The Laryngoscope
C 2016 The American Laryngological,
V

Rhinological and Otological Society, Inc.

Contemporary Management of Carotid Blowout Syndrome
Utilizing Endovascular Techniques
Nauman F. Manzoor, MD; Rod P. Rezaee, MD; Abhishek Ray, MD; Cameron C. Wick, MD;
Kristine Blackham, MD; David Stepnick, MD; Pierre Lavertu, MD; Chad A. Zender, MD
Objectives/Hypothesis: To illustrate complex interdisciplinary decision making and the utility of modern endovascular
techniques in the management of patients with carotid blowout syndrome (CBS).
Study Designs: Retrospective chart review.
Methods: Patients treated with endovascular strategies and/or surgical modalities were included. Control of hemorrhage,
neurological, and survival outcomes were studied.
Results: Between 2004 and 2014, 33 patients had 38 hemorrhagic events related to head and neck cancer that were
managed with endovascular means. Of these, 23 were localized to the external carotid artery (ECA) branches and five localized to the ECA main trunk; nine were related to the common carotid artery (CCA) or internal carotid artery (ICA), and one
event was related to the innominate artery. Seven events related to the CCA/ICA or innominate artery were managed with
endovascular sacrifice, whereas three cases were managed with a flow-preserving approach (covered stent). Only one patient
developed permanent hemiparesis. In two of the three cases where the flow-preserving approach was used, the covered stent
eventually became exposed via the overlying soft tissue defect, and definitive management using carotid revascularization or
resection was employed to prevent further hemorrhage. In cases of soft tissue necrosis, vascularized tissues were used to
cover the great vessels as applicable.
Conclusions: The use of modern endovascular approaches for management of acute CBS yields optimal results and
should be employed in a coordinated manner by the head and neck surgeon and the neurointerventionalist.
Key Words: Carotid blowout syndrome, carotid reconstruction, endovascular, embolization, and covered stents.
Level of Evidence: 4.
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INTRODUCTION
Carotid blowout syndrome (CBS) represents a devastating complication of head and neck cancer and treatment. The prevalence of CBS for patients treated with
advanced head and neck cancer is 3.9%. Risk factors
include malnutrition, wound breakdown, pharyngocutaneous fistula, history of radical neck dissection, and total
neck radiation dose greater than 70 Gy.1,2 The prevalence of CBS may be higher in patients undergoing reirradiation for recurrent disease.3 CBS encompasses three
distinct clinical entities: threatened, impending, and
acute carotid blowout.2 These three entities represent a

From the Ear Nose and Throat Institute (N.F.M., R.P.R., C.C.W., P.L.,
University Hospitals Case Medical Center, Cleveland, Ohio,
U.S.A.; Department of Neuroradiology (A.R.), University Hospitals Case
Medical Center, Cleveland, Ohio, U.S.A.; Department of Radiology and
Nuclear Medicine (K.B.), University Hospital of Basel, Basel, Switzerland;
Department of Otolaryngology (D.S.), Metro Health Medical Center,
Cleveland, Ohio, U.S.A.
Editor’s Note: This Manuscript was accepted for publication May
31, 2016.
Presented as a poster at the American Head and Neck Society
Annual Meeting, Boston, Massachusetts, U.S.A., April 22–23, 2015.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Rod P. Rezaee, MD, Ear Nose and Throat
Institute, LKS 5045, 11100 Euclid Avenue, University Hospitals Case Medical Center, Cleveland, Ohio 44106. E-mail: rod.rezaee@uhhospitals.org
C.A.Z.)

DOI: 10.1002/lary.26144

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spectrum of vessel risk from mere exposure to vessel
perforation with acute hemorrhage. Type 1 (threatened)
CBS represents vessel exposure with no evidence of
bleeding. Type 2 (impending) CBS refers to sentinel
bleeding, whereas type 3 (acute) CBS represents overt
arterial hemorrhage. CBS carries a high mortality rate,
with estimates often exceeding 50%. Relatively less precipitous forms of oropharyngeal hemorrhage can also be
a result of tumoral bleeding from branches of the external carotid artery (ECA) and can also be successfully
diagnosed and treated with endovascular techniques.
Current management strategies for CBS involve
endovascular approaches as a preferred option in centers
where such facilities and expertise are promptly available. Endovascular approaches have revolutionized the
treatment with a flow-preserving approach (covered
stent), or embolization of the bleeding source. Review of
nationwide trends shows proportionally higher utility of
endovascular sacrifice (88.6%) compared to covered
stenting (11.4%) in management of acute CBS. Overall
mortality rates (8.0%–10.2%) and acute ischemic stroke
rates (2.3%–3.4%) are reported as similar with both
strategies.4
Endovascular covered stents have been used successfully for management of acute CBS in select cases
and provide a window for optimal attempt at definitive
vascular reconstruction. However, long-term efficacy of
endovascular covered stents for CBS is still under

