19 Endovascular Management for Head and Neck Tumors
Paula Klurfan and Seon Kyu Lee
P. Klurfan, MD
Interventional Neuroradiology Clinical Fellow, Department of Medical Imaging, University of Toronto, Toronto Western Hos- pital, 399 Bathurst Street, Toronto, Ontario, Canada, M5T 2S8 S. K. Lee, MD, PhD
Assistant Professor and Staff Neuroradiologist, Department of Medical Imaging, University of Toronto, Toronto Western Hos- pital, 399 Bathurst Street, Toronto, Ontario, Canada, M5T 2S8
Head and neck tumors consist of primary tumors arising from various regional tissues including lymph nodes and metastatic lesions. Most of these lesions are highly vascularized due to both abun- dant vascularities of the head and neck region and their histological types.
Magnetic resonance imaging (MRI) is the most useful imaging study for the initial evaluation of head and neck tumors. Computed tomography (CT) is also helpful in defining the anatomical disposi- tion of these lesions. In addition, the CT can pro-
CONTENTS
19.1 Nasopharyngeal Tumors 247 19.2 Juvenile Angiofibroma 248 19.2.1 Classification 248 19.2.2 Anatomic Features 248 19.2.3 Imaging Features 248 19.2.4 Natural History 249 19.2.5 Diagnosis 250 19.2.6 Treatment 250
19.2.7 Embolization Technique 250 19.3 Paragangliomas 251 19.3.1 Classification 251 19.3.2 Pathology 251 19.3.3 Imaging 252 19.3.4 Treatment 252
19.4 Thyrolaryngeal Tumors 254 19.5 Craniofacial Tumors 254
19.6 Miscellaneous Applications of Embolization Therapy in the Head and Neck 254 19.6.1 Preoperative Embolization 254 19.6.2 Pain Management 255 19.6.3 Hemorrhagic Emergencies 255
Cookbook 255
References 256
vide important complementary information such as the presence of calcifications and the extent of bony involvement. Diagnostic angiography is hardly used as a diagnostic purpose. In fact, its main role is a carrier for the endovascular procedures for head and neck tumor managements. Endovascular proce- dures for head and neck tumors consist of (1) selec- tive devascularization procedures of the feeding arteries such as transcatheter arterial embolization and (2) adjunctive embolotherapy including intra- arterial chemoembolization. Functional vascular embolization such as intra-arterial chemotherapy for malignant head and neck cancers to maximize local concentration with minimized toxic effect has also been studied, however, further investigations are necessary for its clinical application.
19.1
Nasopharyngeal Tumors
Juvenile angiofibroma (JAF) represents 0.5% of the head and neck tumors [1] and 15% of nonepithelial tumors of the nasal and paranasal cavities [2]. It is the most common benign tumor of the nasopharynx and is typically diagnosed on adolescent males, with a peak age of 14–17 years. However, up to 20% of these tumors are diagnosed after the age of 20 [3].
The most frequent clinical presentations of juvenile angiofibroma are nasal obstruction and recurrent nose bleeding. These symptoms can be followed by sinusitis, otitis, hearing loss, or anosmia. Life- threatening massive nose bleeding can occur and is often difficult to control with nasal packing. In these cases, it requires urgent endovascular treat- ment after blood transfusion and establishment of diagnosis. The growth of JAF seems to be influenced by hormonal activity, although tumor samples fail to show the presence of estrogen, progesterone, or androgen receptors.
Tumors developing in the nasopharyngeal region
in the adult population are most likely to be malig-
nant. Intra-arterial embolization may play a signifi- cant role when performed prior to diagnostic biopsy, radical excision or palliative treatment.
The angiographic and therapeutic protocols described for JAFs are applicable to other hyper- vascular tumors of this region. Percutaneous embo- lization has also been described to be effective in the treatment of severe or recurrent epistaxis from nasopharyngeal carcinomas previously irradiated.
