Acta Oto-Laryngologica. 2015; 135: 302–306
ORIGINAL ARTICLE
Advantages of superficial femoral vein grafts for carotid artery reconstruction following carotid artery resection in the treatment of head and neck cancer
JUNKICHI YOKOYAMA1,5, MASAKI YAZAWA2, HITOSHI YOSHIMOTO3, SEIGO MATSUO4 & SHINICHI OHBA1 1
Department of Otolaryngology, Head and Neck Surgery, Juntendo University School of Medicine, Tokyo, Japan, Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan, 3Second Department of Oral and Maxillofacial Surgery, Osaka Dental University, Osaka, Japan, 4Department of Neurosurgery, Moriyama Memorial Hospital, Tokyo, Japan and 5Department of Otolaryngology, Head and Neck Surgery, Kyorin University School of Medicine, Tokyo, Japan
2
Abstract Conclusion: Reconstruction of the carotid artery using the superficial femoral vein (SFV) is very effective due to the ease in harvesting the vessel and its optimal size and length for carotid artery replacement. Objectives: To evaluate the effectiveness of carotid artery reconstruction using the SFV. Methods: Ten patients with malignant tumors involving the carotid artery underwent carotid artery resection followed by reconstruction with the SFV. The SFV between the deep femoral vein and branches to the great saphenous vein and deep femoral vein at the popliteal region was used as a reconstructive vessel. Results: The mean length and diameter of the grafted SFVs were 13.9 cm and 11.2 mm, respectively. The mean time for acquisition of SFV was 18 min. Ultrasonography measurements indicated that the mean lumen diameter of the common carotid artery was 8.37 mm. None of the patients experienced any permanent neurologic complications. The 2-year and 5-year overall survival rates were 60% and 40%, respectively. En bloc resection of the cancer and involved carotid artery followed by reconstruction with the SFV provides effective locoregional control. Our results indicated no postoperative vascular graft thrombosis and no donor site complications.
Keywords: Surgical complications, vein graft, en bloc resection, revascularization
Introduction In the treatment of recurrent head and neck squamous cell carcinoma (HNSCC) and radiationineffective malignant tumors involving the carotid artery the management of the tumor remains a challenging problem. This is particularly the case when carrying out the operative therapy. Resection of the carotid artery has been advocated for local control of advanced head and neck carcinoma [1]. However, resection alone without revascularization usually results in neurologic complications [2]. Carotid artery reconstruction is
superior to resection and ligation in reducing serious complications [3]. In this study, we evaluated the effectiveness of reconstructing the carotid artery using superficial femoral vein (SFV) grafts in patients with carotid artery invasion. Material and methods From January 2000 to December 2009, 10 patients with head and neck malignant tumors involving the carotid artery underwent resection and reconstruction of the carotid artery using SFV. The patient
Correspondence: Junkichi Yokoyama MD PhD, 113-8421, 2-1-1, Hongo, Bunkyo-ku, Tokyo, Japan. Tel: +81 3 3813 3111. Fax: +81 3 5802 1095. E-mail: [email protected]
(Received 7 July 2014; accepted 12 August 2014) ISSN 0001-6489 print/ISSN 1651-2251 online Ó 2015 Informa Healthcare DOI: 10.3109/00016489.2014.956336
Carotid artery reconstructed with femoral vein
303
Table I. Patient characteristics.
Site
Age Neurologic (years) New/recurrent Shunt Reconstruction complications
Ischemic Length of time femoral vein (min) (cm) Patency
Prognosis
Oropharynx
60
Recurrent
No
CCA-ICA
Temporary
20
12
Patent
Distant metastasis
Cervical esophageal cancer
60
Recurrent
Yes
CCA-ICA
No
5
12
Patent
Locoregional recurrence
Thyroid
72
New
No
CCA-CCA
No
20
11
Patent
NED
Tongue
35
Recurrent
No
CCA-ICA
No
29
14
Patent
Locoregional recurrence
Thyroid
70
New
No
CCA-CCA
No
19
13
Patent
NED
Hypopharynx
67
Recurrent
No
CCA-ICA
No
33
16
Patent
Locoregional recurrence
Larynx
71
Recurrent
No
CCA-ICA
No
28
15
Patent
NED
Larynx
68
Recurrent
No
CCA-ICA
No
30
15
Patent
Distant metastasis
Tongue
45
Recurrent
No
CCA-ICA
No
25
16
Patent
Distant metastasis
Malignant carotid body tumor
76
New
No
CCA-ICA
No
25
14
Patent
NED
CCA, common carotid artery; ICA, internal carotid artery; NED, no evidence of disease.
