Successful devascularization of carotid body tumors by covered stent ...

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interrupting vascular supply via covered stent placement in the external carotid artery is ... raphy scan was performed initially on all 3 patients demonstrating.
CASE REPORTS From the Eastern Vascular Society

Successful devascularization of carotid body tumors by covered stent placement in the external carotid artery James M. Scanlon, MD,a Jacob J. Lustgarten, MD,b Stewart B. Karr, MD,c and Jules I. Cahan, MD,d Washington, DC; and Silver Spring, Md Management of highly vascular carotid body tumors can involve pre-operative percutaneous embolization before definitive surgical resection. This step reduces tumor size, reduces operative blood loss, and makes for a less hazardous dissection with the goal of reducing morbidity and mortality. The effectiveness of a recently described technique of interrupting vascular supply via covered stent placement in the external carotid artery is further described in a series of three recent cases. This technique may be useful for large tumors with a primary blood supply from the external carotid since it avoids the intracranial embolic risk of coils used for this purpose. ( J Vasc Surg 2008;48:1322-4.)

Tumors of the carotid body (CBT) are uncommon neoplasms that arise from the paraganglion cells within these organs.1 Surgical resection is usually indicated for symptoms due to growth and to exclude malignancy.1-2 Historically, surgical resection of these hypervascular tumors can incur significant blood loss and can carry significant risk of stroke and cranial nerve injury.3-5 Present-day management of these tumors, particularly larger ones, often includes pre-operative vascular exclusion through embolization of feeder vessels. Vascular exclusion has been shown to reduce blood loss, shrink tumor bulk, and make dissection and resection easier,1,4,6,7 but the embolization procedure itself can be quite tedious and hazardous in its own right.5 In 2003, Tripp et al8 reported on a new technique of achieving “devascularization” of a CBT with theoretically less risk than embolization. We report on our recent results using this same approach of covered stent placement in the external carotid artery in three patients. CASE REPORT All 3 patients (2 males ages 40 and 68, 1 female age 51) presented with a slowly enlarging neck mass. Duplex ultrasonogFrom the Department of Surgery, Division of Vascular Surgery, Georgetown University and Washington Hospital Center,a Department of Vascular Surgery, Kaiser Permanente (Mid-Atlantic),b Department of Radiology,c and Department of Surgical Education,d Holy Cross Hospital. Competition of interest: none. Presented at the Twenty-first Annual Meeting of the Eastern Vascular Society, Baltimore, Md, Sep 27-29, 2007. Reprint requests: James M. Scanlon, MD, Division of Vascular Surgery, Georgetown University/Washington Hospital Center, 3800 Reservoir Rd., NW, Washington, DC 20007 (e-mail: [email protected]). 0741-5214/$34.00 Copyright © 2008 by The Society for Vascular Surgery. doi:10.1016/j.jvs.2008.05.031

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raphy scan was performed initially on all 3 patients demonstrating a hypervascular mass located at and splaying the carotid bifurcation. Our patients had either computed tomographic angiography (CTA) or magnetic resonance angiography (MRA) as part of their work-up demonstrating a hypervascular mass ranging in size of 3.7 cm to 5.0 cm (37 to 59 cm3). Each patient had arch aortograms and cerebral arteriograms performed via femoral access under local anesthesia by one operator (S.K.). The images were carefully interpreted in order to identify the blood supply to the tumor. Each patient was noted to have more than one major vessel from the external carotid artery feeding the tumor, there were no branches to or from the vertebral or internal carotid arteries identified. As expected, the arteries most commonly involved were the superior thyroid, ascending pharyngeal, lingual, and occipital arteries. Guidewire access of the external carotid artery was then obtained and vessel measurements were made in order to plan stent placement to cover all feeding branches. Overlapping JOMED JOSTENT GraftMaster (JOMED, Helsingborg, Sweden) coronary stent grafts were then positioned via a balloon-tipped delivery system and dilated to exclude the targeted branches and match the target vessel diameter with up to 1 mm of overdilation. Two patients required two 26-mm long stent grafts and the third required an additional 16-mm stent graft. Angiography performed after stent insertion showed no dissections or extravasation of contrast (Figs 1 and 2). There were no complications from the procedure and each patient was admitted as an in-patient until their operation. Within 24-48 hours of the stent placement, each patient was taken to the operating room where they had complete resection of their tumor under general anesthesia by the same vascular surgeon (J.L.). Dissection was carried out as described by Gordon-Taylor in the peri-adventitial plane with low rates of blood loss.2,9 The estimated blood loss ranged from 200 cc to 600 cc and averaged 367 cc. The dissection of the tumor, even where it appeared quite