Benign tumors including paragangliomas, neu- roblastomas, esthesioneuroblastomas, hemangio- pericytomas, and hemangioendotheliomas (most of them are considered malignant) may be diagnosed in the nasopharyngeal region. These tumors are all generally highly vascularized and have a relatively benign course. The treatment strategy for these lesions is a radical surgery whenever possible and therefore they will also be benefited from presurgi- cal embolization.
Extracranial meningiomas are very rare (1%). In some cases they may be located in the parapharyn- geal space even though most of the tumors within this location are benign salivary grand tumors or neurogenic tumors like schwannomas.
19.2
Juvenile Angiofibroma
19.2.1 Classification
Several grading systems of JAF have been presented but the Fisch classification [] is the most extensively used one. Fisch classifies JAF into four types. Fisch type 1 is when the tumor is limited to the nasophar- ynx and nasal cavity without bony erosion. Fisch type 2 defines a JAF that invades the pterygomaxil- lary fossa and the maxillary, ethmoid and parasellar region but remains lateral to the cavernous sinus.
Type 3 is defined as JAF tumors that invade the infratemporal fossa, orbit and parasellar region but remain lateral to the cavernous sinus. Finally, the type 4 tumors are those that show massive invasion of the cavernous sinus, the optic chiasmal region, or the pituitary fossa.
19.2.2
Anatomic Features
JAF is a highly vascular and locally invasive tumor.
It is usually originated from the superolateral aspect of the choana, near the spheno-palatine foramen, but may also arise more medially, near the vomer, from the pharyngeal roof where it involves the body of the sphenoid bone, or from the adjacent pterygoid plates.
Regardless the uncertain histological origin, this tumor has a significant vascularity and prolifera- tive activity. It may cause significant bone erosion, even though the JAF does not invade the bone tis- sues directly. Attached to the neighboring osseous structures, it extends through the submucosal space into the adjacent open spaces. Macroscopically, JAF is reddish-gray or red purple in color and has a firm rubbery consistency with a lobulated shape. Multi- focal tumors have never been reported.
19.2.3
Imaging Features
Imaging (CT, MRI) studies usually show the pres- ence of an expansible lobulated lesion located at the nasopharynx. Due to the local extension of the JAF, it can show significant bony erosion expanding into the surrounding nasopharyngeal cavities, maxillary sinus, and sphenoid sinus and infrequently to the anterior skull base and the orbit (extra-capsular and extraconal). MRI is an excellent complemen- tary study for JAF evaluation. Intracranial invasion and intradural tumor extension can be evaluated and certainly is a decisive factor to determine radi- cal treatment. MRI is also useful to differentiate tumor extension into the sinuses from sinusitis.
The contrast enhanced MRI also shows extensive enhancement of tumor due to its hypervascularity (Fig. 19.1a). Contrast enhancement is essential for the JAF CT examination. Reviewing CT scans with both soft tissue and bone window setting is nec- essary to evaluate the extent of the tumor as well as bony erosions. Coronal and axial views provide good anatomical information regarding the rela- tionships among tumor, nasopharyngeal soft tis- sues and osseous structures of skull base. On CT, the JAF usually shows displacement and thinning of bony structures without definite bony destruc- tions considering the size of main mass (Fig. 19.1 b).
These are useful radiologic findings to differentiate
the JAF from other malignant tumors in children
Fig. 19.1a-f. JAF: An 18-year-old male presenting with epistaxis. The MRI and the CT scan shows orbital and intracranial (left temporal fossa) extension of tumor with signifi cant bony erosion (a,b). Angiogram shows tumoral blush arising from the internal maxillary artery, the facial artery and the ascending pharyngeal artery (c–f). Preoperative embolization with particles was performed after selective catheterization of the feeding arteries. Courtesy of Dr. K. terBrugge
b
d f
a c
e
such as rhabdomyosarcoma that typically destroys adjacent bony structures.
