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The control of carotid arterial haemorrhage in head and neck surgery by balloon catheter tamponade and detachable balloon embolisation
British Journal ofPlasric Surgery (1986) 39,72-75 7 1986 The Trustees of British Association of Plastic Surgeons
The control of carotid arterial haemorrhage in head and neck surgery by balloon catheter tamponade and detachable balloon embolisation CT.
K. KHOO, A. J. MOLYNEUX,
The Department of Plastic Surgery, Radcliffe Infirmary. Oxford
f?. RAYMENT
Wexham
Park Hospital,
and M. N. SAAD Slough,
and the Section
of Neuroradiology,
The
Summary-Radical surgery in the neck is hazardous after irradiation. Rupture of the carotid artery Reported mortality rates following this serious may lead to uncontrollable haemorrhage. complication are between 18% and 50% (Heller and Strong, 1979). We describe a simple method for controlling acute carotid haemorrhage using a standard Fogarty biliary catheter, with selective detachable balloon embolisation for permanent occlusion of the carotid artery.
Case report
the arterial wall defect with a further muscle patch. The catheter was then withdrawn and the arteriotomy closed. Recovery was uneventful and there was no bleeding. The upper oesophageal anastomosis broke down, and the new fistula was managed with suction drainage. A further reconstructive procedure was planned and on the eve of the planned operation 5 weeks later there was a second sudden arterial haemorrhage. The neck was explored again. There was a large segment of necrosis of the carotid artery with a defect extending over more than half the circumference of the vessel, over a length of 1 cm. Control was again established with a size 6FG Fogarty biliary catheter passed directly through the defect in the arterial wall. The balloon was inflated with saline after exclusion of air. The catheter was brought out through the side of the neck, and inflation of the balloon was maintained by using a one-way valve taken from the inflation tube of a disposable Portex tracheostomy tube. The catheter was sutured to the skin of the neck and the patient returned to the ward (Fig. 2). It was clear that it would not be possible to dissect out the friable, irradiated artery to achieve secure ligation, as any attempt to do so would risk further breakdown of the arterial wall. As the intra-luminal route had proved effective for temporary control of haemorrhage it was decided to attempt to achieve permanent occlusion of the artery using the technique of selective embolisation by detachable balloon. The next day the Fogarty catheter was deflated and withdrawn. and immediately replaced with a detachable balloon catheter (Fig. 3) which was positioned in the vessel under direct fluoroscopic control. The balloon was inflated with liquid silicone polymer, and the catheter was withdrawn, detaching the balloon when firm occlusion had been achieved as the polymer set within the balloon.
A 53-year-old male with poorly differentiated squamous carcinoma of the larynx was treated with full dose irradiation after an initial biopsy. Three months later he was noted to have residual disease and his ENT surgeon performed total laryngectomy. He was later referred for reconstructive surgery with a large area of tissue breakdown and an extensive fistula (Fig. I). It was elected to excise the area of necrosis and to reconstruct the defect with pectoralis major and deltopectoral flaps. At operation. the tissue above the tracheostoma was found to be indurated and fibrosed and the area of necrosis was very much more extensive than the external appearances suggested. During excision of an area of slough there was torrential arterial haemorrhage. This was controlled by digital pressure and with some difficulty a defect in the carotid artery was identified and closed with a muscle patch. The reconstruction of the oesophagus was achieved with a tubed left pectoralis major musculocutaneous flap. and a left deltopectoral flap was used for cover. As the patient awoke from anaesthesia he coughed and there was brisk arterial haemorrhage. External compression was applied and the patient was re-anaesthetised and the wound reopened. The common carotid artery was identified proximally and ligated. but due to reverse flow there was persistent severe distal bleeding from the defect in the arterial wall whenever local pressure was released. The artery was encased in a mass of fibrous tissue following previous irradiation, and it proved impossible to achieve external control of the artery. The bleeding was then controlled by inserting a size 6FG Fogarty biliary catheter, which was passed through a small arteriotomy proximal to the “blowout” so that the balloon lay sufficiently far distally to allow repair of 72
THE CONTROL
OF CAROTID
ARTERIAL
HAEMORRHAGE
A Figure
IN HEAD
AND
NECK
SURGERY
73
FGg. 1 l-(A)
Appearance
of laryngeal
fistula pre-operatively;
(B) Close-up photograph of the fistula.