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TABLE I.
Characteristics of Site of Tumors and Hemorrhage.
Etiology, n 5 56
Head and neck cancer related
Epistaxis

33 (58.9%)
12 (21.4%)

Post-tonsillectomy/biopsy

3 (5.4%)

Diagnostic only
Benign etiology

5 (8.9%)
3 (5.4%)

Age, yr, median (range), n 5 33

58 (45–81)

Primary site of tumor, n 5 33
Larynx/hypopharynx

12 (36.4%)

Oropharyngeal

12 (36.4%)

Oral cavity

9 (27.3%)

debate, as there is a requirement for systemic antiplatelet therapy, a high rate of local rebleeding (30%), or conversely, in-stent thrombosis.5,6
In this study, we analyzed the spectrum of oropharyngeal hemorrhage in head and neck cancer patients
treated at a single institution and elaborate our management algorithm through the discussion of selected cases.

MATERIALS AND METHODS
Data Collection
After institutional review board (IRB) approval (IRB #0814-23C) at the University Hospitals Case Medical Center, a dedicated neurointerventional database was used to identify patients
treated for extracranial hemorrhage. In addition, patients with a
biopsy-proven diagnosis of head and neck squamous cell cancer
treated between 2004 and 2014 at the Head and Neck Institute at
University Hospitals Case Medical Center and who underwent
surgical management of profuse oropharyngeal hemorrhage
were reviewed. Patients who were treated for epistaxis, posttonsillectomy hemorrhage, and bleeding related to benign disease
(vascular malformations, endonasal surgery complications) were
excluded from the study. Details regarding patient demographics,
site of disease, as well as previous surgical and nonsurgical treatment modalities were collected in a retrospective manner.

Embolization and Stenting Procedures
Procedures were performed in a neurointervention suite
with monitored anesthesia care using moderate sedation or general anesthesia. Endovascular large vessel occlusion was performed using pushable and/or detachable coils as well as selfexpandable occlusion devices (Amplatzer vascular plug; AGA
Medical Corp., Plymouth, MN). Flow preservation with covered
stent (GORE VIABAHN Endoprosthesis; W. L. Gore & Associates, Newark, DE) was used in selected cases of internal carotid
artery (ICA)/common carotid artery (CCA) hemorrhage. In such
cases, a postprocedure antiplatelet agent was used to prevent
thrombosis. Before parent vessel occlusion of the ICA/CCA, a
balloon occlusion test (BOT) was performed in stable patients to
assess collateral circulation. In other cases, however, a BOT
was not possible because the patient was intubated, sedated, or
unstable. In such cases, angiograms of the ICA and vertebral
arteries (as needed) was performed bilaterally to evaluate for
adequacy of the circle of Willis, so as to estimate potential collateral flow via an anterior communicating artery or posterior
communicating arteries. If bleeding was localized to the ECA
trunk or its branches, then polyvinyl alcohol (PVA) particles,

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pushable fibered platinum coils, detachable coils, or a combination of these materials was used for hemorrhage control.
Descriptive statistics were used to characterize distribution of bleeding, neurological morbidity, and mortality. Survival
data were also recorded for the CCA/ICA and innominate bleeding group.