On angiography, the JAF presents with a dense tumor blush (Fig. 19.1c), and this is highly accurate to delimit tumor extension. Although it has intense hypervascularity, angiographic findings of arterio- venous shunting or early venous drainage have not been reported. Feeding arteries of JAF are mainly external carotid artery (ECA) branches such as distal internal maxillary branches, accessory men- ingeal artery, superior pharyngeal division of the ascending pharyngeal artery and the ascending palatine artery.
Internal carotid artery (ICA) may supply the JAF without having intracranial portion of the tumor.
However, if angiographic tumor blush is located above the skull base on AP and/or lateral views and has vascular supply from the ICA branches and/or from ascending pharyngeal and/or proximal inter- nal maxillary arteries, it might represent intra- cranial extension of the tumor. However, the sub- arachnoid space extension of tumor is exclusively
supplied by the ICA branches. The evaluation of the venous phase of the internal carotid angiography is an essential part of diagnostic angiography, since it will demonstrate the patency of the cavernous sinuses and adjacent venous plexus those will affect surgical respectability of the tumor.
19.2.4
Natural History
Osborn and Friedman suggested that repeated
hemorrhages within the tumor could stimulate the
formation of granulation tissue and a fibrous reac-
tion (1). This would explain some cases present-
ing spontaneous regression and tumors that tend
to have a slower rate of growth after adolescence
due to a higher proportion of fibrous tissue and
less tendency to bleed. As the disease progresses,
facial deformities, proptosis, blindness and cranial
nerve palsy may occur. Thus, complete spontaneous
regression of these tumors should not be expected
and treatment should not be delayed due to the tumor’s potential to behave aggressively.
The recruitment of new vascular supply is proba- bly related to the production of angiogenetic factors and it may explain the local invasiveness of some types of the JAF.
19.2.5 Diagnosis
The diagnosis of JFA is mainly based on a careful clinical history and nasal endoscopic examination in addition to the imaging studies (CT and MRI).
Biopsy to establish histological diagnosis is not indicated, and definitive diagnosis can be estab- lished by angiography, which certainly will play an important role in the patient management and treatment.
19.2.6 Treatment
The objective of the treatment is complete resection of the tumor. Surgical removal and radiation therapy are considered as the best therapeutic options. Con- troversy still exists as to how patients with recurrent or residual disease should be treated and how large tumors of the skull base should be managed.
Surgical techniques have been mostly successful by using advancing endonasal techniques with the use of the microscope for limited midface degloving procedures but in a small group of cases: transpala- tal, lateral rhinotomy and craniofacial approaches can be used.
Tumoral resection of JAF may be challenging and can be limited due to the risk of profuse intraop- erative bleeding and the size and extension of the tumor.
To diminish these risk factors and to facilitate the surgical resection, preoperative intra-arterial embo- lization, radiation therapy and exogenous estrogens has been largely used.
Preoperative exogenous estrogens have shown to produce positive effects on the bleeding rate. How- ever, the morbidity cause by the administration of such drugs to an adolescent male population is very high, with consequences on the gonadal develop- ment and function, which turns this treatment into an undesirable choice.
Radiation therapy is known to produce partial tumoral mass reduction or at least a significant
arrest of the tumor growth (80%), but functional morbidity and the high rate of long term secondary neoplasm induction place this treatment option in a secondary role. Thus, in general, radiation therapy for JNF is restricted to certain cases where intracra- nial extension prevents a complete resection of the lesion. Its effects are secondary to post radiation vasculitis and not the targeting of the cellular com- ponent. The use of radiation as a sole treatment has shown an overall rate of recurrence of 20%.
Intra-arterial embolization has resulted in a help- ful and reliable technique in preparation for surgery, and currently is the preferred combined treatment.
This procedure, when performed by an experienced team carries no significant morbidity or mortality.
Reported complications or unsatisfactory results are likely related to insufficient training or knowledge or poor judgment during the procedure itself.
