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Endovascular repair of radiation-induced bilateral common carotid artery stenosis and pseudoaneurysms: a case report
Endovascular Repair Of RadiationInduced Bilateral Common Carotid Artery Stenosis and Pseudoaneurysms: A Case Report Robert A. Koenigsberg, D.O., F.A.O.C.R., Lisa M. Grandinetti, M.M.S., Louis P. Freeman, M.D.,* Daniel McCormick, D.O., and Fong Tsai, M.D. Department of Radiologic Sciences, MCP Hahnemann University, Philadelphia, Pennsylvania, *Department of Cardiology, MCP Hahnemann University, Philadelphia, Pennsylvania
Koenigsberg RA, Grandinetti LM, Freeman LP, McCormick D, Tsai F. Endovascular repair of radiation-induced bilateral common carotid artery stenosis and pseudoaneurysms: a case report. Surg Neurol 2001;55:347–52.
KEY WORDS
Carotid, arteries, stents, electrolytically detachable coils, radiation vasculopathy.
BACKGROUND
Radiation-induced damage to small and medium-sized vessels has been observed in both animals and humans. Changes may appear in the immediate postradiation period or many years later. In this case, we report an unusual presentation of bilateral radiation-induced carotid artery stenoses associated with pseudoaneurysms, and a previously unreported application of a recently established treatment. CASE DESCRIPTION
A 72-year-old African-American male presented with recurrent right hemispheric transient ischemic attacks (TIA) and neck pain. Thirteen years previously, the patient had received radiation therapy for laryngeal carcinoma. Diagnostic carotid angiography demonstrated moderate radiation-induced bilateral carotid artery stenosis and associated common carotid pseudoaneurysms. The patient was treated with bilateral endovascular stents and electrolytically detachable coils in staged procedures. At his most recent follow-up, there is no evidence of re-stenosis and the patient remains asymptomatic.
adiation-induced damage to the intimal wall of large and medium-sized vessels causing accelerated atherosclerotic disease has been documented in both animals and humans [1– 6,9,13]. The pathological consequences of radiation have been shown to include depolymerization of the collagenous fibers and infiltration of fat into the intima, followed by adventitial fibrosis and obstructive changes [13]. Particularly in the neck region, treatment presents a surgical challenge. This is further complicated when stenosis occurs bilaterally, compromising the cerebral vascular flow and predisposing the patient to multiple ischemic attacks. We describe a case in which stenting and secondary coiling were employed to correct bilateral common carotid artery stenosis and pseudoaneurysms induced by radiation therapy previously administered for laryngeal carcinoma.
R
CONCLUSIONS
This case illustrates a novel and successful treatment for the endovascular repair of post-radiation bilateral carotid artery stenosis and pseudoaneurysms. In our practice, we have seen three such cases of radiation-induced vasculopathy. Therefore, patients with a previous history of radiation therapy for head and neck neoplasms merit cautious monitoring and judicious use of stents and secondary coils, when necessary. © 2001 by Elsevier Science Inc.
Address reprint requests to: Dr. Robert A. Koenigsberg, Department of Radiologic Sciences, MCP Hahnemann University, Broad and Vine Streets, Philadelphia, PA 19102. Received December 22, 1999; accepted May 9, 2001. © 2001 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
Case Report A 72-year-old African-American male with a history of hypertension, gout, and benign prostatic hypertrophy received radiation therapy for laryngeal carcinoma 13 years before admission. Although the patient did not receive his radiation therapy at our institution, his course of treatment was believed to have been between 6000 –7200 cGy. He presented to us complaining of right neck pain and right hemispheric TIA symptoms. Arch angiography demon0090-3019/01/$–see front matter PII S0090-3019(01)00476-1
348 Surg Neurol 2001;55:347–52
1
Arch angiogram demonstrating bilateral common carotid artery stenosis and pseudoaneurysms.
