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Carotid artery protection by means of a trapezius muscle flap
Carotid Artery Protection by Means of a Trapezius Muscle Flap LTC DARRELL A. JAQUES, MD, MC, Washington, MAJ LESLIE M. HOVEY, MD, MC, Washington, DC ROBERT
G. CHAMBERS,
MD,
Baltimore,
DC
Maryland
One of the most catastrophic complications of head and neck surgery is postoperative carotid artery hemorrhage. Fortunately it does not occur in more than 3 per cent of patients having radical head and neck operations [1,2]. Morbidity and mortality, however, have been reported as high as 65 per cent when hemorrhage has occurred [2]. The present report reviews the predisposing factors and the alternatives in prevention and treatment of carotid artery “blowout.” A new method of protecting the vessel is described.
muscular wall. This vascular adventitia is compromised by irradiation, and often removed in standard radical neck operations. The vessel is then dependent on other surrounding tissues for its integrity against necrosis. (7) Suture lines or ligatures on the carotid system increase the risk of hemorrhage. (8) Tumor recurrence in the wound causes dehiscence, failure to heal and eventual erosion of the vessel from tumor or necrosis.
Predisposing
The common denominator in all of the factors listed is wound breakdown with carotid artery exposure. (Figure 1.) If this can be anticipated, the best approach is to protect the vessel at the time of initial surgery. If prophylactic protection has not been accomplished, it should be effected as soon as the wound breaks down. Once the vessel has become exposed, the only other alternative would be a test to determine the ability of the patient to survive without the carotid artery. This is done by first injecting local anesthesia around the vessel to prevent arrhythmias and then occluding the exposed vessel for three to four minutes while asking the patient to move the fingers and to answer questions. If he becomes confused or obtunded from the compression test, resection of the vessel would not be tolerated. Gradual occlusion of the common carotid artery with a Selverstone clamp over a period of five to seven days may convert the patient to a lower risk of stroke or death from ligation. Sometimes a patient will tolerate occlusion of the common carotid and not the internal carotid artery. If such is the case, ligation and division of the common carotid artery will decrease the flow past the carotid bulb, since the only source of blood flow in that circum-
Factors in Carotid Artery Blowout
An analysis of reported series of carotid artery blowouts suggests that this complication occurs due to several predisposing factors : (1) Prior irradiation decreases the rate and quality of wound healing, especially when doses of more than 4,000 r have been given more than three months before surgery. (2) Wound infection may necessitate wide separation of skin flaps for adequate drainage, but in so doing the artery may, become exposed. (3) Fistula formation from oropharyngeal wound breakdown permits saliva to drain over the carotid artery. (4) Sterile fluid collections or massive chylous fistulas can result in wound break down and carotid exposure. (5) Dehiscence of skin suture lines will expose the vessel to infection and drying if incisions are oriented over the vessel. (6) Loss of vasa vasorum in the adventitia covering the vessel decreases the blood supply to the From the Head and Neck Surgery Service, Department of Surgery, Walter Reed General Hospital, Washington, DC 20012; and The Johns Hopkins University, Baltimore, Maryland. Reprint requests should be addressed to Dr Jaques, Head and Neck Suraerv Service. Daoartment of Suraerv. _ _. Walter Reed General Hosoital. , Wa;hington, DC 20612. Presented at the Seventeenth Annual Meeting of the Society of Head and Neck Surgeons, Vancouver, British Columbia, May 10-12, 1971.
744
Alternatives
in Prevention
and Treatment
The American
Journal
of Surgery
Trapezius
Muscle Flap Protecting
Carotid
Artery
a
figure 1. The common denomlnator In carotid ,blowout is wound breakdown. Neck ,incision (a); radical Figure 2. neck wound (b). Note exposed carotid artery and trapezius muscle insertion laterally on cl&tide.