RESULTS
Between 2004 and 2014, 56 patients were identified
who were treated using endovascular techniques for
bleeding related to extracranial head and neck vasculature. After excluding epistaxis (n 5 12, 21.4%), post-tonsillectomy/postbiopsy hemorrhage (n 5 3, 5.4%), and other
benign etiologies (n 5 3, 5.4%), we identified 33 head and
neck cancer patients who underwent procedures for control of hemorrhage involving the extracranial head and
neck vasculature (Table I). There were five patients who
had evidence of clinical bleeding, but diagnostic angiography did not show any discrete evidence of vessel wall
irregularity, significant tumor blush, or pseudoaneurysm,
and thus no intervention was done. In these five cases,
bleeding stopped with conservative management and no
further episodes of hemorrhage occurred.
In the 33 remaining patients who ultimately underwent intervention, the median age was 58 years (range,
45–81 years). Distribution of the primary site of cancer is
detailed in Table I, with larynx and oropharyngeal sites
being the most common. A total of 38 discrete events of
hemorrhage were identified in these 33 patients, and all
episodes were controlled successfully by the endovascular
procedure. Patterns and site of hemorrhage are detailed
in Table II.
Twenty-three hemorrhagic events related to distal
ECA circulation are also detailed in Table II. Most commonly, the lingual branch of the ECA was involved
(47.8% of ECA branch cases), whereas multiple branches
were involved in 30.4% of cases and included complex
blood supply from the lingual-facial trunk and branches
originating from the superior thyroid and inferior thyroid arteries. In all such cases, embolization (coil embolization and/or PVA particles) was used successfully with
resultant complete control of hemorrhage.
TABLE II.
Pattern of Bleeding.
Great vessel related, events n 5 15
CCA/ICA
ECA
Innominate
ECA branches related, events n 5 23

9 (60%)
5 (33.3%)
1 (6.6%)

Lingual artery

11 (47.8%)

Facial artery (isolated)
Multiple (lingual-facial trunk, superior
thyroid, inferior thyroid)
Superior thyroid artery

1 (4.35%)
7 (30.4%)

Inferior thyroid artery

2 (8.70%)

Internal maxillary artery

1 (4.35%)

1 (4.35%)

CCA 5 common carotid artery; ECA 5 external carotid artery; ICA 5
internal carotid artery.

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TABLE III.
Management of Great Vessel Bleeding.
Patient
No.

Site of Bleeding/Type of Carotid
Blow-Out Syndrome

1

Right CCA (acute)

Recurrent disease

Right CCA embolized

None

2
3

Left ICA (acute)
Left CCA/ICA (acute)

Left ICA embolized
Left CCA/ICA embolized

Permanent hemiparesis
None

4

Left ICA (acute)

Soft tissue necrosis
Pharyngocutaneous
fistula
Recurrent disease

Left CCA/ICA embolized

None

5

Right ICA (acute)

Recurrent disease

Right ICA embolized

None

6
7

Right CCA (acute)
Right carotid (threatened)

Soft tissue necrosis
Pharyngocutaneous
fistula

None
Reversible hemiparesis

8

Left CCA (acute)

Soft tissue necrosis

9

Left CCA (acute)

Soft tissue necrosis

Right CCA embolized
Right carotid artery stented,
embolized after BOT, and
eventually resected with
closure of wound
Left CCA pseudoaneurysm
stented; left carotid artery
resection and reconstruction
with superficial femoral vein
Left CCA embolized

10

Innominate (acute)

Recurrent disease

Innominate artery stented

Etiology

Complications
(Neurological)

Management

Transient aphasia

None
None

BOT 5 balloon occlusion test; CCA 5 common carotid artery; ECA 5 external carotid artery; ICA 5 internal carotid artery.

Fifteen procedures were related to great vessel
hemorrhage including the innominate artery, CCA, ICA,
and the ECA trunk. Of these 15 events, five were localized to the ECA trunk, and in all cases successful control
was achieved using embolization.
Of the remaining 10 procedures, nine were related to
the CCA/ICA, whereas one event was related to the innominate artery. Details of CCA/ICA and innominate bleeding,
the treatment employed, and the outcome/complications
are depicted in Table III. Nine procedures were performed
emergently, whereas one case was elective in the setting of
threatened CBS (exposed carotid artery in a case of pharyngocutaneous fistula). Three of 10 cases were managed
initially with a constructive (flow preserving) approach
utilizing endovascular covered stents with control of immediate hemorrhage. Seven of 10 were managed in a deconstructive approach with sacrifice of the carotid artery. Five
of these events were related to unresectable recurrent/
persistent disease, whereas the remaining were secondary
to soft tissue necrosis/exposure of carotid due to pharyngocutaneous fistula. Most of these patients were transferred
from outside hospitals after sentinel events, and the majority had prior radiation treatment elsewhere. Three patients
with details on primary radiation had an mean dose of 71.7
Gy. Patients were followed for an average of 16.9 months
(range, 0.2–80 months). There was one patient with postembolization hemiparesis. At the time of study conclusion,
four patients were alive, four patients had succumbed
to the primary disease, and two patients had an unknown
survival status.