strated nearly symmetric, bilateral, long segment stenoses associated with moderate sized (5 ⫻ 3 mm on the right and 4 ⫻ 2 mm on the left) pseudoaneurysms (Figure 1). After obtaining informed consent, endovascular treatment was performed. An 8F sheath was placed in the right common femoral vein and a 10F sheath in the right common femoral artery. A 5F Berenstein catheter was manipulated over a guidewire to select for the right CCA. Digital subtraction angiography of the right CCA demonstrated atherosclerotic stenosis measuring approximately 50% of the maximum diameter. There was also a pseudoaneurysm seen at the level of the stenosis. An exchange wire was placed through the sheath with its tip secured in a branch of the right ECA. A guiding catheter was then navigated over the exchange wire to select the right common carotid artery below the level of stenosis. An 8 ⫻ 20 mm Wallstent was deployed within the right common carotid artery, covering the area of stenosis, with the intent that the side wall pseudoaneurysm
Koenigsberg et al
would subsequently thrombose, due to epithelialization of the Wallstent. Throughout this procedure, the patient received a total of 9000 units of heparin intravenously with ACT monitoring to ensure adequate anticoagulation. Follow-up angiography at 1 month, however, revealed persistent luminal filling of the pseudoaneurysm, without evidence of thrombosis. Therefore, using a microcatheter 10 (Johnson and Johnson), embolization was performed through the interstices of the stent, with the deployment of three Guglielmi electrolytically detachable coils. Two 3 ⫻ 8 mm and one 4 ⫻ 10 mm electrolytically detachable coils (GDC-10, Boston Scientific) were positioned, occluding the majority of the pouch except for a small inferior portion of the lumen. Diagnostic angiography after coil placement demonstrated nearly complete obliteration of the pseudoaneurysm with only minimal residual filling seen within the more inferior aspect, which was expected to thrombose (Figures 2A, D). At 3 months, follow-up angiography confirmed obliteration of the pouch. At this time, we decided to proceed with stenting of the contralateral lesion. To decrease the risk of carotid rupture, treatment of the asymptomatic left side lesion was believed to be warranted. The patient was given 5,000 units of heparin. A 10F sheath was then positioned within the right common femoral artery. Using a 7F JB1 catheter in combination with a 10F guide catheter, successful catheterization of the left common carotid artery was achieved. Before stent deployment, an additional 2,000 units of heparin were administered. A 10 ⫻ 20 mm Wallstent was then deployed into the patient’s left common carotid artery. There was immediate improvement of the caliber of the artery and a favorable change with some diminished contrast filling of the side wall pseudoaneurysm (Figures 3A, B). Given our experience with the lack of thrombosis in the right carotid artery, we decided to perform a coil embolization of the left pseudoaneurysm at this time. Embolization on the left was performed through the stent, using a microcatheter 10 (Johnson and Johnson), and deploying two 3 ⫻ 8 mm electrolytically detachable coils (GDC-10 Boston Scientific) into the aneurysm sac (Figure 3C). The patient tolerated all procedures well. He was placed on antiplatelet therapy, consisting of Plavix 75 mg daily for 1 month (loading dose of 300 mg) after the initial stent procedures, and long-term aspirin therapy (325 mg daily). At 6 month follow-up, the patient denied any further TIA episodes and seemed to be asymptomatic.
Endovascular Repair Of Radiation-Induced Vasculopathy
Surg Neurol 349 2001;55:347–52
(A) Stenotic right common carotid artery with pseudoaneurysm before stenting. (B) Microcatheter angiogram showing entry through the Wallstent. Arrow demonstrates tip of the microcatheter. (C) Embolization of the pseudoaneurysm pouch using electrolytically detachable coils. (D) Right common carotid artery angiogram showing obliteration of the pseudoaneurysm.
2
350 Surg Neurol 2001;55:347–52
Koenigsberg et al
(A) Selective left common carotid artery angiogram showing carotid stenosis and pseudoaneurysm before treatment. (B) Left common carotid artery after stenting showing increase in the caliber of the artery but only partial closure of the sidewall pseudoaneurysm. (C) Left common carotid artery angiogram showing obliteration of the pseudoaneurysm.