Based on the classification of Fisch, most sur- geons in the international literature tend to operate on stages 1 and 2, some on stage 3 and few on stage 4. The overall mortality of JFA is 3% and the rate of recurrence after surgery varies from 12% to 35% and is likely owing to inadequate surgical removal.
Radiation therapy should be reserved for bilateral cavernous sinus involvement and for the situation where adequate surgical or therapeutic angiographic teams are not available in a given geographic loca- tion.
The use of surgical tumor resection precede by intra-arterial embolization has shown strong evi- dence in terms of reducing the number of recur- rences and repeated recurrences as a consequence of a reduction of the tumoral size and intraopera- tive bleeding, and therefore a higher rate of complete surgical resection of the JFA.
19.2.7
Embolization Technique
During preoperative angiography, major feeding vessels arising from the external carotid system are superselectively embolized and subsequent surgery can be scheduled within 12 to 48 hours after embo- lization.
The goal of the endovascular procedure is to devas-
cularize the tumor at the level of capillary bed, not
just proximal occlusion. Arterial supply of the tumor
may vary depending on the site of the tumor and these
vessels can only be moderately enlarged. The internal
carotid artery supply to the tumor is usually the most
important factor to limit the capacity of pre-operative
embolization. Therefore it is recommended to begin the study by performing a contralateral injection of the ICA with cross compression in the Caldwell view followed by an ipsilateral ICA injection. This will show the tumor’s ethmoidal, sphenoidal and middle cranial fossa extension. If the ICA branches can be purchased easily and can get a safe position for the embolization, there cannot be any restriction for the procedure. However, in general, it is technically chal- lenging to obtain a safe enough position to embolize JNF thru the ICA branches.
Regarding the ECA branches embolization. Spe- cial precaution has to be taken to identify potential anastomosis between branches of the internal max- illary and ascending pharyngeal arteries and the intracranial or intraorbital arteries, and internal carotid artery supply to the tumor.
For the last years, 150–250 um in size polyvi- nyl alcohol (PVA) has been the material of choice to reach the tumor capillary bed during the endo- vascular procedure. Smaller particles (50 µm) have shown to pass through the capillary vessels reaching the lungs with no therapeutic impact. Embolization can be completed by the injection of Gelfoam pled- gets (3 mm in caliber and up to 1 cm in length) to achieve a transient devascularization of the region (ligation) and in addition facilitate the distal throm- bosis within the tumor itself.
Strong evidence indicates that presurgical embo- lization facilitates surgical resection of JNF. Fur- thermore, either embolization alone or emboliza- tion associated with estrogens favors patients that present surgically unresectable tumors due to size or location.
The endovascular management may require the usage of other techniques such as injection of fluid materials such as NBCA or alcohol with flow con- trol thru the internal maxillary artery or ascending pharyngeal branches. Sacrifice of the ICA can be considered on an individual basis in patients with intracavernous extension.
In this last case neurologic examination as well as a transitory carotid occlusion test should always be carried out before the procedure.
The endovascular treatment results in a sig- nificant benefit for the JAF treatment whether it is preoperative or palliative. Usually shrinkage of the tumor mass can be observed both radiological and clinically within 12 hours after the procedure and breathing is usually improved indicating the return of nasal patency.
19.3
Paragangliomas
19.3.1 Classification
Paragangliomas, glomus tumors, chemodectomas, neurocristopathic tumors or nonchromaffin para- gangliomas are several names that have been given to the neuroendocrine neoplasms arising from the neural crest derivates.
These tumors present with a wide range of locations:
tympanic, jugular, carotid, vagal, laryngeal, nasopha- ryngeal and orbital. Tympanic and Jugular paragan- gliomas are classified as temporal paragangliomas.
