Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature.

The Carotid Artery
John S. Oghalai, M.D.
April 6, 2000

Anatomy: There is the external carotid artery and the internal carotid artery. The external has multiple branches. When operating on the carotid artery, the main issue is the internal carotid artery, because it supplies the brain. The first branch of the internal carotid artery is the ophthalmic artery, followed by the anterior cerebral artery, the middle cerebral artery and then the posterior communicating artery, which will connect up with the basilar artery. Of course anytime you operate on this artery you worry about a stroke.

When head and neck squamous cell carcinoma of the oral cavity, oral pharynx and larynx, hypopharynx and so on metastasizes to the neck, it tends to spread to the nodes along the jugular vein, and along the carotid sheath. These nodes are right along with the carotid artery and that is why we are concerned with the carotid artery during this type of operation. Carotid artery involvement is very rare in a patient who first presents with a cancer that has spread to the neck, mainly because there is a thick barrier of this arterial wall. The adventitia and a tunica media of the artery act as a barrier to invasion.

Where we start worrying is when the patient has been irradiated, has had disease that has spread to the neck and now disease has recurred. Radiation appears to affect the way a tumor grows; it affects the lymphatic pathways. The tumor can then start growing into the wall of an artery. While carotid resection can be beneficial in patients with benign skull base tumors where you think you can resect the whole thing or perform a subtotal resection and then control the disease, it is often unrewarding for patients with squamous cell carcinoma that has spread to the neck. This is because of two reasons. First of all, if squamous cell carcinoma in the neck has been treated and has recurred in the neck, systemic disease will appear next. You are going to have distant metastasis. Even if you can resect what is in the neck, it may show up elsewhere in the body very soon and the patient will have very poor outcome. Secondly, it is hard to do a complete resection of the neck. There is a lot of extra capsular spread after you have irradiated the tissue, and it can go into the prevertebral fascia and prevertebral musculature, and into the carotid artery. All of these things make it very hard to resect a recurrent tumor.

With a patient who has recurrent disease, there are several different options. The first would be to do no treatment. A lot of people would just simply chose that option. Chemotherapy could be tried. Additional external or interstitial irradiation could be tried, although there is a dose limit to how much irradiation can be given. There are also surgical options. Whenever the tumor can be easily separated from the carotid artery, it is possible to attempt to save the carotid artery. Another option is a carotid peel where the tumor is really invading the carotid artery. The tumor is simply peeled off the artery, presumably leaving some tumor cells behind. In a 1986 study by Urken, 40% of carotid peels will have tumor left behind in the wall of the carotid artery and have a very high risk of rupture. The carotid artery can be resected, ligating both the proximal and distal stumps of the artery. The other option would be to attempt to resect the carotid and reconstruct the blood flow, either by some type of a saphenous vein graft or other type of graft or a bypass operation. The single most important prognostic factor in patients with squamous cell carcinoma of the head and neck is to achieve complete tumor removal at the time of the surgery. If microscopic tumor is left behind in the neck, 67% of these patients will have a local regional recurrence. That is even with radiation.

In recurrent squamous cell carcinoma of the neck, complete tumor removal is the only therapy that offers a complete chance of cure. Patients with carotid artery involvement are often referred to major head and neck centers or major academic institutions.

Relative indications for resection of the carotid: If the tumor is actually invading the carotid artery or the patient has had a carotid rupture, you have to decide what you are going for. Are you trying for a cure or are you just trying to palliate this patient? One might consider a palliative effort if it looks as if the patient might have a carotid blowout. Well maybe you should go ahead and resect it and maybe that would offer them some type of palliation if they don?t want to die that way. On the other hand, some people would say that maybe that is not a bad way to die.

Carotid blowout: Radiation decreases blood flow to the vasa vasorum of the carotid artery. When there is less blood flow, it is much easier for the artery to rupture. After 3000 rads, there is a 50% reduction in the blood flow that supplies the wall of the artery. At 9000 rads, there is 70% reduction. Radiation certainly affects the carotid artery: it makes it more vulnerable.

Surgical salvage: It is actually quite rare for recurrent squamous cell carcinoma in the neck to invade the artery and cause a blowout. In fact, this is really an end stage process. A blowout usually would occur if a neck dissection was done in combination with some type of an oral cavity or pharyngeal resection, and then there is a postoperative salivary fistula. It is the proteolytic enzymes within the saliva that flow over the carotid and can lead to a carotid blowout.