3
Discussion Stenting, and secondary coiling when appropriate, is currently used to repair various types of carotid
artery disease, including carotid bifurcation atherosclerotic disease, internal carotid artery and extracranial vertebral artery aneurysms, and traumatic pseudoaneurysms [7–9,11,15]. Risk factors
Endovascular Repair Of Radiation-Induced Vasculopathy
Surg Neurol 351 2001;55:347–52
previously described in the literature such as hyperlipidemia, hypertension, age, gender, and smoking are known to predispose one to accelerated atherosclerotic disease. However, the consequences of radiation therapy on large vessels, and subsequent corrective measures, have not been as clearly defined. Feehs et al measured carotid artery wall thickness in previously irradiated head and neck cancer patients and compared the results to a group of epidemiologically similar but nonirradiated head and neck cancer patients [4]. It was found that there was a statistically significant narrowing of the vessel lumen in those patients receiving radiation therapy. Additionally, in a retrospective study performed by Carmody et al, it was concluded that high-dose radiotherapy to the head and neck region may be a significant risk factor for accelerated carotid atherosclerotic disease [2]. Irradiation studies done in the rat brain further support the role of radiotherapy in the structural and functional changes seen in the cervicocerebral vasculature. A study performed by Munter et al at the German Cancer Research Center demonstrated that all rats irradiated with 100 Gy developed radiation necrosis after 9 months. Rats having received 20 –50 Gy showed no morphological changes. Microangiography and immunohistochemical fluorescence staining of the endothelial cells revealed dosedependent vascular dilatation and rarefaction. The study concluded that the observed effect had a definite dependence on dose, volume, and time after treatment [12]. There is an increased risk of surgical complications in patients with a previous history of radiation; however, endovascular treatment can be a successful alternative treatment for radiationinduced vessel damage [3]. Loftus et al classified radiation-induced carotid vasculopathy into three categories: (1) acute carotid artery rupture, (2) acute vessel occlusion within several months as a probable direct arterial injury, and (3) late development of atheromatous and occlusive carotid disease [6,9]. The majority of patients, including ours, fall into this third category. We have seen the development of carotid artery pseudoaneurysms in previously irradiated head and neck cancer patients in our practice, but it has not been described in the literature. Additionally, supporting literature review revealed the incidence of radiation-induced vesical arterial aneurysms, in a study done by Pontin et al [14]. The acceleration of atherosclerosis as a result of radiation therapy for soft tissue neck malignancies is, therefore, clinically significant and merits cautious monitoring. Review of the literature
did not reveal previous cases in which the carotid arteries were both treated with bilateral stent placement and secondary coiling for repair of radiation-induced carotid stenosis and pseudoaneurysms. Although long-term results of this case have yet to be shown, we feel that the potential benefits of this endoluminal intervention outweigh the risks often encountered with more traditional methods of surgical repair or conservative treatment alone. It has been shown that patients with a history of radiation therapy for malignant neoplasms of the head and neck can be successfully evaluated with routine carotid Doppler ultrasound to monitor for possible development of carotid arterial changes [2]. If stenosis or pseudoaneurysm is suspected, angiography and the possible use of selfexpandable stents and coils for endovascular reconstruction may be considered. REFERENCES 1. Benson EP. Radiation injury to large arteries. Radiology 1973;106:195–7. 2. Carmody BJ, Arora S, Avena R, Curry KM, Simpkins J, Cosby K, Sidawy AN. Accelerated carotid artery disease after high-dose head and neck radiotherapy: is there a role for routine carotid duplex surveillance? J Vasc Surg 1999;30:1045–51. 3. Dubec JJ, Munk PL, Tsang V, Lee MJ, Janzen DL, Buckley J, Seal M, Taylor D. Carotid artery stenosis in patients who have undergone radiation therapy for head and neck malignancy. Br J Radiol 1998;71:872–5. 