Branchial paragangliomas are found in a vari- ety of locations in the head or the neck with almost one half arising in the temporal bone. These are the most common tumors of the middle ear. Its fea- tures include multicentricity and frequent associa- tion with other neural crest tumors. Other frequent locations are: jugular, carotid, vagal, laryngeal, nasopharyngeal and orbital, but pure single local- ization is uncommon and paragangliomas are usu- ally found to extend to multiple regions. Almost all of the paragangliomas located in the head and neck develop from a pre-existing normal paraganglion.
The clinical presentation of paragangliomas is related to the location of the tumor (mass, bruit, pain or cranial nerve palsy) and is usually progressive.
The malignant potential of paraganglioma is reported as between 10% and 18% on the vagal, carotid and laryngeal locations while in the tem- poral area is about 3%. Spontaneous regression of paragangliomas has never been reported. It usually has a slow growing rate but in some cases can be rapid or associated with additional tumors in other locations.
19.3.2 Pathology
Depending on the location, the paraganglioma may be lobulated or oval in shape and histologically it consists of a capsulated, highly vascular stroma with a paraganglion structure and epithelial cells (Fig. 19.2h). An irregular narrowing of the internal carotid artery can be seen in some cervical paragan- gliomas but is similar to tumoral encasement and is probably not specific.
The ascending pharyngeal artery is a unique
link between paragangliomas in various territories.
The tympanic, jugular, vagal, carotid and laryngeal locations of paragangliomas are supplied by differ- ent branches of the ascending pharyngeal artery.
The internal maxillary artery and the superior and inferior laryngeal arteries are also responsible for supplying paragangliomas in their respective ter- ritories.
19.3.3 Imaging
CT and MRI are important methods for the ini- tial evaluation of a paraganglioma. Even though the findings are usually not specific for this tumor and may mimic other nerve sheath neoplasms, these studies are highly effective to demonstrate the extension of the tumor into different regions like the carotid canal, the inner and middle ear, mas- toid process, posterior fossa or pterygoid muscles.
(Fig. 19.2a,d,e)
These studies should always be performed with and without contrast enhancement and a bone windowed as well as a soft tissue windowed evaluation of the CT scan of the lesion should be done. Direct coronal images are indispensable in the presence of cervical or skull base mass lesion and 1 to 3 mm sections are required for the petrous temporal bone evaluation.
Due to the hypervascularity of the paragangliomas, intense homogeneous enhancement of these tumors occurs following the contrast administration.
Superselective angiography still represents the most reliable study for pre treatment evaluation of paragangliomas. If the diagnosis is suspected, the angiogram should be performed before any biopsy attempt. (Fig. 19.2b,c,f,g)
The topography of the lesion will always indi- cate the arterial supply to the tumor. This could consist of a single artery or multiple vascular sup- plies. Angiographic findings are usually an intense tumoral blush, enlargement of the arterial feeders and rapid venous filling. Just like in JAF, it is recom- mended to perform the endovascular treatment at the time of the diagnostic angiogram, whenever it is possible.
The principal arteries that should be studied include the ipsilateral vertebral artery, the internal carotid artery, the distal external carotid, the pos- terior auricular, the occipital arteries and bilateral ascending pharyngeal arteries. It is important to visualize the venous drainage pattern and recognize the presence of a venous thrombosis.
Diagnosis of a carotid canal invasion can be performed by detecting expansive mass and bone destruction on the carotid canal on the CT scan associated with a narrowing of the intrapetrosal carotid artery at the angiography.
19.3.4 Treatment
Interdisciplinary management has shown to be criti- cal for the optimal treatment of paragangliomas.
Even though complete surgical excision has shown to be the treatment of choice, radiotherapy and endovascular embolization have become important therapeutic options for treating unresectable tumors and perform palliative treatment. Preoperative pro- cedures such as embolization to reduce the surgical procedure timing and the bleeding risk contem- plated in surgery have become an important thera- peutic tool for these tumors. Endovascular emboli- zation, when performed by an experienced operator, is a highly efficient and a low-risk method.