stance
is by “stealing” from the external carotid collaterals and thence into the internal carotid. This asumes, of course, that the external carotid was left intact at surgery. Extra-anatomic bypass vascular procedures are probably technically impossible since the entire neck on the side requiring bypass is usually open and infected. The other alternative would be to wait for the disaster of hemorrhage to occur and accept the risk of stroke and/or death from emergency ligation. If this course of action is forced upon the surgeon, the patient should receive transfusions to normal volume before ligation since the incidence of stroke and death is diminished when the patient is normovolemic [ S,4]. It is also recommended that the entire exposed vessel be removed, when possible, since further erosion and hemorrhage may occur. In any case the ligated vessel should be divided to permit retraction of the vessel and prevent erosion at the ligature. Previous
Methods
of Carotid
Protection
1. Prophylactic coverage of the vessel was first advised in 1956 when Grady et al [5] described rotation of the levator scapulae muscle over the vessel. This report was followed by more elaborate descriptions of the technic by Staley [6] and Schweitzer [ ?‘I. 2. Carotid bulb rotation under adjacent muscle was described by Conley [8] in 1962. 3. Use of dermal grafts sutured over the entire carotid artery was described by Corso and Gerold [9] in 1963 and later by Reed [IO]. 4. Prevertebral fascia was rotated over the vessel and described by Cheek and Rise [11] in 1967. 5. Mobilization of a pedicle of omental apron from the abdomen through a skin tunnel across the chest to the neck was recommended for carotid coverage by Goldsmith and Beattie [12] in 1970.
Volume 122, December 1971
Technic of a New Method
For the past year we have utilized the trapezius muscle to cover the carotid artery when the risk of eventual wound breakdown and hemorrhage was greatest. Specifically, we protect the vessel on any patient with prior irradiation. We also transfer the trapezius flap in composite operations in which risk of oropharyngeal fistula is significant. The trapezius muscle inserts along the lateral third of the clavicle as well as the scapula. (Figure 2.) The entire clavicular insertion is dissected free from the periosteum and forms a discrete bundle of muscle which can be separated from the scapular portion by blunt and sharp dissection. (Figure 3.) The dissection is carried back toward the origin of the muscle until sufficient length is gained to permit the muscle to cover the carotid artery. It is a highly vascular muscle which survives well as a flap, The muscle will fan out for broader coverage if its fascia is partially incised on one surface. It then can be anchored by suturing to the digastric muscle and tendon and to the strap muscles. (Figure 4.) If laryngectomy has been performed, the muscle can be anchored to the prevertebral fascia. The skin incisions are then closed over wound suction tubes. Comments We have utilized the trapezius muscle flap in twenty-eight patients and have found it to be a reliable, viable protection for the carotid artery in all but two cases. In six of the twenty-eight patients there was wound breakdown for various reasons and in two instances the carotid artery became exposed and hemorrhage occurred. The failures will be described in some detail as follows : 1. In the first patient the muscle was transferred after the fistula became apparent and the wound
745
Jaques, Hovey, and Chambers
Figure 3. Trapezius muscle insertion excised from clavicle and separated from scapular portion. Figure 4. Treoezius muscle sutured to prOteot carotid artery.
dehisced seven days postoperatively. This patient had a poorly differentiated squamous cell carcinoma on the opposite side as a second primary lesion in the mouth. This occurred one year after the first primary lesion on the opposite side had been treated with 6,000 r of a cobalt 60 irradiation preoperatively. A portion of the muscle necrosed and the vessel became exposed in a wound which had failed to heal at a normal rate. The exposed vessel hemorrhaged at five weeks and required excision of the carotid system, which the patient tolerated well. In retrospect the trapezius muscle should have been utilized to cover the carotid at the time of the initial surgery. 2. The second patient also had a second oral primary lesion requiring subtotal glossectomy and neck dissection five years after 6,000 r of cobalt 60 irradiation had been given to the mouth and neck for the first oral primary lesion. Fistula formation and wound breakdown exposed the muscle and in due course the extremely enlarged, tortuous, atherosclerotic, irradiated carotid bifurcation penetrated the patient’s unusually thin trapezius muscle and exposed the bulb. All other areas of the carotid remained well covered. Resection of the total carotid system was eventually required and the outcome was favorable. Significant carotid protection in the past has essentially been limited to the use of the levator scapulae or dermal graft technics. The levator has not always remained viable on transfer due to its tenuous blood supply. The levator can be left intact if the trapezius muscle is used and thus acts as a valuable elevator of the shoulder. It is for these reasons that we searched for a broader, stronger, more viable muscle flap in the region which would not further increase disability. We have used and will occasionally continue to use dermal grafts for carotid protection, especially when the spinal accessory nerve has been preserved or grafting is planned. Dermal graft, however, requires the use of tissue from a painful re-
746
mote donor site and must survive in a relatively unhospitable bed in previously irradiated tissue. The trapezius has an abundant blood supply and is readily available in the wound. It is a functionless muscle in a standard neck dissection if the spinal accessory nerve has been removed. This muscle, of course, cannot be used if the spinal accessory nerve is to be preserved or if a nerve graft is planned. The trapezius also adds bulk to the neck and decreases the scaphoid depression after radical neck dissection. The eventual contour is cosmetically more pleasing. In situations which are high risk for eventual wound breakdown and carotid hemorrhage we advise prophylactic use of the trapezius muscle flap. It can also be used after wound breakdown has occurred, but the condition of such wounds is less favorable for ultimate carotid protection. Summary Catastrophic hemorrhage from carotid artery blowout may occur when the vessel becomes exposed from wound breakdown after radical head and neck surgery. A new technic for carotid artery protection is described in which a trapezius muscle flap is utilized. In addition, other methods of prevention and control of carotid hemorrhage are reviewed and discussed. We recommend the prophylactic use of this flap as carotid protection in high risk cases. References 1. Keichum AS, Hoye RC: Spontaneous carotid artery hemorrhage after head and neck surgery. Amer J Sulrg 110: 649,1965. 2. MacComb WS: Mortallity from radical1 neck dissection. Amer J Surg 1%: 352, 1968. 3. Moore OS, Baker HW: Carotid artery ligation in swgery of the head and neck. Cancer 8: 712.1955. 4. Moore OS, Karlan CM,Sigler L: Factors infkrendng the safety of carotid ligation. Amer J Surg 118: 666, 1969. 5. Grady 6D, Robinson JS, White JB, Krantz S: Technical
The American
Journal
of Surgery
Trapezius
6. 7. 8. 9.