4. Feehs R, McGuirt WF, Bond MG, Strickland HL, Craven TE, Hiltbrand JB. Irradiation: a significant risk factor for carotid atherosclerosis. Arch Otolaryngol Head Neck Surg 1991;117:1135–7. 5. Glick B: Bilateral carotid occlusive disease. Arch Pathol 1972;93:352–5. 6. Horimoto M, Kodama N, Takamatsu H. Bilateral internal carotid artery disease secondary to cervical radiation. Angiology 1996;47:609 –13. 7. Horowitz MB, Miller G, Meyer Y, Carstens G, Purdy PD. Use of intravascular stents in the treatment of internal carotid and extracranial vertebral artery pseudoaneurysms. AJNR 1996;17:693– 6. 8. Klein GE, Szolar DH, Raith J, Fruhwirth h, Pascher O, Hausegger KA. Posttraumatic extracranial aneurysm of the internal carotid artery: combined endovascular treatment with coils and stents. AJNR 1997;18:1261– 4. 9. Loftus CM, Biller J, Hart MN. Management of radiation-induced accelerated carotid atherosclerosis. Arch Neurol 1987;44:711– 4. 10. Mencken GS, Wholey MH, Eles GR. Use of coronary artery stents in the treatment of internal carotid artery stenosis at the base of the skull. Cathet Cardiovasc Diagn 1998;45:434 – 8. 11. Mericle RA, Lanzino G, Wakhloo AK, Guterman LR, Hopkins LN. Stenting and secondary coiling of intracranial internal carotid artery aneurysm: technical case report. Neurosurgery 1998;43:1229 –32. 12. Munter MW, Karger CP, Reith W, Schneider HM, Peschke P, Debus J. Delayed vascular injury after
352 Surg Neurol 2001;55:347–52
Koenigsberg et al
single high-dose irradiation in the rat brain: histologic, immunohistochemical and angiographic studies. Radiology 1999;212:475– 82. 13. Nardelli E, Fiaschi A, Ferrari G: Delayed cerebrovascular consequences of radiation to the neck. Arch Neurol 1978;35:538 – 40. 14. Pontin AR, Barnes RD, Young CJ. Radiation induced vesical arterial aneurysm cured by selective embolization. Bju International 1999;84:743– 4. 15. Reiter BP, Marin ML, Teodorescu VJ, Mitty H. Endoluminal repair of an internal carotid artery pseudoaneurysm. JVIR 1998;9:245– 8. COMMENTARY
Koenigsberg et al describe a very interesting case of bilateral stenosis and pseudoaneurysms diagnosed 13 years after cervical radiation. They highlight the changes that may occur after radiation therapy, and emphasize the difficulty of surgical treatment. The experience with stenting in the cervical and intracranial circulation is growing. Studies have indicated that placement of the stent across the neck of an aneurysm may change the flow dynamics enough to induce occlusion by thrombosis of the aneurysm and obviate the need for coiling. Clearly, as seen in this case, such thrombosis does not always occur, and treatment with coils may be required. I think this article adds to our knowledge of the long-term risks associated with radiation therapy, and also presents us with more information on the progress of aneurysm treatment. John Thornton, FFR, RCSI Department of Radiology Beaumont Hospital Dublin, Ireland
This single case report presents a successful treatment of radiation-induced bilateral common carotid stenoses and associated pseudoaneurysms using a combination of stents and coils. Accelerated atherosclerosis from earlier radiation therapy presents a challenge to the surgeon, not only because of the diminished healing capacity of irradiated tissue, but also because of the more difficult surgical access to the proximally-located disease in the common carotid arteries. Although the use of stents has proliferated dramatically over the past few years— not always with clinical justification—radiationinduced atherosclerosis was one of the first diseases that lent itself to endovascular treatment (at first with angioplasty alone, and later in combination with stent placement). Regarding the associated pseudoaneurysms, I agree with the authors’ initial decision to treat with a stent alone, as some pseudoaneurysms might heal without any additional treatment. The coils were added only after follow-up revealed that the pseudoaneurysms were still present. At this time, there are no covered stents available that provide exclusion of flow outside the stent and lack of thrombogenicity. A covered stent that would not promote in situ thrombosis would be a valuable tool indeed. Christopher F. Dowd, M.D. Department of Radiology UCSF Medical Center San Francisco, California
he cost of health care for American baby boomers and their children could be much lower in later life than is now believed. However, Asia faces an epidemic of cancer, heart disease, and other chronic and fatal illnesses related to health habits.