The main complication of operating on the carotid artery stroke. Several studies have shown roughly a 30% risk of permanent hemiplegia, coma or death in cases where a simple carotid ligation is performed. There is a very poor outcome in about one-third of patients. The other two-thirds will not have any real symptoms or very minor symptoms. Why is this? The average cerebral blood flow in the head requires 50 milliliters of blood per 100 grams of brain tissue per minute. In the gray matter, where the cell soma are, more blood flow is required. The white matter, where the axons are, requires less blood flow. But the average is 50. If the blood flow is decreased to 20 milliliters per 100 grams per minute, the patient would lose consciousness. But if it is replenished back up to 50, the patient regains consciousness and there is no real long-term impact. When the blood flow is reduced to 8 milliliters per 100 grams per minute, there is irreversible brain damage. There is the principal of autoregulation: no matter what the arterial pressure is in the body, within this range, the cerebral blood flow will remain constant at about 50.

If the carotid is to be operated on, a preoperative assessment must be made regarding the cerebral blood flow after one carotid artery is taken. Is it going to be in this range? Several test options exist. Carotid angiography simply looks at the anatomy of the vasculature and makes sure that there is a patent circle of Willis. One of the earliest tests involved simply pushing on the neck, occluding the carotid for ten minutes, and see if the patient has any neurologic symptoms. Obviously, this is not very sensitive. Another method was to do a preliminary operation before the major operation. Dissect down on the carotid artery and put on a clamp. Wake the patient up, keep them in their hospital room and every day click the clamp down one or two clicks. Over time you will gradually occlude the carotid, and if they have symptoms then you have to open the clamps back up.

Now days we have angiography. You can do an awake temporary balloon occlusion. Put a balloon up the internal carotid at the skull base, blow up the balloon and see if the patient has any neurologic symptoms over a 5 - 10 minute period. You can also have a pressure sensor after the balloon, distal to the balloon, and measure the stump pressure. If you have a high stump pressure, then there is quite good collateral circulation from the other carotid and from the basilar artery through the circle of Willis back over to the stump. If you have a high stump pressure (70 milliliters of mercury), there is a low risk of stroke, if the carotid is ligated. If the stump pressure declines, there is a higher risk of neurologic complications.

You can do ocular plasmography. Measure the pressure of the eye as the balloon occludes the carotid. Supposedly, the pressure is proportional to the collateral flow: if eye pressure goes down then a poor collateral flow is indicated.

A recent development has been direct imaging of cerebral blood flow. One method is Single Photon Emission Computed tomography, the SPECT scan. The SPECT involves technesium, which is radioactive. Inject the technesium, put in a balloon and occlude one carotid. As well as checking to see if the patient has neurologic symptoms, you can also actually image the blood flow. Another way is using xenon commuted tomography. Xenon is a gas that can be breathed, but also allows imaging of blood flow.

Other issues: All of these preoperative tests can be unreliable in predicting cerebral collateral blood flow. There is no guarantee that just because a patient has passed a SPECT scan that they will do okay. People suspect that once the carotid artery is ligated, you have got the distal stump and the blood in that stump is going to clot off. It will clot off up until the first branch, which is the ophthalmic artery. At that juncture, where blood flow is flowing to the eye, there may be little emboli flicked off. Indeed, the patient may have a retinal ischemia from these emboli. It has been suggested that patients be given postoperative heparin in an effort to prevent this. But of course you are also operating on major vascular supplies and you don?t want them to have a postoperative bleed, so it is kind of a plus/minus issue.

Okay, now we are going to review a couple of studies on the subject. In a 1997 study from Japan, where carotid resection and reconstruction had been done, 9 patients were described. All had been previously treated with radiation therapy for squamous cell carcinoma to the neck. After carotid resection, reconstruction was performed by first putting a temporary shunt tube from the proximal to the distal stump and then putting a saphenous vein graft in place. The different types of bypass included: common carotid, internal carotid, the middle cerebral or contralateral or ipsilateral. Out of the 9 patients, 2 patients had a postoperative hemiplegia, and 1 had monoplegia. All 3 of these patients resolved within 24 hours. They state the patients had no permanent severe neurologic complications. One pharyngocutaneous fistula required a flap closure and there was one death from a heart failure. It is interesting to note that when they looked at the carotid artery to see how the tumor was invading the artery, only 8 out of the 9 showed tumor involved in the adventitia. None showed tumor going into the tunica media. It might have been possible to use carotid peel on these kinds of patient. But, looking at the outcome for the 9 patients: 2 were alive and disease-free 2 years after surgery. One was alive and disease-free one year after surgery. Three had distant metastases and two had regional recurrence. So, unfortunately, there is always a population that is going to do badly.