suggestions for cancer of the tongue and floor of mouth. N CaroHna Med J 17: 466, 1956. Staley CJ: A muscle cover for the carotid artery after radical neck dissecti,on. Amer J Surg 102: 815, 1961. Schweitzer RJ: Use of muscle flaps for protection of carotid artery after radical neck dissection. Ann Swg 156: 811, 1%2. Conley JJ: Carotid artery protection. Arch Otolaryng 75: 60, 1962. Corso PF, Gerold FP: Use of autogenous dermis for pro-
Volume 122, December 1971
Muscle
Flap Protecting
Carotid
Artery
tection of the carotid artery and pharyngeal suture lines in radical head and neck surgery. Surg Gynac Obstet 117: 37, 1963. 10. Reed GF: The use of dermal grafts in otolaryngology. Ann Otol 74: 7’69, 1965. 11. Cheek HB, Rise EN: Carotid artery protection and a new technique. Arch Otolaryng 86: 73, 1967. 12. Goldsmith HS, Beattie EJ Jr: Carotid artery protection by pedicled omental wrapping. Surg Gynec Obstet 130: 57, 1970.
747
G. CHAMBERS,
MD,
Baltimore,
DC
Maryland
One of the most catastrophic complications of head and neck surgery is postoperative carotid artery hemorrhage. Fortunately it does not occur in more than 3 per cent of patients having radical head and neck operations [1,2]. Morbidity and mortality, however, have been reported as high as 65 per cent when hemorrhage has occurred [2]. The present report reviews the predisposing factors and the alternatives in prevention and treatment of carotid artery “blowout.” A new method of protecting the vessel is described.
muscular wall. This vascular adventitia is compromised by irradiation, and often removed in standard radical neck operations. The vessel is then dependent on other surrounding tissues for its integrity against necrosis. (7) Suture lines or ligatures on the carotid system increase the risk of hemorrhage. (8) Tumor recurrence in the wound causes dehiscence, failure to heal and eventual erosion of the vessel from tumor or necrosis.
Predisposing
The common denominator in all of the factors listed is wound breakdown with carotid artery exposure. (Figure 1.) If this can be anticipated, the best approach is to protect the vessel at the time of initial surgery. If prophylactic protection has not been accomplished, it should be effected as soon as the wound breaks down. Once the vessel has become exposed, the only other alternative would be a test to determine the ability of the patient to survive without the carotid artery. This is done by first injecting local anesthesia around the vessel to prevent arrhythmias and then occluding the exposed vessel for three to four minutes while asking the patient to move the fingers and to answer questions. If he becomes confused or obtunded from the compression test, resection of the vessel would not be tolerated. Gradual occlusion of the common carotid artery with a Selverstone clamp over a period of five to seven days may convert the patient to a lower risk of stroke or death from ligation. Sometimes a patient will tolerate occlusion of the common carotid and not the internal carotid artery. If such is the case, ligation and division of the common carotid artery will decrease the flow past the carotid bulb, since the only source of blood flow in that circum-
Factors in Carotid Artery Blowout
An analysis of reported series of carotid artery blowouts suggests that this complication occurs due to several predisposing factors : (1) Prior irradiation decreases the rate and quality of wound healing, especially when doses of more than 4,000 r have been given more than three months before surgery. (2) Wound infection may necessitate wide separation of skin flaps for adequate drainage, but in so doing the artery may, become exposed. (3) Fistula formation from oropharyngeal wound breakdown permits saliva to drain over the carotid artery. (4) Sterile fluid collections or massive chylous fistulas can result in wound break down and carotid exposure. (5) Dehiscence of skin suture lines will expose the vessel to infection and drying if incisions are oriented over the vessel. (6) Loss of vasa vasorum in the adventitia covering the vessel decreases the blood supply to the From the Head and Neck Surgery Service, Department of Surgery, Walter Reed General Hospital, Washington, DC 20012; and The Johns Hopkins University, Baltimore, Maryland. Reprint requests should be addressed to Dr Jaques, Head and Neck Suraerv Service. Daoartment of Suraerv. _ _. Walter Reed General Hosoital. , Wa;hington, DC 20612. Presented at the Seventeenth Annual Meeting of the Society of Head and Neck Surgeons, Vancouver, British Columbia, May 10-12, 1971.