T
—Marvin J. Centron & Owen Davies, “Trends Now Changing the World” “The Futurist,” Jan/Feb 2001
Koenigsberg RA, Grandinetti LM, Freeman LP, McCormick D, Tsai F. Endovascular repair of radiation-induced bilateral common carotid artery stenosis and pseudoaneurysms: a case report. Surg Neurol 2001;55:347–52.
KEY WORDS
Carotid, arteries, stents, electrolytically detachable coils, radiation vasculopathy.
BACKGROUND
Radiation-induced damage to small and medium-sized vessels has been observed in both animals and humans. Changes may appear in the immediate postradiation period or many years later. In this case, we report an unusual presentation of bilateral radiation-induced carotid artery stenoses associated with pseudoaneurysms, and a previously unreported application of a recently established treatment. CASE DESCRIPTION
A 72-year-old African-American male presented with recurrent right hemispheric transient ischemic attacks (TIA) and neck pain. Thirteen years previously, the patient had received radiation therapy for laryngeal carcinoma. Diagnostic carotid angiography demonstrated moderate radiation-induced bilateral carotid artery stenosis and associated common carotid pseudoaneurysms. The patient was treated with bilateral endovascular stents and electrolytically detachable coils in staged procedures. At his most recent follow-up, there is no evidence of re-stenosis and the patient remains asymptomatic.
adiation-induced damage to the intimal wall of large and medium-sized vessels causing accelerated atherosclerotic disease has been documented in both animals and humans [1– 6,9,13]. The pathological consequences of radiation have been shown to include depolymerization of the collagenous fibers and infiltration of fat into the intima, followed by adventitial fibrosis and obstructive changes [13]. Particularly in the neck region, treatment presents a surgical challenge. This is further complicated when stenosis occurs bilaterally, compromising the cerebral vascular flow and predisposing the patient to multiple ischemic attacks. We describe a case in which stenting and secondary coiling were employed to correct bilateral common carotid artery stenosis and pseudoaneurysms induced by radiation therapy previously administered for laryngeal carcinoma.
R
CONCLUSIONS
This case illustrates a novel and successful treatment for the endovascular repair of post-radiation bilateral carotid artery stenosis and pseudoaneurysms. In our practice, we have seen three such cases of radiation-induced vasculopathy. Therefore, patients with a previous history of radiation therapy for head and neck neoplasms merit cautious monitoring and judicious use of stents and secondary coils, when necessary. © 2001 by Elsevier Science Inc.
Address reprint requests to: Dr. Robert A. Koenigsberg, Department of Radiologic Sciences, MCP Hahnemann University, Broad and Vine Streets, Philadelphia, PA 19102. Received December 22, 1999; accepted May 9, 2001. © 2001 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
Case Report A 72-year-old African-American male with a history of hypertension, gout, and benign prostatic hypertrophy received radiation therapy for laryngeal carcinoma 13 years before admission. Although the patient did not receive his radiation therapy at our institution, his course of treatment was believed to have been between 6000 –7200 cGy. He presented to us complaining of right neck pain and right hemispheric TIA symptoms. Arch angiography demon0090-3019/01/$–see front matter PII S0090-3019(01)00476-1
348 Surg Neurol 2001;55:347–52
1
Arch angiogram demonstrating bilateral common carotid artery stenosis and pseudoaneurysms.