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Fig 1. Pre-stenting angiogram demonstrating a carotid body tumor in a 40-year-old man.

adherent to the artery, was noteworthy for the relative paucity of bleeding. Resection performed within 48 hours of stent placement appeared optimal in regards to achieving vascular exclusion while avoiding the onset of inflammation and neo-vascularization. Although the regional anatomy was distorted due to the mass effect of the tumors, all vagus and hypoglossal nerves were readily identified and preserved. The patient with the largest blood loss (600 cc) had a tumor that was encircling the external carotid artery and very adherent to the bifurcation. In this case, safe resection required resecting it en-bloc after ligating and dividing the external carotid artery above the stent and reconstructing the bifurcation with an interposition vein graft between the common and internal carotid arteries. Because of its invasiveness, this tumor was classified a Shamblin 3 (the others were Shamblin 1). The other two tumors were able to be resected leaving the carotid arteries intact. Analysis of all specimens confirmed the presence of paragangliomas of the carotid body without evidence of malignancy. There were no strokes as a result of the operation. All 3 patients had some mild cranial nerve dysfunction postoperatively. One patient experienced a transient weakness of the marginal branch of the mandibular nerve which resolved within a few weeks. The patient who had the interposition graft had a mild Horner’s syndrome with unilateral pupillary constriction that also resolved. The third had mild vocal cord dysfunction that resolved over a few months. Follow-up ranged from 23 to 36 months with no other morbidities or deaths.

DISCUSSION Surgical resection of CBTs has historically been associated with significant mortality and morbidity, mostly from extensive blood loss, cranial nerve injury, and stroke.3-6 The evolution of surgical management of CBTs regarding

Fig 2. Post-stenting angiogram demonstrating vascular exclusion of the carotid body tumor. At surgery the tumor was found to be enveloping the external carotid artery.

technique and pre- and intra-operative measures has sought to address these difficulties. Pre-operative tumor embolization has become a possible approach in an effort to minimize blood loss and thereby, in theory, make the dissection less hazardous and reduce the incidence of cranial nerve injury and stroke.1,4,7 First described in the early 1980s, this procedure has been well described and accepted with low complication rates.10,11 Several studies have, in fact, attributed to the significant reduction in blood loss and simplification of dissection as leading to lower rates of stroke and even mortality.4-6,12-16 These studies have shown a dramatic reduction in blood loss with amounts of roughly one-third of that seen without embolization. However, in most of these series, as in this one, the incidence of cranial nerve injury is still significant. In both resection with and without embolization, as in this series, the vast majority of cranial nerve injuries are temporary and resolve spontaneously. Several authors have suggested that this complication seems more a function of tumor invasiveness and not the reduction in blood loss.4,7 The act of embolization itself can incur risk of stroke which underscores the potential dangers involved in tumor embolization and the need for skilled expertise to perform these often long and tedious interventions.3,5-7,15,17 External carotid artery stenting, first described in 2003, has thus far only been described in a single case report. However, the results of the original case and the current series are encouraging in terms of success of the procedure in reducing operative blood loss and yielding minimal