The fistula at the upper end of the tubed musculocutaneous flap was eventually explored, and further irradiated tissue was excised from the pharynx. A right pectoralis major musculocutaneous flap was tubed and brought in to bridge the defect. Cover was provided by a right deltopectoral flap. The deltopectoral flap was raised uneventfully, but complete necrosis was evident 24 hours later. The flap was excised and split skin graft was applied to the pectoralis major muscle of the reconstructed oesophagus (Fig. 4). Despite these problems with healing the reconstructed oesophagus remained intact. The overlying soft tissue heal.ed and the patient was discharged, and was able to take a soft diet. The initial reconstructive procedure was carried out on Ma:y 15th, 1984 and the patient remains fit and well 11 months later and is able now to eat a normal diet.
Discussion This patient suffered several problems associated with radical surgery in an irradiated field: the origi-
nal breakdown following laryngectomy, the sloughing of his carotid artery, and the loss of a normally reliable axial pattern flap. Distal ligation of the carotid artery following the “blowout” was impossible because the vessel was totally encased in post-irradiation fibrous tissue, was friable, and fragmented on dissection. The size of the balloon, and the length of the Fogarty biliary catheter were ideal for this application. Standard arterial and venous embolectomy catheters are made long enough to clear emboli from limb vessels, and this length would have made them unwieldy for indwelling placement. However a recent report suggests that standard vascular Fogarty catheters are effective for temporary control of bleeding whilst penetrating injuries of the carotid artery are repaired (Clifford and Immelman, 1985). Although the balloon is intended for transient inflation, in the second use of this technique there were no problems when the balloon was kept in-
74
BRITISH
JOURNAL
OF PLASTIC
SURGERY
+ Fig. 2 Figure 2-Fogarty catheter brought out percutaneously. Valve from Portex tracheostomy tube cuff inserted, into syringe connection to retain fluid within catheter balloon.
Fig. 3
Fig. 4
Figure 3-(A) Becton-Dickinson detachable balloon catheter, deflated. (B) Detachable balloon catheter-inflated. (C) Hardened silicone polymer. This material is liquid when injected into the balloon, but hardens, as can be seen from the firm mass on the needle tip. Figure &Appearance of healed fistula.
THE
CONTROL
OF CAROTID
ARTERIAL
HAEMORRHAGE
flated with saline for 24 hours. Air was removed from the system, and the saline was effectively retained without leakage by engaging the standard Portex tracheostomy tube one-way valve in the Luer connector of the end of the Fogarty biliary catheter. The use of angiographic catheters with detachable balloons was first described by Serbinenko (1974) for occlusion of cerebral vessels, and later by Debrun for the selective embolisation of carotid cavernous fistulae (Debrun et al., 1975). They have also been used for controlling haemorrhage from an aberrant carotid artery during myringotomy (Reilly et al., 1983). but to our knowledge this is the first time that a detachable balloon has been used to achieve control of haemorrhage due to acute rupture of an irradiated carotid artery. If definitive therapeutic embolisation is not immediately available, the temporary use of a Fogarty catheter will control haemorrhage until embolisation can be carried out. If a radiologist with special expertise is not available, we suggest permanent occlusion of the artery with a large piece of muscle, introduced into the vessel under direct vision, and anchored within the lumen of the vessel with a transfixion suture to prevent possible complications from subsequent random embolisation.
IN HEAD
AND
NECK
SURGERY
75
References Clifford, P. C. and Immelman, E. J. (1985). Management of penetrating injuries of the carotid artery. Annals ofthe Rqval College of Surgeons of England, 61.45. Debrun, G., Lacow, P., Caron, J. P., Hunter, M., Comoy, J. and Kearet, Y. (1975). Inflatable and released balloon technique experimentation in the dog-application in man. ,Yeuroradiology, 9.261. Heller, K. S. and Strong, E. (1979). Carotid arterial haemorrhage after head and neck surgery. American Journal of Surgery. 138,607. Reilly, J. J., Caparosa, R. J., Latchaw, R. E. and Sheptak, P. E. (1983). Aberrant carotid artery injured at myringotomyControl of haemorrhage by a balloon catheter. Journal of fhe American Medical Association. 249. 1473. Serbinenko, F. A. (1974). Balloon catheterisation and occlusion of major cerebral vessels. Journal qf Nrurouurgery. 41, 125.
The Authors C. T. K. Khoo, FRCS, Consultant Plastic Surgeon. Department of Plastic Surgery, Wexham Park Hospital, Slough. A. J. Molyneux, FRCR, Consultant Neuroradiologist, The Section of Neuroradiology, Department of Radiology. The Radcliffe Infirmary. Oxford. Ruth Rayment, FRCS, Senior Registrar, Department of Plastic Surgery. Wexham Park Hospital, Slough. %I. N. Saad, FRCS, Consultant Plastic Surgeon. Wexham Park Hospital, Slough. Requests for reprints to: C. T. K. Khoo, FRCS, Department of Plastic Surgery. Wexham Park Hospital. Slough, Berkshire, England.