744
Alternatives
in Prevention
and Treatment
The American
Journal
of Surgery
Trapezius
Muscle Flap Protecting
Carotid
Artery
a
figure 1. The common denomlnator In carotid ,blowout is wound breakdown. Neck ,incision (a); radical Figure 2. neck wound (b). Note exposed carotid artery and trapezius muscle insertion laterally on cl&tide.
stance
is by “stealing” from the external carotid collaterals and thence into the internal carotid. This asumes, of course, that the external carotid was left intact at surgery. Extra-anatomic bypass vascular procedures are probably technically impossible since the entire neck on the side requiring bypass is usually open and infected. The other alternative would be to wait for the disaster of hemorrhage to occur and accept the risk of stroke and/or death from emergency ligation. If this course of action is forced upon the surgeon, the patient should receive transfusions to normal volume before ligation since the incidence of stroke and death is diminished when the patient is normovolemic [ S,4]. It is also recommended that the entire exposed vessel be removed, when possible, since further erosion and hemorrhage may occur. In any case the ligated vessel should be divided to permit retraction of the vessel and prevent erosion at the ligature. Previous
Methods
of Carotid
Protection
1. Prophylactic coverage of the vessel was first advised in 1956 when Grady et al [5] described rotation of the levator scapulae muscle over the vessel. This report was followed by more elaborate descriptions of the technic by Staley [6] and Schweitzer [ ?‘I. 2. Carotid bulb rotation under adjacent muscle was described by Conley [8] in 1962. 3. Use of dermal grafts sutured over the entire carotid artery was described by Corso and Gerold [9] in 1963 and later by Reed [IO]. 4. Prevertebral fascia was rotated over the vessel and described by Cheek and Rise [11] in 1967. 5. Mobilization of a pedicle of omental apron from the abdomen through a skin tunnel across the chest to the neck was recommended for carotid coverage by Goldsmith and Beattie [12] in 1970.
Volume 122, December 1971
Technic of a New Method
For the past year we have utilized the trapezius muscle to cover the carotid artery when the risk of eventual wound breakdown and hemorrhage was greatest. Specifically, we protect the vessel on any patient with prior irradiation. We also transfer the trapezius flap in composite operations in which risk of oropharyngeal fistula is significant. The trapezius muscle inserts along the lateral third of the clavicle as well as the scapula. (Figure 2.) The entire clavicular insertion is dissected free from the periosteum and forms a discrete bundle of muscle which can be separated from the scapular portion by blunt and sharp dissection. (Figure 3.) The dissection is carried back toward the origin of the muscle until sufficient length is gained to permit the muscle to cover the carotid artery. It is a highly vascular muscle which survives well as a flap, The muscle will fan out for broader coverage if its fascia is partially incised on one surface. It then can be anchored by suturing to the digastric muscle and tendon and to the strap muscles. (Figure 4.) If laryngectomy has been performed, the muscle can be anchored to the prevertebral fascia. The skin incisions are then closed over wound suction tubes. Comments We have utilized the trapezius muscle flap in twenty-eight patients and have found it to be a reliable, viable protection for the carotid artery in all but two cases. In six of the twenty-eight patients there was wound breakdown for various reasons and in two instances the carotid artery became exposed and hemorrhage occurred. The failures will be described in some detail as follows : 1. In the first patient the muscle was transferred after the fistula became apparent and the wound
745
Jaques, Hovey, and Chambers
Figure 3. Trapezius muscle insertion excised from clavicle and separated from scapular portion. Figure 4. Treoezius muscle sutured to prOteot carotid artery.
