Management of carotid 'blowout' with endovascular stent grafts

Since 1992, endovascular techniques for vascular occlusion and stenting have evolved significantly. Endovascular occlusion of the carotid artery has been used in the management of carotid "blowout." Although it seems logical to expand this application to the use of arterial stents to repair rather than occlude the artery when cerebral cross-circulation is inadequate, concerns remain regarding the placement of a foreign body in a contaminated field. The purpose of the present report is to describe our experience with endovascular stents for control of carotid hemorrhage.

Retrospective case review.

Retrospective review of three cases of acute or threatened carotid hemorrhage managed with endovascular stent placement.

Two patients presented with acute carotid blowout, and one patient with a probable sentinel bleed. All patients previously had been heavily treated with surgery and irradiation: Two had developed pharyngocutaneous fistulas, and one had an open wound filled with tumor that surrounded the carotid artery. All were thought to be at significant risk for stroke if the carotid artery was occluded. In all three patients, stent placement resolved the acute hemorrhage. Mean duration of follow-up was 8.3 months. In two patients, the stent became exposed, ultimately thrombosed or extruded, or both. The third patient had no residual sequelae of stenting but died 3 months later.

When an unacceptable risk of cardiovascular accident makes occlusion unwise, acute carotid hemorrhage can be successfully managed with directed placement of endovascular stents, but the long-term sequelae of placing these foreign bodies in a field with ongoing contamination make this a temporizing rather than permanent measure for use while more definitive long-term solutions are pursued.