strated nearly symmetric, bilateral, long segment stenoses associated with moderate sized (5 ⫻ 3 mm on the right and 4 ⫻ 2 mm on the left) pseudoaneurysms (Figure 1). After obtaining informed consent, endovascular treatment was performed. An 8F sheath was placed in the right common femoral vein and a 10F sheath in the right common femoral artery. A 5F Berenstein catheter was manipulated over a guidewire to select for the right CCA. Digital subtraction angiography of the right CCA demonstrated atherosclerotic stenosis measuring approximately 50% of the maximum diameter. There was also a pseudoaneurysm seen at the level of the stenosis. An exchange wire was placed through the sheath with its tip secured in a branch of the right ECA. A guiding catheter was then navigated over the exchange wire to select the right common carotid artery below the level of stenosis. An 8 ⫻ 20 mm Wallstent was deployed within the right common carotid artery, covering the area of stenosis, with the intent that the side wall pseudoaneurysm
Koenigsberg et al
would subsequently thrombose, due to epithelialization of the Wallstent. Throughout this procedure, the patient received a total of 9000 units of heparin intravenously with ACT monitoring to ensure adequate anticoagulation. Follow-up angiography at 1 month, however, revealed persistent luminal filling of the pseudoaneurysm, without evidence of thrombosis. Therefore, using a microcatheter 10 (Johnson and Johnson), embolization was performed through the interstices of the stent, with the deployment of three Guglielmi electrolytically detachable coils. Two 3 ⫻ 8 mm and one 4 ⫻ 10 mm electrolytically detachable coils (GDC-10, Boston Scientific) were positioned, occluding the majority of the pouch except for a small inferior portion of the lumen. Diagnostic angiography after coil placement demonstrated nearly complete obliteration of the pseudoaneurysm with only minimal residual filling seen within the more inferior aspect, which was expected to thrombose (Figures 2A, D). At 3 months, follow-up angiography confirmed obliteration of the pouch. At this time, we decided to proceed with stenting of the contralateral lesion. To decrease the risk of carotid rupture, treatment of the asymptomatic left side lesion was believed to be warranted. The patient was given 5,000 units of heparin. A 10F sheath was then positioned within the right common femoral artery. Using a 7F JB1 catheter in combination with a 10F guide catheter, successful catheterization of the left common carotid artery was achieved. Before stent deployment, an additional 2,000 units of heparin were administered. A 10 ⫻ 20 mm Wallstent was then deployed into the patient’s left common carotid artery. There was immediate improvement of the caliber of the artery and a favorable change with some diminished contrast filling of the side wall pseudoaneurysm (Figures 3A, B). Given our experience with the lack of thrombosis in the right carotid artery, we decided to perform a coil embolization of the left pseudoaneurysm at this time. Embolization on the left was performed through the stent, using a microcatheter 10 (Johnson and Johnson), and deploying two 3 ⫻ 8 mm electrolytically detachable coils (GDC-10 Boston Scientific) into the aneurysm sac (Figure 3C). The patient tolerated all procedures well. He was placed on antiplatelet therapy, consisting of Plavix 75 mg daily for 1 month (loading dose of 300 mg) after the initial stent procedures, and long-term aspirin therapy (325 mg daily). At 6 month follow-up, the patient denied any further TIA episodes and seemed to be asymptomatic.
Endovascular Repair Of Radiation-Induced Vasculopathy
Surg Neurol 349 2001;55:347–52
(A) Stenotic right common carotid artery with pseudoaneurysm before stenting. (B) Microcatheter angiogram showing entry through the Wallstent. Arrow demonstrates tip of the microcatheter. (C) Embolization of the pseudoaneurysm pouch using electrolytically detachable coils. (D) Right common carotid artery angiogram showing obliteration of the pseudoaneurysm.
2
350 Surg Neurol 2001;55:347–52
Koenigsberg et al
(A) Selective left common carotid artery angiogram showing carotid stenosis and pseudoaneurysm before treatment. (B) Left common carotid artery after stenting showing increase in the caliber of the artery but only partial closure of the sidewall pseudoaneurysm. (C) Left common carotid artery angiogram showing obliteration of the pseudoaneurysm.