dehisced seven days postoperatively. This patient had a poorly differentiated squamous cell carcinoma on the opposite side as a second primary lesion in the mouth. This occurred one year after the first primary lesion on the opposite side had been treated with 6,000 r of a cobalt 60 irradiation preoperatively. A portion of the muscle necrosed and the vessel became exposed in a wound which had failed to heal at a normal rate. The exposed vessel hemorrhaged at five weeks and required excision of the carotid system, which the patient tolerated well. In retrospect the trapezius muscle should have been utilized to cover the carotid at the time of the initial surgery. 2. The second patient also had a second oral primary lesion requiring subtotal glossectomy and neck dissection five years after 6,000 r of cobalt 60 irradiation had been given to the mouth and neck for the first oral primary lesion. Fistula formation and wound breakdown exposed the muscle and in due course the extremely enlarged, tortuous, atherosclerotic, irradiated carotid bifurcation penetrated the patient’s unusually thin trapezius muscle and exposed the bulb. All other areas of the carotid remained well covered. Resection of the total carotid system was eventually required and the outcome was favorable. Significant carotid protection in the past has essentially been limited to the use of the levator scapulae or dermal graft technics. The levator has not always remained viable on transfer due to its tenuous blood supply. The levator can be left intact if the trapezius muscle is used and thus acts as a valuable elevator of the shoulder. It is for these reasons that we searched for a broader, stronger, more viable muscle flap in the region which would not further increase disability. We have used and will occasionally continue to use dermal grafts for carotid protection, especially when the spinal accessory nerve has been preserved or grafting is planned. Dermal graft, however, requires the use of tissue from a painful re-
746
mote donor site and must survive in a relatively unhospitable bed in previously irradiated tissue. The trapezius has an abundant blood supply and is readily available in the wound. It is a functionless muscle in a standard neck dissection if the spinal accessory nerve has been removed. This muscle, of course, cannot be used if the spinal accessory nerve is to be preserved or if a nerve graft is planned. The trapezius also adds bulk to the neck and decreases the scaphoid depression after radical neck dissection. The eventual contour is cosmetically more pleasing. In situations which are high risk for eventual wound breakdown and carotid hemorrhage we advise prophylactic use of the trapezius muscle flap. It can also be used after wound breakdown has occurred, but the condition of such wounds is less favorable for ultimate carotid protection. Summary Catastrophic hemorrhage from carotid artery blowout may occur when the vessel becomes exposed from wound breakdown after radical head and neck surgery. A new technic for carotid artery protection is described in which a trapezius muscle flap is utilized. In addition, other methods of prevention and control of carotid hemorrhage are reviewed and discussed. We recommend the prophylactic use of this flap as carotid protection in high risk cases. References 1. Keichum AS, Hoye RC: Spontaneous carotid artery hemorrhage after head and neck surgery. Amer J Sulrg 110: 649,1965. 2. MacComb WS: Mortallity from radical1 neck dissection. Amer J Surg 1%: 352, 1968. 3. Moore OS, Baker HW: Carotid artery ligation in swgery of the head and neck. Cancer 8: 712.1955. 4. Moore OS, Karlan CM,Sigler L: Factors infkrendng the safety of carotid ligation. Amer J Surg 118: 666, 1969. 5. Grady 6D, Robinson JS, White JB, Krantz S: Technical
The American
Journal
of Surgery
Trapezius
6. 7. 8. 9.
suggestions for cancer of the tongue and floor of mouth. N CaroHna Med J 17: 466, 1956. Staley CJ: A muscle cover for the carotid artery after radical neck dissecti,on. Amer J Surg 102: 815, 1961. Schweitzer RJ: Use of muscle flaps for protection of carotid artery after radical neck dissection. Ann Swg 156: 811, 1%2. Conley JJ: Carotid artery protection. Arch Otolaryng 75: 60, 1962. Corso PF, Gerold FP: Use of autogenous dermis for pro-
Volume 122, December 1971
Muscle
Flap Protecting
Carotid
Artery
tection of the carotid artery and pharyngeal suture lines in radical head and neck surgery. Surg Gynac Obstet 117: 37, 1963. 10. Reed GF: The use of dermal grafts in otolaryngology. Ann Otol 74: 7’69, 1965. 11. Cheek HB, Rise EN: Carotid artery protection and a new technique. Arch Otolaryng 86: 73, 1967. 12. Goldsmith HS, Beattie EJ Jr: Carotid artery protection by pedicled omental wrapping. Surg Gynec Obstet 130: 57, 1970.
747