Decision Making in Management of CBS
Management of CBS has been revolutionized with
the use of modern endovascular techniques. Outcomes
including initial control of hemorrhage, rebleeding rates,
immediate and late complications, and overall success of
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both constructive, flow-preserving, and deconstructive (endovascular sacrifice) approaches have been widely reported in
the literature.1,7,8
Our aim in the present study was to highlight complex decision making in these challenging scenarios.
Although the goal of initial immediate hemorrhage control is paramount, head and neck surgeons and neurointerventionalists have to identify a myriad of patient- and
disease-related factors and employ a strategy that not
only ensures rapid control of hemorrhage but also minimizes neurological morbidity and maximizes long-term
success. We will discuss approaches for managing acute
CBS in the following three scenarios: acute hemodynamic
instability, threatened blowout syndrome, and management of acute CBS with contralateral carotid stenosis.

Management of Acute CBS With
Hemodynamic Instability
Case 1. A 66-year-old male with prior left oropharyngeal squamous cell cancer treated with definitive chemoradiation presented with a left neck abscess involving
the carotid space (Fig. 1A). Direct laryngoscopy and tissue biopsies of the left oropharyngeal necrotic cavity was
planned to rule out persistent disease. Intraoperatively,
there was acute oropharyngeal arterial bleeding, which
was managed with intraoral digital pressure (Fig. 1C).
The source was above the carotid bifurcation and based
on unfavorable anatomic factors including prior radiation associated rigid neck tissues, active infection, and
abscess as well as prior cervical spinal fusion (C4–C6
level), endovascular management was chosen over operative ligation of carotid artery. Figure 1B depicts the digital subtraction angiography (DSA) run postembolization
with Amplatzer vascular plugs in the CCA. There was
complete and rapid resolution of hemorrhage and no
neurological deficits were apparent after extubation.

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Fig. 1. (A) Left carotid space abscess abutting the carotid artery. (B) Successful embolization of left common carotid artery with Amplatzer
plugs. (C) Focused digital pressure over the site of rupture. Notice the cervical spine hardware that precluded spine extension in this case and
hence limited surgical access. (D) Preserved contralateral flow after left vertebral artery injection via a patent posterior communicating artery.

Postintervention DSA images via injection of the left
vertebral artery showed adequate filling of left middle
cerebral artery distribution via a patent posterior communicating artery (Fig. 1D).

Management of Threatened CBS

Fig. 2. (A) Exposed right carotid artery in the neck wound. (B) Preserved flow after covered stent placement in the right carotid artery.
(C) Endovascular sacrifice of right carotid artery.

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Case 2. A 52-year-old male presented with recurrent supraglottic squamous cell cancer treated initially
with definitive chemoradiation. Salvage laryngectomy
and reconstruction with radial forearm free flap was performed. One month after the procedure, he developed a
large right pharyngocutaneous fistula with exposed
carotid artery (Fig. 2A). He was admitted with concerns
for threatened CBS and a covered stent was placed in
the right CCA (Fig. 2B). Clopidogrel (antiplatelet therapy) was started. He then underwent successful balloon
occlusion testing (BOT). Nutritional and hypothyroid
status was optimized and endovascular sacrifice of CCA
was then performed (Fig. 2C). Following embolization,
he had transient neurological symptoms that completely
resolved conservatively. The neck wound was then
debrided and eventually closed. He has been doing well
with no evidence of recurrence or rebleed 18 months
after the embolization procedure.

Manzoor et al.: Endovascular Techniques for Management of CBS

Fig. 3. (A) Left carotid artery (LCA)
pseudoaneurysm.
(B)
Successful
placement of covered stent across the
neck of pseudoaneurysm. (C) Direct
pharyngoscopy showing exposed covered stent in the pharynx. (D) Definitive
vascular reconstruction of the LCA with
superficial femoral vein graft. [Color figure can be viewed in the online issue,
which is available at www.laryngoscope.com.]

