillary artery in 55.2% of specimens, and from a site peripheral to the facial artery in 44.8%. The lengths from the auricular point to the origins of the upper branches of the external carotid artery were: 2.8 mm to the transverse facial artery, 3.2 cm to the maxillary artery, 3.8 cm to the posterior auricular artery, 6.6 cm to the occipital artery, 7.4 cm to the facial artery, 8.8 cm to the lingual artery, and 10.4 cm to the superior thyroid artery. Conclusions. These results, have led to some clarification of the clinicoanatomical basis for intraarterial infusion. These data should be helpful for assessing the approximate level of the catheter tip and for evaluating whether the catheter is placed appropriately, by transient staining of the infused area. Received: February 12, 1999 / Accepted: July 28, 1999     

Prospective analysis of carotid artery flow in breast cancer patients treated with supraclavicular irradiation 8 or more years previously: no increase in ipsilateral carotid stenosis after radiation noted

BACKGROUND: To the authors' knowledge, the effects of supraclavicular fossa radiation on the carotid artery are not well described. In the current study, the authors performed a prospective study to examine the long-term risk of carotid artery stenosis after supraclavicular irradiation for breast cancer. METHODS: A total of 46 breast cancer patients who were treated with adjuvant radiation to the supraclavicular fossa with >8 years of follow-up underwent bilateral Doppler imaging of the carotid artery. Two independent cardiologists interpreted each ultrasound study with no knowledge of which side was treated. RESULTS: The median follow-up from the date of diagnosis was 14.6 years and the mean patient age at the time of ultrasound was 55 years. The median prescribed dose to the supraclavicular fossa was 50 grays. Four patients were found to have clinically relevant, asymptomatic carotid stenosis, for which a cardiology referral was necessary. Only 1 of these 4 patients had stenosis involving the irradiated carotid artery only; 1 patient had bilateral stenosis and 2 patients had only contralateral stenosis. There was no difference noted with regard to isolated ipsilateral versus contralateral medial intimal thickening of the carotid artery (5 patients vs 6 patients, respectively). Furthermore, there were no differences noted with regard to ipsilateral versus contralateral peak systolic flow in the internal (83.5 vs 85.6 cm/seconds; P= .522 by the Student t test and P= .871 by the signed rank test) or common (74.4 vs 77.0 cm/seconds; P= .462 by the Student t test and P= .246 by the signed rank test) carotid artery. CONCLUSIONS: In this prospective study of breast cancer patients with long follow-up, there was no evidence of late, clinically relevant stenosis, increased intimal thickening, or increased peak systolic carotid artery flow secondary to supraclavicular irradiation.     

Cervical synovial sarcoma at the bifurcation of the carotid artery.

Cervical synovial sarcoma has been reported in only 15 cases; in none of these was there any association with a vascular structure. A patient with cervical synovial sarcoma encompassing the bifurcation of the left carotid artery underwent a left radical neck dissection, including excision of the left external carotid artery and the hypoglossal nerve. The tumor was dissected away from the common carotid and internal carotid arteries. Although the fibrous pseudocapsule of the tumor had not involved the fibrous adventitia of the carotid arteries. Radiation therapy with 6000 rads tumor dose was administered to a wide local field. There is no evidence of recurrence 1 year postoperatively. Histologic and ultrastructural findings were similar to those reported previously in a case of synovial sarcoma of an extremity.     

High Resolution Computed Tomography in the Evaluation of Glomus Tumours of the Petrous Temporal Bone.

Recent advances in surgery have made it possible to resect virtually all glomus tumours involving the petrous temporal bone. The surgical approach depends on the extent of the tumour and the degree of involvement of the intrapetrous portion of the internal carotid artery. High resolution computed tomography offers an accurate means of staging these tumours and of distinguishing them from an aberrant internal carotid artery. The CT scans of eighteen patients thought clinically to have glomus tumours of the temporal bone were reviewed. The final diagnoses in our series included twelve glomus turnours, three aberrant internal carotid arteries, two carcinoid tumours and one meningioma.     

Diagnosis and surgical treatment of carotid body chemodectoma]

The authors present an analysis of clinical, angiographic and operation finginds in 11 patients showing large chemodectomas with involvement of the common, external and internal carotid arteries and jugular vein. The carotid body angiography was found to be of great diagnostic value. In the presence of a patent internal carotid in 10 cases radical chemodectomy was performed, preserving the patent internal carotid and the vein. In case of a pathologically convoluted internal carotid the common carotid artery was resected with an end-to-end anastomosis. Late results were favourable even in patients with histological signs of an incipient malignant transformation of chemodectomy.     

