Carotid Blowout Management #251

Background

Carotid blowout is the rupture of the extracranial carotid arteries or their major branches. It is an uncommon but devastating complication of head and neck cancer.^1,2 Predisposing factors include prior radiation therapy, extensive surgery, wound breakdown, local infection, tumor recurrence, and pharyngocutaneous fistulae.^3,4 This Fast Fact will discuss the approach to patients with carotid blowout, including patients near the end of life whose care goals are focused on safety and comfort.

Diagnosis

The carotid blowout syndrome (CBS) ranges from asymptomatic exposure of a carotid artery to acute hemorrhage. CBS is described as threatened when there is evidence on physical and radiologic examinations suggests inevitable hemorrhage if no immediate action is taken, such as an exposed artery; impending when there is an episode of transcervical or transoral hemorrhage or “sentinel bleeding,” typically caused by a pseudoaneurysm, that either resolves spontaneously or with packing/pressure; or acute when there is hemorrhage that cannot be stopped by packing or pressure. The gold standard for diagnosing CBS is angiography, and it is the preferred diagnostic modality because of its potential therapeutic capabilities (endovascular stenting, for instance, can occur during the same procedure. ⁵ Diagnostic angiography has an overall 8.5% complication rate, including a 2.6% rate of neurologic complications such as stroke. ⁷ Computed tomographic and magnetic resonance angiography can also be helpful in identifying and characterizing threatened lesions. ⁶

Management

Prior to the era of endovascular intervention, treatment for CBS was surgical ligation of the bleeding artery causing high morbidity (stroke) and mortality. ⁵ A newer technique, endovascular stenting, is associated with far fewer immediate complications.^6,7

• Threatened CBS. Early endovascular stenting is indicated before frank hemorrhage occurs.

Approach to the Patient at the End of Life

All the above interventions may be appropriate depending on the patient's goals and prognosis. However, patients near the end of life (EOL) may want medical care solely focused on symptom alleviation without life prolongation. If CBS is thought to be likely for a dying patient, careful discussion about the patient's goals and preferences with the patient/family in collaboration with surgery and radiology is critical. For instance, preventative arterial stenting may be acceptable to an ambulatory patient receiving hospice care, whereas emergency transport and interventions may be unacceptable and unlikely to substantially improve a patient's quality or length of life if that patient is already bedbound and in the final days/weeks of her or his life.

For dying patients at high risk of bleeding, professional and family caregiver preparation is important to minimize panic and distress from copious amounts of blood, and to ensure patient comfort during bleeding. There is no consensus about how to best identify patients for deliberate education and emergency planning, as for some patients this may unnecessarily worry them. At minimum, patients who have had a sentinel bleed should have a plan. ¹⁰ An emergency care plan should include the following elements:

• Ready availability of dark colored linens/towels to cover and absorb blood (less distressing than seeing bright red blood on white linens); gloves, face/eye protection (in case of brisk arterial spraying); and other universal precautions. Suctioning equipment for clearing the mouth or tracheostomy of blood is desirable, if available.