Auris·Nasus·Larynx (Tokyo) 12 (Supp\. II) S 103-S 106, 1985

RECONSTRUCTION OF CAROTID ARTERY IN
RADICAL NECK DISSECTION
Hiroshi OKAMURA, M.D., Koshiro NAKAMURA, M.D.,
and Naoaki Y ANAGIHARA, M.D.
Department of Otolaryngology, School of Medicine,
Ehime University, Ehime, 791-02 Japan

No permanent cure of head-and-neck cancer can
be expected when the cancer infiltrates into the
wall of the carotid artery. When the carotid
artery was resected, the resultant hemiplegia
poses very difficult postoperative rehabilitation
problems, even though the cancer is eradicated.
The recent development of vascular surgery has
made reconstruction of the carotid artery feasible. In this paper, the authors reported the indications of reconstruction of the carotid artery in
radical neck dissections and the surgical procedures. The indication of reconstruction of
the carotid artery is determined by using of
angiography, CT-scan and echography. Especially, echography is useful for determining the
possibility of reconstructing the carotid artery.
In the case of the infiltration type, we can start
to remove tumor after preparing for the reconstruction of the carotid artery. The principle of
surgical procedures consists of by-pass shunt
with a vascular graft between the common and
internal carotid arteries, excision of the artery
with tumor and insertion of a vascular graft with
end-to-end anatomoses. Concerning the selection of a vascular graft, an auto-vein graft is
preferable to a synthetic graft in consideration of
the postoperative patency of the vascular flow.
Moreover, in the case of reconstructing the artery, preoperative irradiation has often been
applied and a wide removal of the soft tissue is
required, so it is recommended that the myocutaneous flap be used to cover the reconstructed
area.
No permanent cure of head-and-neck cancer can be expected when the cancer cells
infiltrate into the wall of the carotid artery.
When the carotid artery was resected, the
resultant hemiplegia poses very difficult

postoperative rehabilitation problems, even
though the cancer is eradicated. The recent
development of vascular surgery, however,
has made reconstruction of the carotid artery
feasible. In selected patients with a neck
tumor infiltrating the carotid artery, a radical
neck dissection with the use of reconstruction
of the carotid artery can be carried out without risks of brain damage.
In this paper, the authors report the indications of the reconstruction of the carotid
artery in radical neck dissections and the
surgical procedures.
Indication
At the authors' clinic, the indication of
reconstruction of the carotid artery is determined by using of angiography, CT-scan and
echography. Especially, echography, which
is a non-invasive examination, has some
advantages in investigating the relationship
between the tumor and the carotid artery
preoperatively. Echography makes it possible to display the pulsation of the wall of
the carotid artery and the anatomical situation of the tumor and the artery in detail.
From our experience of echographic examinations, we could classify anatomical
situations of the tumor and the carotid artery
into the following two types; the compression type and the infiltration type, depending
on whether or not the echo from the base
of the tumor is recorded. Figure 1 shows
an example of the compression type recorded
from a case of papillary adenocarcinoma of
the thyroid gland. The operation showed
that the tumor did not infiltrate into the wall

S 104

H. OKAMURA et al.

infiltration type, there is a possibility that the
tumor infiltrates into the wall of the carotid
artery, so we need to prepare for reconstrucing the carotid artery.

Fig. 1. An example of the compression type
recorded by an echography. The wall of
the carotid artery is well displayed.

Fig. 2. An example of the infiltration type recorded by an echography. The wall of the
carotid artery disappears.

of the carotid artery and, therefore, the
artery was conserved. Figure 2 shows an
example of the infiltration type recorded
from a case of cervicallymphnode metastasis
due to a tongue cancer, and the opeation
showed that the tumor infiltrated into the
wall of the carotid artery. In the case of the

Surgical Procedures
The principle of reconstruction of the
carotid artery consists of by-pass shunt with
a vascular graft between the common and
internal carotid arteries, excision of the carotid artery with tumor and, then, insertion
of a vascular graft with end-to-end anastomoses by using an atraumatic needle and 4-0
proline threads. To prevent recurrence of
the tumor, the site of the anastomosis should
have a margin longer than 2 cm at least
from the end of the tumor on the carotid
artery.
An auto-vein graft is preferable to a synthetic vascular graft, and the reason will be
discussed later. When we operate the oral
or pharyngeal cavity with the reconstruction
of the carotid artery simultaneously, the cavity should be closed watertight at the first
step and, then, an auto-vein graft should be
selected. We make it a rule to cover the
operated area with a myocutaneous flap.
Case Report
Case 1. The patient, who was a 49-yearold male with tongue cancer T2NuMo, was
treated by using a synthetic vascular graft.
The primary lesion was treated by radiation
therapy and was well controlled, but a cervical lymph node metastasis was found one
year and three months later. The CT-scan
showed that the tumor surrounded the carotid artery. Since we did not need to operate
the oral and pharyngeal cavities, a :synthetic
vascular graft (Dacron double velour) with
the diameter of 6 mm was utilized. As the
first step, a by-pass shunt inserted into the
preclotted graft was made between the common and internal carotid arteries and, then,
the tumor with the carotid artery was removed. Finally, end-to-end anastomoses of
the graft were performed to the internal and
common carotid arteries respectively (Fig. 3).
The operated area was covered by the pectoral

H. OKAMURA et at.

Fig. 3. The reconstruction of the carotid artery
by using a synthetic vascular graft.