Clinical Features of Radiation-induced Carotid Atherosclerosis

Carotid arteries frequently receive significant incidental doses of radiation during the treatment of malignant diseases, including head and neck cancer, breast cancer and lymphoma. Vascular injury after treatment may result in carotid artery stenosis and increased risk of neurological sequelae, such as stroke and transient ischaemic attack. The long latent interval from treatment to the development of clinical complications makes investigation of this process difficult, particularly in regard to the design of interventional clinical studies. Nevertheless, there is compelling clinical evidence that radiation contributes to carotid atherosclerosis. This overview examines the effect of radiotherapy on the carotid arteries, the underlying pathological processes and their clinical manifestations. The use of serum biomarkers in risk-prediction models and the potential value of new imaging techniques as tools for defining earlier surrogate end points will also be discussed.     

13例头颈部恶性肿瘤行大隐静脉颈动脉置换术患者的围手术期护理

目的探讨头颈部恶性肿瘤患者行大隐静脉颈动脉置换手术围手术期的护理方法。方法选取2018年9月至2019年12月间中国医学科学院肿瘤医院收治的13例头颈部恶性肿瘤行大隐静脉颈动脉置换术患者,在患者手术治疗前进成立多学科治疗小组、心理护理和颈总动脉压迫试验等术前护理,手术后采用术后护理,包括血压管理、病情观察、抗凝药物效果观察、体位护理、气道管理、营养管理、心理护理和并发症预防,分析总结头颈部恶性肿瘤患者行大隐静脉颈动脉置换手术的围手术期护理方法。结果 11例患者术后未出现脑卒中和偏瘫等严重并发症,均顺利出院;1例患者出现轻微脑梗塞,治疗观察四周后出院,1例患者出现急性心肌梗塞,转入专科医院治疗四周后顺利出院。结论对头颈部恶性肿瘤行大隐静脉动脉置换术患者行针对性围手术期护理,可提高手术成功率,减少术后并发症,促进患者康复。     

Regional chemotherapy through a saphenous vein graft for the treatment of head and neck cancers

Regional chemotherapy was given through a vein grafted between the common carotid and external carotid arteries to 20 patients who had a variety of advanced head and neck cancers. The objective response rate was 73.6%, which included 36.8% complete response. The median duration of response was more than 10 months. The toxicity was mild and well tolerated. The complication rate associated with the procedure was low. This form of regional chemotherapy has significant advantages over the conventional form that uses drugs given through the retrograde temporal artery because the catheter-related complications are eliminated, the perfusion of the tumor can be maintained consistently, and, consequently, the response rate is high and the duration of response is increased.     

Variations of the Cervical Internal Carotid Artery

The objective of this study was to report the variations of the cervical internal carotid artery, as encountered during neck dissection for head and neck malignancies. A retrospective analysis of neck dissections performed for the management of various head and neck cancers, during 2006–2010 was carried out. Among 102 patients and 119 neck dissections, five of them were found to be having abnormalities of the cervical part of the internal carotid artery during its course in the neck and were analyzed in detail. Out of five subjects, four were males and the other was female with age ranging from 50 to 74 years. Of the five patients two had mild degree of tortuosity, two patients had moderate degree of tortuosity and another patient had severe degree of tortuosity in the course of internal carotid artery in the neck. Based on our cases, the possibilities of various vascular variations should be kept in mind while performing the neck dissection. This will help in preventing inadvertent injury to these vital structures and prevents subsequent consequences.     

Bilateral common carotid occlusion without neurological deficit

A 40‐year‐old man presented with pain and numbness in his right arm. On his clinical examination, no neurological deficit was found. Bilateral common carotid artery duplex sonography scan demonstrated no flow in either lumen. No abnormality was recognized on brain CT. On cerebral digital substraction angiogram, total occlusion of the brachiocephalic trunk and left carotid artery were shown. There was a modest stenosis in the left vertebral artery. Collateral circulation feeding the intracranial carotid system mainly originated from the left vertebrobasilar system. Previous cases of bilateral carotid occlusion are reviewed and discussed.     

