Preliminary experience with endovascular reconstruction for the management of carotid blowout syndrome.

BACKGROUND AND PURPOSE Permanent balloon occlusion (PBO) of the carotid artery has been previously shown to be an effective means to treat carotid blowout syndrome (CBS). However, despite the effectiveness of this endovascular technique, concern remains regarding its potential for producing delayed cerebral ischemic complications in 15% to 20% of patients. This significant limitation of carotid PBO led our group to evaluate an alternative management strategy, consisting of endovascular reconstruction of the carotid artery (ERCA) in patients thought to be at particularly high risk for carotid occlusion (ie, provocative balloon test occlusion, angiographic documented incomplete circle of Willis, or contralateral carotid artery occlusion). METHODS We reviewed all cases of CBS referred to our service, in which ERCA was chosen as a management strategy for patients thought to be at high risk for PBO, based on previously defined criteria. RESULTS Sixteen carotid blowout events occurred in 12 patients with CBS who were deemed to be at high risk for cerebral ischemic complications, which were managed with ERCA by using a variety of stent devices and techniques. Adjunctive embolization of carotid pseudoaneurysms was performed in five of these patients by using platinum coils or acrylic glue. Hemostasis was achieved in all cases, although one patient with traumatic CBS and three patients with aggressive head and neck cancer-related CBS, required retreatment with ERCA. Recurrent CBS rates were similar to those reported in other studies using PBO. Overall, no treatment-related strokes or deaths occurred. CONCLUSION CBS managed with ERCA can be performed safely and with efficacy of outcomes at least equivalent to those previously reported in association with conventional carotid PBO, therefore representing an excellent alternative endovascular technique for patients who are at increased risk of stroke after PBO.