Fig. 4. The reconstruction of the carotid artery
by using an auto-vein graft.

major myocutaneous flap. The ultrasonic
Doppler method showed the patency of the
reconstructed artery during the one month
after the operation. However, that part was
thereafter obliterated by a formation of
thrombus, but no postoperative complications including hemiplegia occurred. Unfortunately, this patient died due to a metastasis
of the tumor to the cervical vertabra 10
months later.
Case 2. The patient, who was a 63-yearold male with hypopharyngeal cancer
T2N3Mo, was treated by using an auto-vein
graft. The cervical metastatic tumor was
diagnosed to have infiltrated into the wall
of the carotid artery through CT-scan, angiography and echography. In this case, we
planned to remove the hypo pharyngeal tu-

S 105

mor and to reconstruct the carotid artery
simultaneously. To avoid the contamination
by saliva of the reconstructed area of the
carotid artery, the hypopharyngeal cavity
was closed watertight after the tumor was
removed and, then , the carotid artery was
reconstructed by using a reversed auto-vein
graft obtained from the great saphenous vein
(Fig. 4). The details of the method were the
same as the first case. The operated area
was covered by the latissimus dorsi myocutaneous flap. The operation was successful, and no postoperative complications occurred. The patient has been well controlled
these two years under our following-up observation.

Discussion and Conclusion
In general, a radical neck dissection cannot
be performed safely when the tumor has already infiltrated into the wall of the carotid
artery. When the carotid artery was ligated
or resected, the resultant hemiplegia poses
very difficult postoperative rehabilitation
problems (CONLEY, 1957; MOOR et at., 1969 ;
KONNO et aI. , 1981). With the development
of vascular surgery, a radical neck dissection
with the use of reconstruction of the carotid
artery can be carried out without risks of
brain damage (CONLEY, 1957; LORE, 1965;
INOKUCHI and YAGl, 1967; TOHYA et at.,
1981).
The recent advances of diagnostic methods,
especially of the imaging diagnosis, have
made it possible to clarify preoperatively the
detailed relationship between the tumor and
the carotid artery. However, it is not easy
to determine the indications of reconstruction of the carotid artery preoperatively,
even though angiography and CT-scan are
applied. On this point, echography is useful
for determining the possibility of reconstructing the carotid artery, as mentioned above.
In the case of the infiltration type, we can
start to remove tumor after preparing for
the reconstruction of the carotid artery.
Concerning the selection of a vascular
graft, an auto-vein graft is preferable to a
synthetic graft for the following two reasons.

S 106

H. OKAMURA et at.

First, the diameter of a synthetic graft is
required to be wider than 6 mm in consideration of the postoperative patency of the
vascular flow. However, the diameter of the
internal carotid artery is not wide enough
for the above requirement in many cases.
Hence the possibility of obliterating the reconstructed artery postoperatively due to a
formation of thrombus, as shown in the first
case. Next, when we operate the oral or
pharyngeal cavity with a simultaneous reconstruction of the carotid artery, there is
the possibility of contaminating the reconstructed area by saliva. In such a case, the
choice of an auto-vein graft might be safer
than that of a synthetic graft, and the use
of the great saphenous vein in reversed fashion is suitable for the reconstruction.
Moreover, in the case of reconstructing
the artery, preoperative irradiation has often
been applied, and a wide removal of the soft
tissue including the sternocleidomastoidal
muscle is required, so it is recommended that
the myocutaneous flap be used to cover the
reconstructed area.
The introduction of the reconstruction of
the carotid artery might reduce the mortality

due to advanced head-and-neck cancer.
But, as mentioned above, the reconstruction
should be preceded by careful considerations
of the anatomical situation of the tumor and
the carotid artery by means of those imaging
diagnostic methods that have recently advanced.
References
CONLEY, J.J.: Carotid artery surgery in the treatment of tumors of the neck. Arch. Otolaryngol.
65: 437-446, 1957.
INOKUCHI, K., and YAGI, H.: Vascular reconstruction for radical neck dissection. Otologia Fukuoka 13: 97-104, 1967.
KONNO, A., TOGAwA, K., and IIzUKA, K.: Analysis
of factors affecting complications of carotid
ligation. Ann. Otol. 90: 222-226, 1981.
LORE, J.M.: Vascular surgery in operations of the
head and neck. Arch. Otolaryngol. 74: 646651, 1965.
MOOR, O.S., KARLAN, M., and SIGLER, L.: Factors
influencing the safety of carotid ligation. Am.
J. Surg. 118: 666-668, 1969.
TOHYA, M., OBUCHI, M., TANAKA, N., KITAO, Y.,
KURODA, T., and ISHIKAWA, T.: The vascular
reconstruction of the carotid artery with radical
neck dissection. Otologia Fukuoka 27: 776-781,
1981.