Endovascular management of carotid blowout syndrome in patients with head and neck cancers

Endovascular treatments for carotid blowout syndrome (CBS) have been advocated by interventional neuroradiologists. We therefore retrospectively evaluated the efficacy of endovascular treatments of CBS in 16 patients with head and neck cancers (HNC). The clinical, treatment and outcome data were evaluated in 16 HNC patients with CBS, all of whom underwent permanent embolization or covered stent graft of the affected carotid artery. All patients received multimodal treatments, including radiotherapy (mean total dose, 78.5Gy). CBS was caused by tumor carotid invasion in 8 patients, pharyngocutaneous fistula in 7, and laryngeal chondroradionecrosis in 1, with the external and common carotid arteries being the most common rupture sites. CBS was occluded by embolization or revascularized by covered stent placement. Immediate hemostasis was achieved in all patients; however, 7 patients had recurrent CBS, all of whom were retreated effectively by endovascular management. Three patients had strokes and four had extrusion of intervention materials from the infected wounds. Most patients died of tumor progression, with a mean survival time of five months from initial CBS; only two patients survived. Endovascular therapy, by both permanent occlusion and stent grafts, is effective in hemostasis of CBS but its long-term efficacy may not be high in these HNC patients.     

The dynamics of the cerebral circulation during the surgical treatment of paragangliomas of the neck]

Clinical and rheoencephalographic studies ot 17 cases of paraganglioma of the neck revealed insufficient collateral blood circulation after compression of the common carotid artery on the affected side. In such cases, surgery carries a risk of brain ischemia. Improvement of collateral blood circulation was achieved by rheoencephalographically controlled compression of the common carotid artery performed daily with increasing duration. A patient was considered eligible for surgery if no signs of brain hemisphere ischemia were apparent following a 40% or less decrease in rheoencephalographic anacrotism amplitude from baseline. Common or internal carotid arteries were resected in 6 out of 17 cases of neck paraganglioma dissection. Adequate preoperative preparation prevented cerebral ischemia development in the postoperative period.     

Hemiplegia as a Complication of Therapeutic Embolisation of the Internal Maxillary Artery

A hemiplegia complicating a successfully treated angioma arising from the internal maxillary artery is described. The probable pathogenesis of the complication is discussed. A right common carotid arteriogram and a selective right external carotid arteriogram were carried out. The common carotid arteriogram showed that the intra-cerebral arteries were normal. The external carotid arteriogram showed an enlarged main stem and a greatly enlarged internal maxillary artery (Figure 1). A rapid series of films in the antero-posterior and lateral projections were taken and subtraction films prepared, to identify the feeding vessels to the arterio-venous malformation and to exclude any connections between the external and internal carotid arterial systems. The internal maxillary artery and its branches were the only feeding vessels demonstrated as supplying a large arterio-venous malformation situated in the pterygo-palatine fossa (Figure 2). Because of the anatomical site of the angioma and its wide ramification, it was decided that the most suitable method of treatment would be embolisation of the main feeding arteries rather than an attempt at surgical removal. Following embolisation the patient developed a hemiplegia. A C.T. Scan confirmed the presence of an area of infarction in the right hemisphere of the brain. The hemiplegia slowly improved over a period of four months but left a residual partial paralysis of the left arm. The embolisation therapy was successful in abolishing the bruit and the vascular hum complained of by the patient.     

Carotid artery stenosis in asymptomatic patients who have received unilateral head-and-neck irradiation

PURPOSE: To determine the prevalence of carotid artery stenosis in patients who have received ipsilateral head-and-neck radiotherapy and have no symptoms of cerebrovascular disease. METHODS AND MATERIALS: Forty patients underwent ultrasound and computed tomography angiography of their carotid arteries. The vessels on the irradiated side were compared with those on the unirradiated side in a matched-pair analysis with regard to any stenosis, stenosis > or =60% in the internal carotid artery/carotid bulb, intima medial thickness (IMT), and grade of wall abnormalities. History, physical, and fasting blood levels were taken to detect risk factors for carotid disease. RESULTS: Fourteen irradiated carotid trees bore one or more stenosis vs. five in the unirradiated ones (p = 0.03). There were six bulb/internal carotid artery stenoses > or =60% in the irradiated carotids vs. one in the unirradiated (OR 6:1, p = 0.13). IMT and grade of vessel wall abnormality were higher in the irradiated carotids, but only at doses > or =50 Gy, and only at measurement points that lay within the radiation portals. CONCLUSION: Radiation appears to cause carotid artery stenosis. There may be a dose threshold for carotid wall changes, which has relevance for radiotherapy in several tumor sites.