The efficacy of radiotherapy is not clear. Several studies have shown a tumor control rate as different as 90% and 25%. The mechanism of treatment is due to its effect on the vascular component causing vas- cular arteritis and fibrosis rather than affecting the tumoral cells. Brain tissue necrosis is an undesirable side effect related with this method and is usually detectable by CT or MRI.
Embolization of these tumors is usually per- formed with 200–350 microns in size polyvinyl alcohol (PVA). After particle injection, ligation of the arterial supply can be performed with Gelfoam strip injection. This will facilitate the intratumoral thrombosis. Liquid embolic agents are usually reserved for palliative lesions and only when strict flow control can be achieved.
As in any endovascular embolization of the cra-
niofacial region, special regards must be taken
towards the multiple anastomosis channels between
the ICA and the orbit, middle meningeal or occipital
arteries. As was previously described, the emboliza-
tion of the ascending pharyngeal artery with fluid
agent may induce lower cranial nerve palsy.
Fig. 19.2a–h. Carotid body tumor (a–c). CT scan a shows the anatomical relationship of the tumor with the carotid artery.
Glomus tumor typically shows enhancement after contrast administration. Selective angiography b,c shows tumor blush aris- ing from small ECA branches. Glomus jugulare (d–h) MRI shows the tumor location in relationship with the petrous bone and the jugular bulb d,e Selective angiography shows tumor blush supplied by the posterior auricular artery (f) and the ascending pharyngeal artery (g). Pathologic examination (h) demonstrates tumor tissue with the typical capsulated structure and epithelial cells surrounded with a vascularized stroma. Courtesy of Dr. K. terBrugge
b
d f
a c
e
g
hh
hb hc
19.4
Thyrolaryngeal Tumors
Tumors located in the thyrolaryngeal region are usually malignant and highly vascularized. Even though cerebral angiography and endovascular embolization can offer a significant help for the management of these tumors, most of cases are not referred for either diagnostic or therapeutic angi- ography.
Pretherapeutic evaluation of the thyrolaryngeal tumors should include conventional radiograms, CT, ultrasound and radionuclide scanning. The highly vascularized tumors of this region are usually sup- plied by the superior and inferior thyroidal arteries and are the most likely involved in the endovascular treatment. These arteries are usually widely selected for endovascular embolization of other head and neck tumors due to the collateral supply to the floor of the mouth and the carotid region.
They even may be the only supply to the floor of the mouth when there is a proximal ligation of the linguo-facial system.
Except for large tumors, the non-invasive tech- niques have shown little help in anatomical local- ization of parathyroid tumors, especially through the detection of secreting hormones at the neck veins.
Endovascular management techniques for these tumors include the superselective injection of 2 to 30 ml of contrast material [] with a higher dose of iodine compared to the conventional dose for cere- bral angiography. The persistence of the tumoral stain indicates the local damage of the tissue, and can be noticed for hours or days. After the proce- dure, a reduction in the calcium level in the blood can be found as a result of the released hormone from the cellular granules. Even though a signifi- cant result can be obtained from this technique, the endovascular procedure should be considered incomplete without a surgical excision. Experience on particle embolization for parathyroid adenomas has shown only a temporary effect and recurrence is always noticed. No evidence has been reported on the use of selective injection of cytotoxic agents.
Some of the vascularized tumors that have shown to be beneficed by a preoperative emboli- zation include: soft tissue and bony hemangiomas in adults, capillary hemangiomas in children and malignant synoviomas.
As previously described, some paragangliomas may be presented in the pharyngeal and thyroidal regions and may require preoperative endovascu-
lar embolization for complete excision. Particles of Liquid agents may be used as an only treatment for palliative management of these lesions.
19.5
Craniofacial Tumors
Endovascular techniques certainly have a role in the management of craniofacial tumors. Most of these lesions are metastasis or primary malignant tumors.