3
Discussion Stenting, and secondary coiling when appropriate, is currently used to repair various types of carotid
artery disease, including carotid bifurcation atherosclerotic disease, internal carotid artery and extracranial vertebral artery aneurysms, and traumatic pseudoaneurysms [7–9,11,15]. Risk factors
Endovascular Repair Of Radiation-Induced Vasculopathy
Surg Neurol 351 2001;55:347–52
previously described in the literature such as hyperlipidemia, hypertension, age, gender, and smoking are known to predispose one to accelerated atherosclerotic disease. However, the consequences of radiation therapy on large vessels, and subsequent corrective measures, have not been as clearly defined. Feehs et al measured carotid artery wall thickness in previously irradiated head and neck cancer patients and compared the results to a group of epidemiologically similar but nonirradiated head and neck cancer patients [4]. It was found that there was a statistically significant narrowing of the vessel lumen in those patients receiving radiation therapy. Additionally, in a retrospective study performed by Carmody et al, it was concluded that high-dose radiotherapy to the head and neck region may be a significant risk factor for accelerated carotid atherosclerotic disease [2]. Irradiation studies done in the rat brain further support the role of radiotherapy in the structural and functional changes seen in the cervicocerebral vasculature. A study performed by Munter et al at the German Cancer Research Center demonstrated that all rats irradiated with 100 Gy developed radiation necrosis after 9 months. Rats having received 20 –50 Gy showed no morphological changes. Microangiography and immunohistochemical fluorescence staining of the endothelial cells revealed dosedependent vascular dilatation and rarefaction. The study concluded that the observed effect had a definite dependence on dose, volume, and time after treatment [12]. There is an increased risk of surgical complications in patients with a previous history of radiation; however, endovascular treatment can be a successful alternative treatment for radiationinduced vessel damage [3]. Loftus et al classified radiation-induced carotid vasculopathy into three categories: (1) acute carotid artery rupture, (2) acute vessel occlusion within several months as a probable direct arterial injury, and (3) late development of atheromatous and occlusive carotid disease [6,9]. The majority of patients, including ours, fall into this third category. We have seen the development of carotid artery pseudoaneurysms in previously irradiated head and neck cancer patients in our practice, but it has not been described in the literature. Additionally, supporting literature review revealed the incidence of radiation-induced vesical arterial aneurysms, in a study done by Pontin et al [14]. The acceleration of atherosclerosis as a result of radiation therapy for soft tissue neck malignancies is, therefore, clinically significant and merits cautious monitoring. Review of the literature
did not reveal previous cases in which the carotid arteries were both treated with bilateral stent placement and secondary coiling for repair of radiation-induced carotid stenosis and pseudoaneurysms. Although long-term results of this case have yet to be shown, we feel that the potential benefits of this endoluminal intervention outweigh the risks often encountered with more traditional methods of surgical repair or conservative treatment alone. It has been shown that patients with a history of radiation therapy for malignant neoplasms of the head and neck can be successfully evaluated with routine carotid Doppler ultrasound to monitor for possible development of carotid arterial changes [2]. If stenosis or pseudoaneurysm is suspected, angiography and the possible use of selfexpandable stents and coils for endovascular reconstruction may be considered. REFERENCES 1. Benson EP. Radiation injury to large arteries. Radiology 1973;106:195–7. 2. Carmody BJ, Arora S, Avena R, Curry KM, Simpkins J, Cosby K, Sidawy AN. Accelerated carotid artery disease after high-dose head and neck radiotherapy: is there a role for routine carotid duplex surveillance? J Vasc Surg 1999;30:1045–51. 3. Dubec JJ, Munk PL, Tsang V, Lee MJ, Janzen DL, Buckley J, Seal M, Taylor D. Carotid artery stenosis in patients who have undergone radiation therapy for head and neck malignancy. Br J Radiol 1998;71:872–5. 4. Feehs R, McGuirt WF, Bond MG, Strickland HL, Craven TE, Hiltbrand JB. Irradiation: a significant risk factor for carotid atherosclerosis. Arch Otolaryngol Head Neck Surg 1991;117:1135–7. 