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complications. This approach has several advantages over embolization. Covering the branches of the external carotid artery from the origin to the level of the highest feeder artery also excludes any smaller, angiographically unseen vessels. In addition, there are usually several vessels feeding the tumor, each one requiring the painstaking and meticulous proper positioning and careful delivery of embolization agent. This can be very time consuming and each step introduces the risk of unwanted distal embolization. As pointed out by Tripp et al,7 the deployment of a covered stent may be less challenging and time consuming for many interventionalists in comparison to embolization that can have success rates as low as 81%. It is hypothesized that there would be a lower stroke risk with stenting as compared with embolization as there are no particulate embolic agents introduced that could cause nontarget organ embolization or traverse across “dangerous anastomosis” into the cerebral circulation. This stroke risk, albeit small, is hard to define based solely on case reports.5,17 Whether this technique will improve upon the total management of CBT will require more experience, but its role in dealing with large and/or invasive tumors appears beneficial. We feel our experience with this technique is further testament of an apparently safe and effective alternative strategy for treating these difficult tumors. AUTHOR CONTRIBUTIONS Conception and design: SK, JC Analysis and interpretation: JS, JL Data collection: JS, JL, JC Writing the article: JS Critical revision of the article: JS, SK, JC Final approval of the article: JL, SK, JC Statistical analysis: Not applicable Obtained funding: Not applicable Overall responsibility: JS

REFERENCES 1. Wang SJ, Wang MB, Barauskas TM, Calcaterra TC. Surgical management of carotid body tumors. Otolaryngol Head Neck Surg 2000;123:202-6. 2. Krupski WC. Uncommon disorders affecting the carotid arteries. In: Rutherford RB, Cronenwett JL, Glovicki P, Johnston KW. Vascular Surgery. Philadelphia, Elsevier Saunders, 2005:2066-73. 3. Muhm M, Polterauer P, Gstottner W, Temmel A, Richling B, Undt G, et al. Diagnostic and therapeutic approaches to carotid body tumors: review of 24 patients. Arch Surg 1997;132:279-84. 4. LaMuraglia GM, Fabian RL, Brewster DC, Pile-Spellman J, Darling RC, Cambria RP, et al. The current surgical management of carotid body paragangliomas. J Vasc Surg 1992;15:1038-45. 5. Smith TP. Embolization in the external carotid artery. J Vasc Interv Radiol 2006;17:1897-913. 6. Williams MD, Phillips MJ, Nelson WR, Rainer WG. Carotid body tumor. Arch Surg 1992;127:963-8. 7. Dardik A, Eisele DW, Williams M, Perler BA. A contemporary assessment of carotid body tumor surgery. Vasc Endovasc Surg 2002;36:277-83. 8. Tripp HF, Fail PS, Beyer, MG, Chaisson GA. New approach to preoperative vascular exclusion for carotid body tumor. J Vasc Surg 2003;38: 389-91. 9. Gordon-Taylor G. On carotid body tumours. Br J Surg 1940;28:163-72. 10. Schick PM, Hieshima AB, White RA. Arterial catheter embolization followed by surgery for large chemodactoma. Surgery 1980;87:459-64. 11. Borges LF, Heros RC, DeBrun G. Carotid body tumors managed with preoperative embolization-report of two cases. J Neurosurg 1983;59: 867-70. 12. Robison JG, Shagets FW, Beckett WC, Spies JB. A multidisciplinary approach to reducing morbidity and operative blood loss during resection of carotid body tumor. Surg Gynecol Obstet 1989;168:166-70. 13. Hallett JW Jr, Nora JD, Hollier LH, Cherry KJ, Pairolero PC. Trends in neurovascular complications of surgical management for carotid body and cervical paragangliomas: a fifty-year experience with 153 tumors. J Vasc Surg 1988;7:284-91. 14. Smith RF, Shetty PC, Reddy DJ. Surgical treatment of carotid paragangliomas presenting unusual technical difficulties: the value of preoperative embolization. J Vasc Surg 1988;7:631. 15. Kafie FE, Freischlag JA. Carotid body tumors: the role of preoperative embolization. Ann Vasc Surg 2001;15:237-42. 16. Sajid MS, Hamilton G, Baker DM. A multicenter review of carotid body tumour management. Eur J Vasc Endovasc Surg 2007;34:127-30. 17. Pandya SK, Nagpal RD, Desai AP, Purohit AT. Death following external carotid arterial embolization for a functioning glomus jugular chemodectoma. J Neurosurg 1978;48:1030. Submitted Jan 4, 2008; accepted May 12, 2008.