The control of carotid arterial haemorrhage in head and neck surgery by balloon catheter tamponade and detachable balloon embolisation CT.
K. KHOO, A. J. MOLYNEUX,
The Department of Plastic Surgery, Radcliffe Infirmary. Oxford
f?. RAYMENT
Wexham
Park Hospital,
and M. N. SAAD Slough,
and the Section
of Neuroradiology,
The
Summary-Radical surgery in the neck is hazardous after irradiation. Rupture of the carotid artery Reported mortality rates following this serious may lead to uncontrollable haemorrhage. complication are between 18% and 50% (Heller and Strong, 1979). We describe a simple method for controlling acute carotid haemorrhage using a standard Fogarty biliary catheter, with selective detachable balloon embolisation for permanent occlusion of the carotid artery.
Case report
the arterial wall defect with a further muscle patch. The catheter was then withdrawn and the arteriotomy closed. Recovery was uneventful and there was no bleeding. The upper oesophageal anastomosis broke down, and the new fistula was managed with suction drainage. A further reconstructive procedure was planned and on the eve of the planned operation 5 weeks later there was a second sudden arterial haemorrhage. The neck was explored again. There was a large segment of necrosis of the carotid artery with a defect extending over more than half the circumference of the vessel, over a length of 1 cm. Control was again established with a size 6FG Fogarty biliary catheter passed directly through the defect in the arterial wall. The balloon was inflated with saline after exclusion of air. The catheter was brought out through the side of the neck, and inflation of the balloon was maintained by using a one-way valve taken from the inflation tube of a disposable Portex tracheostomy tube. The catheter was sutured to the skin of the neck and the patient returned to the ward (Fig. 2). It was clear that it would not be possible to dissect out the friable, irradiated artery to achieve secure ligation, as any attempt to do so would risk further breakdown of the arterial wall. As the intra-luminal route had proved effective for temporary control of haemorrhage it was decided to attempt to achieve permanent occlusion of the artery using the technique of selective embolisation by detachable balloon. The next day the Fogarty catheter was deflated and withdrawn. and immediately replaced with a detachable balloon catheter (Fig. 3) which was positioned in the vessel under direct fluoroscopic control. The balloon was inflated with liquid silicone polymer, and the catheter was withdrawn, detaching the balloon when firm occlusion had been achieved as the polymer set within the balloon.
A 53-year-old male with poorly differentiated squamous carcinoma of the larynx was treated with full dose irradiation after an initial biopsy. Three months later he was noted to have residual disease and his ENT surgeon performed total laryngectomy. He was later referred for reconstructive surgery with a large area of tissue breakdown and an extensive fistula (Fig. I). It was elected to excise the area of necrosis and to reconstruct the defect with pectoralis major and deltopectoral flaps. At operation. the tissue above the tracheostoma was found to be indurated and fibrosed and the area of necrosis was very much more extensive than the external appearances suggested. During excision of an area of slough there was torrential arterial haemorrhage. This was controlled by digital pressure and with some difficulty a defect in the carotid artery was identified and closed with a muscle patch. The reconstruction of the oesophagus was achieved with a tubed left pectoralis major musculocutaneous flap. and a left deltopectoral flap was used for cover. As the patient awoke from anaesthesia he coughed and there was brisk arterial haemorrhage. External compression was applied and the patient was re-anaesthetised and the wound reopened. The common carotid artery was identified proximally and ligated. but due to reverse flow there was persistent severe distal bleeding from the defect in the arterial wall whenever local pressure was released. The artery was encased in a mass of fibrous tissue following previous irradiation, and it proved impossible to achieve external control of the artery. The bleeding was then controlled by inserting a size 6FG Fogarty biliary catheter, which was passed through a small arteriotomy proximal to the “blowout” so that the balloon lay sufficiently far distally to allow repair of 72
THE CONTROL
OF CAROTID
ARTERIAL
HAEMORRHAGE
A Figure
IN HEAD
AND
NECK
SURGERY
73
FGg. 1 l-(A)
Appearance
of laryngeal
fistula pre-operatively;
(B) Close-up photograph of the fistula.
The fistula at the upper end of the tubed musculocutaneous flap was eventually explored, and further irradiated tissue was excised from the pharynx. A right pectoralis major musculocutaneous flap was tubed and brought in to bridge the defect. Cover was provided by a right deltopectoral flap. The deltopectoral flap was raised uneventfully, but complete necrosis was evident 24 hours later. The flap was excised and split skin graft was applied to the pectoralis major muscle of the reconstructed oesophagus (Fig. 4). Despite these problems with healing the reconstructed oesophagus remained intact. The overlying soft tissue heal.ed and the patient was discharged, and was able to take a soft diet. The initial reconstructive procedure was carried out on Ma:y 15th, 1984 and the patient remains fit and well 11 months later and is able now to eat a normal diet.