Management of Acute CBS With Inadequate
Contralateral Flow
Case 3. A 63-year-old female with prior history of
multiple laryngeal primary cancers underwent salvage
laryngectomy for persistent disease. Surgical defect was
reconstructed with a pedicled left latissmus dorsi flap.
For 19 years she then remained disease free.
In January of 2014, she presented with an episode
of sentinel bleed. Computed tomography (CT) of her
neck and chest as well as a bedside flexible scope failed
to identify any locoregional recurrence or active source
of bleeding. Subsequently, during the same admission,
she became hypotensive with brisk arterial oropharyngeal hemorrhage. Airway was secured with an endotracheal tube and oropharynx was packed. A massive
resuscitation protocol was initiated and she was transferred to interventional radiology.
CT angiography (CTA) demonstrated a pseudoaneurysm of the left CCA just proximal to the carotid bifurcation. There was greater than 50% stenosis of the
contralateral ICA. DSA confirmed a left CCA pseudoaneurysm, which was approximately three times the size of a
normal CCA but failed to show obvious extravasation (Fig.
3A). Given that there was a contralateral stenosis and
that vessel sacrifice would affect the dominant hemisphere, a covered stent (GORE VIABAHN 8 mm 3 5 cm)
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was positioned across the neck of the pseudoaneurysm
and into the ICA (Fig. 3B). The covered stent and ICA
were confirmed to be patent. The oropharyngeal packing
was removed, and bleeding had resolved. She remained
neurologically intact and was discharged 5 days later.
Two weeks later, she presented again with bleeding
from a tracheostoma via her tracheoesophageal prosthesis
site. Imaging and subsequent direct laryngoscopy showed
the recently placed left endovascular CCA covered stent
widely exposed in her pharynx (Fig. 3C). Biopsies identified granulation tissue and necrosis but no evidence of
recurrent cancer. In anticipation of a left carotid sacrifice
a BOT was employed. She failed the BOT and acutely
developed significant aphasia and right-sided motor deficits that resolved over the course of 2 days on therapeutic
anticoagulation. Once neurologically stable, she underwent reconstruction of her left carotid artery with a superficial femoral vein (SFV) (Fig. 3D) graft and soft tissue
coverage with a right supraclavicular fasciocutaneous
flap. She tolerated these procedures well and was discharged from the hospital 1 week after her carotid reconstruction. Now, she is 16 months postacute CBS status
without any neurological deficit or recurrent disease.
Figure 4 highlights our current management algorithm
for management of CBS utilizing modern endovascular
approaches as well as surgical control when indicated.

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Fig. 4. Proposed algorithm based on
type and clinical severity of bleeding.
BOT 5 balloon occlusion test; CCA 5
common carotid artery; CTA 5
computed tomography angiography;
ECA 5 external carotid artery; ICA 5
internal carotid artery.

DISCUSSION
The spectrum of CBS entails challenging scenarios,
which require rapid recognition and prompt, often
simultaneous, initiation of diagnostic and therapeutic
modalities by surgeons and neurointerventionalists.
This study affirms the many predisposing risk factors
associated with CBS, such as a history of chemoradiation, reirradiation, soft tissue necrosis, tumor recurrence, and poor nutrition.2,9 The vast time intervals
between treatment and timing of blowout in case 3
emphasize the point that radiation produces long-term
tissue changes. This delayed presentation of CBS has
been noted in the literature before and may represent
only a minor subset of the cases.10
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Surgical ligation for the treatment of hemorrhage
related to head and neck cancer historically carried a high
mortality rates (40%) and major neurologic morbidity
(60%). Over the last 2 decades, the use of endovascular
techniques has revolutionized the treatment of CBS with
a resultant drop in mortality and neurological morbidity.11
Management of acute CBS involves basic principles of
resuscitation with establishment of airway, control of
hemorrhage with manual pressure, and/or packing of the
oropharynx or neck wound. Rapid resuscitation with blood
products and use of other volume expanders/vasopressors
is often required as part of initial resuscitation. In
patients with threatened CBS, large-bore vascular access
and rapid availability of blood products is prudent as well.

