Carotid blowout syndrome: An oncological emergency less discussed

South Asian Journal of Cancer ♦ Volume 6 ♦ Issue 2 ♦ April-June 2017 85 the carotid artery is exposed to the oral cavity or external environment through skin breakdown or by direct tumor invasion; “impending,” in which sentinel bleeds have occurred but have been controlled by conservative management; or “acute,” where there is active bleeding.[5] The gold standard for diagnosing CBS is digital subtraction angiography. In patients presenting with threatened and impending CBS, a CT angiogram of the head and neck is reasonable to evaluate the carotid circulation up to the circle of Willis.[6] Following diagnosis, immediate treatment is crucial and focuses on aggressive critical care with securing the airway and management of hemorrhagic shock.[7] Traditional surgical ligation had been the only choice in the past with a displeasingly high rate of neurological morbidity and mortality due to altered anatomy as a result of prior surgery or radiation. Hence, CBSs main treatment has shifted to endovascular techniques: either embolization or stenting of parent artery.[4] Lesley et al. describe a 15%–20% rate of acute or delayed cerebral ischemia following occlusion, which can be predicted by a balloon occlusion test. This test may however be bypassed in acute cases.[8] Endovascular stents are considered in patients who are at high risk for cerebral ischemia such as those who have an incomplete circle of Willis or occluded contralateral common carotid artery. With increased availability and smaller delivery systems, covered stents are an attractive alternative for CBS.[9] However, long-term results have been less encouraging, with high rates of technical complications including cerebral thromboembolism by the inadequate antiplatelet medication, septic thrombosis of the stent graft, and delayed stenosis/ occlusion of the carotid artery by the strong radial force of the stent graft.[10,11] Patients with acute CBS were associated with a higher rebleeding rate than those with impending and threatened CBS. Rebleeding occurs due to reconstitution of collateral vessels or recanalization of the thrombosed carotid artery. Cross occlusion is preferred in such cases to enhance durable hemostasis. For all patients, clinical severity is the significant factor affecting the hemostatic outcome of endovascular management.[12] A sequential approach of treating impending CBS with induction chemotherapy, embolization, and radiation therapy has also been successfully employed.[13] Carotid blowout syndrome: An oncological emergency less discussed