5. Glick B: Bilateral carotid occlusive disease. Arch Pathol 1972;93:352–5. 6. Horimoto M, Kodama N, Takamatsu H. Bilateral internal carotid artery disease secondary to cervical radiation. Angiology 1996;47:609 –13. 7. Horowitz MB, Miller G, Meyer Y, Carstens G, Purdy PD. Use of intravascular stents in the treatment of internal carotid and extracranial vertebral artery pseudoaneurysms. AJNR 1996;17:693– 6. 8. Klein GE, Szolar DH, Raith J, Fruhwirth h, Pascher O, Hausegger KA. Posttraumatic extracranial aneurysm of the internal carotid artery: combined endovascular treatment with coils and stents. AJNR 1997;18:1261– 4. 9. Loftus CM, Biller J, Hart MN. Management of radiation-induced accelerated carotid atherosclerosis. Arch Neurol 1987;44:711– 4. 10. Mencken GS, Wholey MH, Eles GR. Use of coronary artery stents in the treatment of internal carotid artery stenosis at the base of the skull. Cathet Cardiovasc Diagn 1998;45:434 – 8. 11. Mericle RA, Lanzino G, Wakhloo AK, Guterman LR, Hopkins LN. Stenting and secondary coiling of intracranial internal carotid artery aneurysm: technical case report. Neurosurgery 1998;43:1229 –32. 12. Munter MW, Karger CP, Reith W, Schneider HM, Peschke P, Debus J. Delayed vascular injury after
352 Surg Neurol 2001;55:347–52
Koenigsberg et al
single high-dose irradiation in the rat brain: histologic, immunohistochemical and angiographic studies. Radiology 1999;212:475– 82. 13. Nardelli E, Fiaschi A, Ferrari G: Delayed cerebrovascular consequences of radiation to the neck. Arch Neurol 1978;35:538 – 40. 14. Pontin AR, Barnes RD, Young CJ. Radiation induced vesical arterial aneurysm cured by selective embolization. Bju International 1999;84:743– 4. 15. Reiter BP, Marin ML, Teodorescu VJ, Mitty H. Endoluminal repair of an internal carotid artery pseudoaneurysm. JVIR 1998;9:245– 8. COMMENTARY
Koenigsberg et al describe a very interesting case of bilateral stenosis and pseudoaneurysms diagnosed 13 years after cervical radiation. They highlight the changes that may occur after radiation therapy, and emphasize the difficulty of surgical treatment. The experience with stenting in the cervical and intracranial circulation is growing. Studies have indicated that placement of the stent across the neck of an aneurysm may change the flow dynamics enough to induce occlusion by thrombosis of the aneurysm and obviate the need for coiling. Clearly, as seen in this case, such thrombosis does not always occur, and treatment with coils may be required. I think this article adds to our knowledge of the long-term risks associated with radiation therapy, and also presents us with more information on the progress of aneurysm treatment. John Thornton, FFR, RCSI Department of Radiology Beaumont Hospital Dublin, Ireland
This single case report presents a successful treatment of radiation-induced bilateral common carotid stenoses and associated pseudoaneurysms using a combination of stents and coils. Accelerated atherosclerosis from earlier radiation therapy presents a challenge to the surgeon, not only because of the diminished healing capacity of irradiated tissue, but also because of the more difficult surgical access to the proximally-located disease in the common carotid arteries. Although the use of stents has proliferated dramatically over the past few years— not always with clinical justification—radiationinduced atherosclerosis was one of the first diseases that lent itself to endovascular treatment (at first with angioplasty alone, and later in combination with stent placement). Regarding the associated pseudoaneurysms, I agree with the authors’ initial decision to treat with a stent alone, as some pseudoaneurysms might heal without any additional treatment. The coils were added only after follow-up revealed that the pseudoaneurysms were still present. At this time, there are no covered stents available that provide exclusion of flow outside the stent and lack of thrombogenicity. A covered stent that would not promote in situ thrombosis would be a valuable tool indeed. Christopher F. Dowd, M.D. Department of Radiology UCSF Medical Center San Francisco, California
he cost of health care for American baby boomers and their children could be much lower in later life than is now believed. However, Asia faces an epidemic of cancer, heart disease, and other chronic and fatal illnesses related to health habits.
T
—Marvin J. Centron & Owen Davies, “Trends Now Changing the World” “The Futurist,” Jan/Feb 2001