Discussion This patient suffered several problems associated with radical surgery in an irradiated field: the origi-
nal breakdown following laryngectomy, the sloughing of his carotid artery, and the loss of a normally reliable axial pattern flap. Distal ligation of the carotid artery following the “blowout” was impossible because the vessel was totally encased in post-irradiation fibrous tissue, was friable, and fragmented on dissection. The size of the balloon, and the length of the Fogarty biliary catheter were ideal for this application. Standard arterial and venous embolectomy catheters are made long enough to clear emboli from limb vessels, and this length would have made them unwieldy for indwelling placement. However a recent report suggests that standard vascular Fogarty catheters are effective for temporary control of bleeding whilst penetrating injuries of the carotid artery are repaired (Clifford and Immelman, 1985). Although the balloon is intended for transient inflation, in the second use of this technique there were no problems when the balloon was kept in-
74
BRITISH
JOURNAL
OF PLASTIC
SURGERY
+ Fig. 2 Figure 2-Fogarty catheter brought out percutaneously. Valve from Portex tracheostomy tube cuff inserted, into syringe connection to retain fluid within catheter balloon.
Fig. 3
Fig. 4
Figure 3-(A) Becton-Dickinson detachable balloon catheter, deflated. (B) Detachable balloon catheter-inflated. (C) Hardened silicone polymer. This material is liquid when injected into the balloon, but hardens, as can be seen from the firm mass on the needle tip. Figure &Appearance of healed fistula.
THE
CONTROL
OF CAROTID
ARTERIAL
HAEMORRHAGE
flated with saline for 24 hours. Air was removed from the system, and the saline was effectively retained without leakage by engaging the standard Portex tracheostomy tube one-way valve in the Luer connector of the end of the Fogarty biliary catheter. The use of angiographic catheters with detachable balloons was first described by Serbinenko (1974) for occlusion of cerebral vessels, and later by Debrun for the selective embolisation of carotid cavernous fistulae (Debrun et al., 1975). They have also been used for controlling haemorrhage from an aberrant carotid artery during myringotomy (Reilly et al., 1983). but to our knowledge this is the first time that a detachable balloon has been used to achieve control of haemorrhage due to acute rupture of an irradiated carotid artery. If definitive therapeutic embolisation is not immediately available, the temporary use of a Fogarty catheter will control haemorrhage until embolisation can be carried out. If a radiologist with special expertise is not available, we suggest permanent occlusion of the artery with a large piece of muscle, introduced into the vessel under direct vision, and anchored within the lumen of the vessel with a transfixion suture to prevent possible complications from subsequent random embolisation.
IN HEAD
AND
NECK
SURGERY
75
References Clifford, P. C. and Immelman, E. J. (1985). Management of penetrating injuries of the carotid artery. Annals ofthe Rqval College of Surgeons of England, 61.45. Debrun, G., Lacow, P., Caron, J. P., Hunter, M., Comoy, J. and Kearet, Y. (1975). Inflatable and released balloon technique experimentation in the dog-application in man. ,Yeuroradiology, 9.261. Heller, K. S. and Strong, E. (1979). Carotid arterial haemorrhage after head and neck surgery. American Journal of Surgery. 138,607. Reilly, J. J., Caparosa, R. J., Latchaw, R. E. and Sheptak, P. E. (1983). Aberrant carotid artery injured at myringotomyControl of haemorrhage by a balloon catheter. Journal of fhe American Medical Association. 249. 1473. Serbinenko, F. A. (1974). Balloon catheterisation and occlusion of major cerebral vessels. Journal qf Nrurouurgery. 41, 125.
The Authors C. T. K. Khoo, FRCS, Consultant Plastic Surgeon. Department of Plastic Surgery, Wexham Park Hospital, Slough. A. J. Molyneux, FRCR, Consultant Neuroradiologist, The Section of Neuroradiology, Department of Radiology. The Radcliffe Infirmary. Oxford. Ruth Rayment, FRCS, Senior Registrar, Department of Plastic Surgery. Wexham Park Hospital, Slough. %I. N. Saad, FRCS, Consultant Plastic Surgeon. Wexham Park Hospital, Slough. Requests for reprints to: C. T. K. Khoo, FRCS, Department of Plastic Surgery. Wexham Park Hospital. Slough, Berkshire, England.