RAPID OCCLUSION OF THE INTERNAL CAROTID ARTERY WITH AMPLATZER VASCULAR PLUG

AFTER INJURY

Resident(s): Salim Abboud1, MD; Sasan Partovi1, MD1, and Sunil Manjila, MD2

Attending(s): Kristine Blackham MD1,2, Jeffrey L Sunshine MD PhD1,2

Program/Dept(s): Department of Radiology1, Department of Neurosurgery2

CHIEF COMPLAINT & HPI

Chief Complaint and/or reason for consultation Severe bleeding from left internal carotid artery (ICA) during oropharyngeal abscess debridement.

History of Present Illness The patient has history of oropharyngeal squamous cell carcinoma (SCC) treated with chemoradiation. Patient was transferred from an outside hospital for management of left-sided pharyngocutaneous fistula with associated neck oropharyngeal abscess.

Under general anesthesia, laryngoscope was introduced into the oropharynx. Forceps were used to debride a large amount of necrotic tissue when significant arterial bleeding was encountered. Further examination of that area revealed a tear in proximal left ICA.

Bleeding could be controlled with pressure with the laryngoscope, however attempts to pass a Fogarty catheter into arterial tear were unsuccessful.

Bleeding was temporarily controlled with intra-oral digital pressure.

RELEVANT HISTORY

Past Medical History Primary squamous cell carcinoma (SCC) of the tonsils Chemoradiation therapy for tonsillar SCC Recurrent oropharyngeal abscess following surgical debridement (image is immediately prior to most recent debridement)

Pharyngocutaneous fistula Past Surgical History: Left anterior neck debridement for oropharyngeal and sternocleidomastoid abscess

Medications: Piperacillin + tazobactam Allergies: None

Axial contrast enhanced CT performed immediately prior to most recent debridement of tonsillar SCC (circle).

ICA

DIAGNOSTIC WORKUP

Patient taken emergently to neurointerventional suite.

No active extravasation while holding digital pressure (Image A). Gauze metallic marker overlies site of injury.

With transient release of intra-oral digital pressure, no active contrast extravasation or pseudoaneurysm noted on DSA. There was focal narrowing at C-3-4 level (Image B).

Reflux of contrast was noted into the left vertebral artery (not shown).

Vascular measurements performed: left proximal ICA 5.5 mm and the distal ICA 5.3 mm.

A B

DIAGNOSIS

Iatrogenic injury to the proximal left internal carotid artery

INTERVENTION

4 mm x 6 mm Amplatzer II vascular plug (AVP, see arrow) initially deployed distal to the ICA injury (box). Diminished but persistent antegrade flow was noted (Image A).

6 mm x 6 mm AVP placed immediately proximal to the first AVP (arrows). Both AVPs are distal to the injury site (box). Antegrade flow is further reduced but persistent (Image B).

A B

INTERVENTION (CONT.)

A third AVP II (8 mm x 7 mm) was placed immediately proximal to the bleeding site (arrow) for proximal control of bleeding (Image A).

The AVP was intentionally over-sized relative to vessel lumen (5.6 mm) in order to prevent distal migration.

There is minimal, persistent antegrade flow (Image B).

A fourth AVP (6 mm x 6 mm ) was deployed in the distal left common carotid artery (not shown) with subsequent stasis of contrast.

A B

CLINICAL FOLLOW UP

DSA following left vertebral artery injection shows filling of left middle cerebral artery via patent left posterior communicating artery (Images A , B)

Coronal CT image demonstrates stacked configuration of the 4 AVP in the left CCA and ICA (Image C) .

A B C

QUESTION

1) Following embolization of the left ICA, perfusion of the left MCA was noted via a patent left posterior communicating artery following left vertebral artery injection. In what percentage of patients is there a complete Circle of Willis?

A: > 90%

B: 50-80%

C: 20-50%

D:

CORRECT!

1) Following embolization of the left ICA, perfusion of the left MCA was noted via a patent left posterior communicating artery following left vertebral artery injection. In what percentage of patients is there a complete Circle of Willis?

A: > 90%

B: 50-80%

C: 20-50% The reported incidence of a complete Circle of Willis is highly variable, but reports generally range from between 20 and 50%.

D:

SORRY, THATS INCORRECT!

1) Following embolization of the left ICA, perfusion of the left MCA was noted via a patent left posterior communicating artery following left vertebral artery injection. In what percentage of patients is there a complete Circle of Willis?

A: > 90%

B: 50-80%

C: 20-50% The reported incidence of a complete Circle of Willis is highly variable, but reports generally range from between 20 and 50%.

D:

SUMMARY & TEACHING POINTS

Complete occlusion of the common carotid artery (CCA), internal carotid artery (ICA) or external carotid artery (ECA) has several indications including fistula closure, reducing bleeding risk during surgery, and control of arterial bleeding.

Amplatzer Vascular Plugs (AVPs) were initially developed and currently approved for rapid occlusion of large peripheral vessels.

This case demonstrates that AVPs can be used effectively for CCA and ICA occlusion to control bleeding.

Oversizing of AVPs may minimize the risk of inadvertent distal migration. AVPs allow rapid, permanent vessel embolization, and use of relatively few AVPs may represent a more cost effective solution than use of multiple vascular coils.

REFERENCES & FURTHER READING

Gneyli S, inar C, Bozkaya H, Parldar M, Oran . Applications of the Amplatzer Vascular Plug to various vascular lesions. Diagn Interv Radiol. 2014 Mar-Apr;20(2):155-9.

Macht S, Mathys C, Schipper J, Turowski B. Initial experiences with the Amplatzer Vascular Plug 4 for permanent occlusion of the internal carotid artery in the skull base in patients with head and neck tumors. Neuroradiology. 2012 Jan;54(1):61-4.

Mihlon F, Agrawal A, Nimjee SM1, Ferrell A, Zomorodi AR, Smith TP, Britz GW. Enhanced, Rapid Occlusion of Carotid and Vertebral Arteries Using the AMPLATZER Vascular Plug II Device: The Duke Cerebrovascular Center Experience in 8 Patients with 22 AMPLATZER Vascular Plug II Devices. World Neurosurg. 2013 Aug 3. pii: S1878-8750(13)00898-X.

"AmplatzerTM Vascular Plug II; Instructions for Use." St. Jude Medical Product Manuals. 1 July 2014. Web. 31 Dec. 2014. http://professional.sjm.com/professional/resources/ifu/vas/peripheral-vascular-embolization.

K. Ranil D. De Silva, Rukmal Silva,1 W. S. L Gunasekera,2 and R. W. Jayesekera3 Prevalence of typical circle of Willis and the variation in the anterior communicating artery: A study of a Sri Lankan populationAnn Indian Acad Neurol. 2009 Jul-Sep; 12(3): 157161.