Recurrent Carotid Blowout Syndrome Managed by Infratemporal Internal Carotid Ligation: A Case Report

Carotid blowout syndrome (CBS) is a rare but life-threatening complication of head and neck cancer, with endovascular intervention as the preferred treatment, while surgical ligation remains critical when endovascular management is not feasible. We describe a 59-year-old man with oropharyngeal carcinoma (cT4bN0M0) who had achieved clinical remission after concurrent chemoradiation. Two months after completing treatment, he experienced his first episode of CBS. As immediate endovascular intervention was not feasible at that time, surgical ligation of the left common carotid artery (CCA) was performed as a life-saving measure. He remained stable for 2 months until massive oral bleeding recurred, originating from a pseudoaneurysm of the extracranial internal carotid artery (ICA) distal to the previous ligation. As the proximal CCA had already been ligated and thus occluded, endovascular management was not possible in the second instance of CBS. Therefore, surgical ligation was performed via a preauricular infratemporal approach with intraoperative navigation. The pseudoaneurysm was successfully controlled by ligating the proximal and distal feeding vessels. The patient remained free from rebleeding for 3 years. This case demonstrates that infratemporal ICA ligation is a feasible and life-saving option when CBS occurs distal to a previously sacrificed carotid artery and endovascular treatment is not practical.