The main impact of the procedure is the necrotic changes in the tumor territory and this leads to a significant size reduction in its mass. Rarely in these cases, embolization is used as a single treatment, like recurrent or non-surgical lesions, and reaching as much of the area of the tumor with minimal side effects is the main goal.
Some techniques can be used to maximize the effect of particle embolization, like rearrangement of the vascular supply to the lesion. For this tech- nique a lateralized tumor may be selectively embo- lized to give priority to a single feeder. The feasibil- ity of this technique varies depending on the tumor extent, accessibility of the vessels and potential vas- cular anastomosis. For example, either the ipsilat- eral ascending pharyngeal or the internal maxillary artery can be embolized with particles. The remain- ing feeder is deliberately left open. Repeated angio- gram after a few weeks will verify the redirection of the tumor supply, witch can now be used for a more aggressive treatment: liquid adhesive, powder, cyto- toxics, ethanol, loaded microcapsules, etc. Although little experience has been reported with these mate- rials, significant decrease in the tumor masses has been reported.
19.6
Miscellaneous Applications of Embolization Therapy in the Head and Neck
19.6.1
Preoperative Embolization
Embolization has been described for the preven-
tion of hemorrhagic complications from a planned
tumoral biopsy. Particle embolization preserves
the histoarchitecture and inmunohistoanalysis and
therefore is a safe material for the preservation of
the tissue for diagnostic purposes.
19.6.2
Pain Management
Embolization for control of tumor related pain could be performed in selected cases where decongestion or tumoral mass reduction is thought to decompress the surrounding tissues, resulting in a local pain relief.
19.6.3
Hemorrhagic Emergencies
Craniofacial and neck malignant tumors usually present with a highly aggressive local activity. Bone destruction and ulceration are not uncommon find- ings especially as a secondary effect of radiotherapy.
In some cases, invasion of vascular structures may lead to a recurrent bleeding or severe hemorrhages.
Fig. 19.3a–c. Nasopharyngeal cancer with profuse bleeding treated with covered stent (Jomed®). A 54-year-old female with advanced nasopharyngeal cancer presented with intractable oral and nasal bleeding. Right ICA angiogram a shows pseudoan- eurysm of distal petrosal segment (arrow). Covered stent is introduced and adjusted its position across the pseudoaneurysm.
b A post-stent angiogram. c shows complete occlusion of pseudoaneurysm b
a c
In these emergencies initial clinical management and manual external compression is usually required until the patient can be treated (Fig. 19.3a). Diagnos- tic angiography is a priority to determine the cause for the carotid ‘Blow out’ syndrome. Aggressive tumor invasion or pseudoaneurysm formation of the neck or nasopharynx vessels are usual angio- graphic findings (Fig. 19.3b-c). These are life-threat- ening situations and special consideration must be taken for the overall clinical status of the patient (shock management, blood replacement, etc.) Mild to moderate hemorrhagic event may be temporarily treated with particles in the tumor capillary bed. In some cases ligation of a terminal branch (nasophar- ynx) or even the external or internal carotid artery by endovascular means is required (Fig. 19.3). For these purposes different kinds of material such as detachable or pushable coils, detachable balloons or liquid adhesives are highly effective.
Cookbook:
1. Anesthesia: General anesthesia preferred but the tumor embolization can be performed under neuroleptic anesthesia if the patient is stable and cooperative. In case of emergency such as carotid blow-out syndrome or profuse and active nose bleeding, you may perform the procedure under the local anesthesia.
2. Femoral arterial sheath: 5 or 6 Fr, 11 cm. If the patient has a very tortuous abdominal aorta, you can use longer arterial sheaths (30 ~ 45 cm).
3. Diagnostic catheter: 4 or 5 Fr angled Glider
(Boston Scientifi c®) or Berenstein (Cordis®)
4. Guide wire: 0.035 or 0.038 inch Glider
(Terumo®)
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