头颈部肿瘤术后大动脉破裂出血的救治

目的 探讨头颈部肿瘤术后颈动脉破裂出血的救治及预防.方法 回顾性分析解放军总医院耳鼻咽喉头颈外科2003年10月至2009年8月对7例头颈部肿瘤患者术后颈部大动脉破裂采取的X线介入栓塞和介入内置覆膜支架的救治.7例患者中6例系颈总动脉破裂,1例为颈内动脉破裂.全部患者于肿瘤切除术前或术后曾行放射治疗,其中动脉破裂前手术创面经胸三角皮瓣修复1例,额部带蒂皮瓣修复1例,游离前臂皮瓣修复1例.动脉破裂止血成功后5例局部清创,根据情况的需要,必要时采用肌瓣修复.结果 7例患者中5例患者经X线导管介入得到成功救治,其中3例采用动脉内置覆膜支架,2例行动脉栓塞;另2例因瞬间出血量大而来不及救治死亡.救治成功病例其动脉危险区随后经胸大肌皮瓣修复2例,颏下瓣修复1例,局部肌瓣修复1例,另1例因创面较小而未行皮瓣修复.颈总动脉破裂经置人覆膜支架成功救治的3例患者目前已分别生存6、12及20个月;2例颈总动脉破裂介入栓塞患者分别于抢救成功后2个月和13个月死于血管再破裂.结论 有预案的及时抢救,采用X线介入治疗是抢救颈部大动脉破裂的有效方法,救治后应及时采用转移肌皮瓣覆盖保护动脉.X线介入覆膜支架可基本恢复头颈部正常的血供,并发症少,可能较动脉栓塞更为可靠.

Rescue of postoperative carotid blowout in head and neck neoplasms

Objective To investigate the prevention and rescuing measures of postoperative fatal bleeding induced by carotid blowout in head and neck tumors. Methods Seven cases with postoperative carotid bleeding treated from October 2003 to August 2009 were reviewed retrospectively. Of the patients, 6 were with common carotid blowout and one with internal carotid artery blowout. All patients underwent preor post-operative radiotherapy for primary head and neck tumours and 3 patients had neck defect repair with deltopectoral skin flap, frontal flap or free radial arm flap respectively. After carotid blowout bleeding, the patients were treated in time with X ray transcatheter intervention including transcatheter arterial embolization (TAE) and self-expanding covered stent implantation, followed by repairing the carotid region with appropriate myocutenous flaps. Results Of 7 patients with carotid blowout, 5 patients were successfully rescured with X ray transcatheter intervention, of them 2 with self-expanding covered stent implantation and 2 with TAE respectively, and other 2 patients died due to rapid bleeding. Of the successfully rescued patients, 2 patients were with the repair of carotid area by pectoralis major myocutaneous flap, one by submental flap and one by local flap, but another one not with flap repair. Follow-up showed the 3 patients rescued with self-expanding covered stent implantation were survival for 6,12,and 20 months, respectively, and the 2 patients rescued with TAE died of repeated carotid blowout in 2 and 13 months later, respectively. Conclusions The planned and timely X ray transcatheter intervention is an effective method to treat carotid blowout bleeding in the patients underwent head and neck tumour surgeries. Compared with TAE, selfexpanding covered stent implantation may be more reliable for restoring the blood supply of head and neck region, with less complications. One-stage repair of caratid region with myocutenous flap is of great importance to protect the carotid and to promote the wound healing.