The University of Iowa did another study in 1992. They looked at 20 patients with head and neck cancer who had resection of their carotid. Sixteen had an elective resection and four had emergent ligation after a blowout. None of these patients had any type of reconstruction. In terms of complications, there were five strokes, the timing of which was variable. The first happened during the first 24 hours after surgery. Three strokes occurred within the first two weeks after surgery and then one occurred one-half of a month after surgery. There were six out of the 20 that had perioperative death, three from the stroke, one from ARDS, and one each from sepsis and meningitis. There were three pharyngocutaneous fistulas and two cases of blindness from this embolization of the ophthalmic artery. There was one seizure and one SIADH, and this is why the overall risk of stroke or death with resection of the carotid was 30%. As to the outcomes for these patients: the mean life expectancy was 9.6 months, and in fact all of the 20 died. Fourteen out of the 20 survived the perioperative period. Thirteen out of these 14 died of tumor recurrence. One of the 14 died of an MI..

A University of Colorado study looked at seven patients who had elective carotid resection and ligation with no reconstruction. Four of them had vascular clamp occlusion and three had temporary balloon occlusion tests. Out of these seven, there were two strokes (one of them resolved, the other did not). There were two perioperative deaths, one from the stroke and one from a GI bleed. The five that survived the perioperative period all died within 12 months. All of them had local regional failure and two of these also had distant metastasis.

The last study is a meta analysis that was done at the University of Pittsburgh. Of 158 patients taken from 22 articles in the literature, 35% of them had permanent ligation of the carotid, and 65% had a carotid resection with a reconstruction. The reconstruction was 82% autologous vein, 7% alloplastic materia, and internal carotid artery anastomosis in 11%. The overall rate of neurologic complications was 26%. Major strokes were 16.7%. Mild transient deficits or mild paresis was 10.7%. They found that there was actually no difference in the stroke risk between the patients that had a ligation versus those that had reconstruction of the carotid. As for the 2-year outcomes on these patients, the overall tumor recurrence rate was 74%. Local recurrence rate was 32%. The regional recurrence was 47% and distant recurrence was 21%. They also did a Mantel-Cox life table analysis. The study compared these patients that had surgery to try and remove their tumor along with the carotid artery to a control group. Actually, they used two different control groups. The first control group had 180 patients who that had N1, N2 and N3 necks that did not undergo carotid resection. They show that there is a significant decrease in the percent surviving carotid resection compared to the control group: if you operated on these patients, they did worse. If you look at only the patients with the N3 necks who also had extracapsular spread (the type of patient that you would be more likely to do a carotid resection on), they found that there is no decrease in percent of survival in the surgical patients versus the non-surgical patients. If you operate or if you don?t operate, the patients do about the same. Overall, 2-year disease-free survival rate was 22%. The incidence of major neurologic injury was 17%. The deficiencies in this type of a meta-analysis include the fact that it is a retrospective study and there is, of course, going to be a selection bias in which patients you actually did chose to operate on, compared to those you did not operate on. Also, current preoperative testing has improved since this study was done. Perhaps the new scans could help predict which patients would have problems.

Resection without reconstruction: Here is a list of studies, number of cases in study and here is the combined risk of stroke death. This is if you just simply ligate the carotid. Anywhere from 65, 45, 20, 79 - quite variable. Here is if you resect the carotid and then reconstruct it. Several different studies and the overall mortality and neuro morbidity here. You can see it seems to be a little bit lower on these studies. So if you reconstruct you might think you have lower or a better outcome. Do you just ligate the carotid or do you reconstruct? If your preoperative testing shows that the patient may have a good tolerance for carotid resection and carotid ligation, then you should just do this. If the tumor recurs in the neck, and you have reconstructed it with a vein graft, the vein graft is very weak and there is a good chance for a carotid blowout in that case. Also, if the patient gets a salivary fistula, there is a much higher risk of a blowout. Most people would say that a revascularization procedure should be performed only if you really need to resect the carotid and the patient fails at preoperative tests.

In conclusion, carotid artery resection is feasible. It has a reasonable perioperative complication rate, considering the patient condition and the severity of this type of surgery. It certainly does not increase the patients? survival and indeed the complications of this type of surgery really shorten their lives.

Case Presentation

R.G. is a 65-year-old male diagnosed with a T3N2cM0 squamous cell carcinoma of the right tonsil in December of 1998. He was treated with primary radiation therapy that was completed in February 1999. This included 6000 cGy to the primary tumor bed, 5000 cGy to the supraclavicular regions, and a 1750 cGy neck boost. He subsequently developed an aspiration pneumonia in March of 1999 and required a tracheotomy and a PEG tube. A right radical neck dissection for FNA positive residual disease was done in April 1999, by an outside physician.

He was seen at Baylor in July 1999 for a complaint of right otalgia, and was found to have a middle ear effusion. He also had a punctate area of wound breakdown on his neck. He was admitted to the hospital, underwent multiple wide local debridements in the operating room, and had aggressive wound care with dressing changes. All biopsies negative for malignancy. He had a carotid blowout, that was managed by carotid resection and flap coverage.

He was discharged home in November 1999.

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