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CTA can be employed in hemodynamic stable patients to
ascertain the likely site of the bleeding and the assessment of patency of the circle of Willis.
If the patient survives this acute hemodynamic
change, then utilization of endovascular techniques
either in a constructive (covered stent) or a destructive
(endovascular sacrifice) manner should be employed
based on hemodynamic status, contralateral anatomy,
and overall goals, keeping in view the long-term prognosis of individual patients.12 In the present scenarios,
both approaches utilized were successful in achieving
immediate control. Reviews have indicated a 95% efficacy rate for endovascular covered stents in controlling
acute hemorrhage if the patient can be stabilized long
enough to make it to the interventional radiology
suite.5,6 Although these endovascular techniques may be
efficacious for acute hemostasis, their role is often only a
temporizing measure. A review of 10 patients with acute
CBS, in which endovascular covered stents were placed,
showed a 30% rate of recurrent bleeding.6 Our experience supports the need for definitive treatment after covered stent placement, particularly if the etiology of the
tissue breakdown has not been addressed and is not the
result of unresectable cancer. This should be achieved
with aggressive wound management and nutritional
optimization before rebleeding or stent exposure ensues.
In two out of three cases in our series, a covered stent
became exposed after a mean duration of 19.5 days. In
addition, covered stent deployment in an infected field
raises the chances of septic emboli and may serve as
a source for potential problems including cerebral
abscess.13
Definitive management of CBS is dependent upon
collateral arterial flow. Case 3 exemplifies this important
determinant that guides selection of proper endovascular
approach. Initial CTA showed a high-grade contralateral
carotid stenosis, indicating that sacrifice of the patient’s
vulnerable carotid artery would carry increased risk of
neurological morbidity, and thus an attempt at reconstruction or bypass must be employed. In this case, the
necrotic portion of the CCA and ICA after initial management were resected and reconstructed with a SFV
graft. The reconstructed vessels were then covered with
healthy, nonradiated tissue from the contralateral supraclavicular region for added protection with no resultant
neurological morbidity.
In case of threatened CBS, the imaging and the
anatomy should be discussed with the interventional
radiologist, and BOT should be done to ascertain collateral circulation. In case 2, we employed an approach of
initial covered stenting of the carotid artery followed by
nutritional and overall optimization. However, the stent
eroded through the arterial wall in the fistula site.
Endovascular sacrifice was then employed after the
patient passed the BOT successfully. Because of the
exposed neck wound, however, the patient had eventual
resection of the carotid artery, and the wound was closed
with vascularized tissue. This serves to illustrate the
critical importance of follow-up, as any exposure of covered stent or coils in the exposed field would require surgical intervention and wound closure.
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All stents and particularly covered stents, however,
are thrombogenic, and patients require antiplatelet medication prior to the procedure if it is performed electively
(i.e., threatened CBS) or during the procedure if it is
performed emergently, after ensuring the success of the
covered stent in controlling the hemorrhage. Systemic
heparinization may also be used in nonemergent procedures and selectively in emergent cases. Furthermore,
patients need to be maintained on dual antiplatelet therapy for several months to ensure covered stent patency.
Covered stents can also be used for the treatment of
pseudoaneurysms of the carotid artery associated with
head and neck cancer.
If injury is localized to the ECA trunk or its branches,
a BOT is not necessary, because the risk of brain injury
during embolization is negligible. PVA particles, pushable
fibered platinum coils, detachable coils, or a combination
of these materials are used for ECA hemorrhage, which is
commonly due to tumoral oozing. There are, however, a
number of potentially dangerous ECA-ICA connections
that the interventionalist should be aware of when using
PVA particles in the external carotid circulation to avoid
embolic intracranial complications.14

CONCLUSION
This study highlights the successful triage and
management of CBS using a modern stepwise approach.
In patients with impending or acute hemorrhage, utilization of endovascular covered stenting serves to achieve
rapid hemostasis while protecting cerebral blood flow.
The long-term efficacy of endovascular covered stents
largely depends on patient factors such as tissue necrosis or disease recurrence. In most cases, the covered
stents should be viewed as a temporizing measure until
definitive reconstruction or ablative procedure can be
performed. The above case scenarios represents the full
spectrum of contemporary, multidisciplinary triage of
acute CBS, in which multiple therapeutic interventions
were necessary to save the life and limit morbidity.

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