characteristics are shown in Table I. All patients were males, with an average age of 62.4 years. Preoperative evaluations included neurologic physical examination, temporary balloon occlusion test, color Doppler imaging of carotid vessels, and computed tomography (CT). A balloon occlusion test for the internal carotid artery was performed on all patients. A balloon catheter was brought into position in the internal carotid artery above bifurcation and inflated for 15 min. Patients were evaluated continuously for development of neurologic deficits such as extremity numbness and myodynamia decrease [4]. In addition, rSO2 (regional cerebral oxygen saturation) monitoring was used during surgical procedures. The diameters of the SFV and carotid artery were measured preoperatively by ultrasonography. With regard to surgical treatment, neck dissection was conducted until the invaded artery was exposed. The internal and common carotid segments were exposed 2 cm on the proximal and distal sides of the invaded artery. Before resecting the involved internal carotid artery, the length of artery to be resected and reconstructed was measured. As regards the harvesting method for SFV, the SFV communicates with the great saphenous vein and deep femoral vein at the level of the inguinal ligament and also has many perforator branches to the great saphenous vein and deep femoral vein in the popliteal region [5]. Between the deep femoral vein and the perforator branches to the great saphenous vein or deep femoral vein at the popliteal region, we can use the SFV safely
as a reconstructive vessel without reconstruction (Figure 1). After harvesting the SFV for reconstruction, resection of the internal carotid artery was performed as the last procedure in the en bloc resection of the whole cancer. The carotid stump pressure was measured in all cases. In cases when the carotid stump pressure was below 50 mmHg, a bypass shunt tube was inserted between the common and internal carotid to establish collateral circulation during reconstruction. The tumor was resected with the segment of the invaded artery, and a clear surgical margin was confirmed by intraoperative frozen section assessment. Head b a c
d
Figure 1. Anatomic findings of superficial femoral vein. Between the deep femoral vein behind the saphenous vein (a) and perforator branches (c), we can use the superficial femoral vein (b) safely as a reconstructive vessel without reconstruction (between two white arrowheads); d, femoral artery.
304
J. Yokoyama et al.
A distal SFV was anastomosed to the proximal common carotid artery. A proximal SFV was anastomosed to the distal internal carotid artery. Then the resected carotid was reconstructed with the SFV by end-to-end anastomosis (Figure 2). Color Doppler imaging of the vascular grafts was performed on postoperative days 3 and 7. CT was performed to evaluate recurrence and the patency of the grafts every 3 months. Results During a balloon occlusion test, one patient indicated slight contralateral upper extremity numbness. The balloon was deflated and the patient recovered from the neurologic deficits immediately. The other nine patients did not experience any neurologic deficits during the occlusion period. The mean length of the grafted SFV was 13.9 cm (range 11–16 cm). Preoperative ultrasonography indicated that the mean diameter of the grafted SFV was 11.2 mm (range 10.5–12.0 mm). Ultrasonography measurements also indicated that the mean lumen diameters of the common carotid artery and internal carotid artery were 8.37 mm and 6.87 mm, respectively. The mean time for acquiring SFV was 18 min. The blood supply to the brain was blocked for a short period of time (mean 23.1 min, ranging from 5 to 30 min). Measurements of the carotid stump pressures indicated a pressure of 60–70 mmHg for three patients, 50–60 mmHg for six patients, and 40–50 mmHg for one patient. Donor site complications did not occur. There was no postoperative vascular graft thrombosis, and no lower limb swelling. There was no need for any special treatment such as compression stockings or anticoagulation. In the following discussion, we describe a representative case in which a patient’s malignant carotid body tumor resulted in frequent syncope. The patient
had bilateral carotid body tumors (Figure 2A). Preoperative neurological examination indicated that the right carotid body tumor caused syncope. We resected the right carotid body tumor with the carotid artery and conducted neck dissection with reconstruction of the carotid artery. The preoperative syncope was significantly cured following surgery. The postoperative 5-year CT confirmed the patency of the reconstructed carotid artery (Figure 2B). Figure 3 demonstrates the reconstruction of the carotid artery with the SFV. The resected specimen of vagal nerve is swollen from the invasion of the malignant carotid body tumor. Pathological findings of the vagal nerve indicated tumor invasion. With regard to postoperative complications, one patient temporarily experienced slight hemiparesis in the immediate postoperative period. After 1 week, the patient recovered without any permanent neurologic deficit. While rSO2 monitoring was employed, it did not effectively indicate that the patient suffered from ischemia during the surgical procedure. The remaining nine patients did not experience any vascular or neurologic complications. Patients with preoperative dysphagia or extreme pain achieved complete remission after surgery. The 2-year and 5-year overall survival rates were 60% and 40%, respectively (Figure 4). Discussion The optimal treatment for patients with head and neck carcinoma involving the carotid artery remains controversial. Since the majority of patients with tumor invasion of the carotid artery are either cases of recurrence after radiation therapy, or cases in which
a
Head a
b
Figure 2. Malignant carotid body tumor. (A) Preoperative CT; (B) postoperative CT. The right carotid body tumor was resected and the right reconstructed carotid artery maintained good blood flow after 5 years (arrow).
Figure 3. Intraoperative findings. Carotid artery reconstruction with superficial femoral vein (black arrow). An arrowhead indicates the ideal anastomosis between the graft and the common carotid artery.
Carotid artery reconstructed with femoral vein
305
Overall survival rate 100 Nonsquamous cell carcinoma
90 80 Survival rate
70 60 50
Total cases
40 30 20 10 Recurrent squamous cell carcinoma 0 0
10
20
30
40
50
60
70
Months Figure 4. Overall survival rate.
radiation therapy has been ineffective for malignant tumors such as thyroid cancers, nonsurgical treatment with radiation and chemotherapy cannot achieve a satisfactory curative outcome [6]. En bloc resection, which can provide locoregional control and the possibility of prolonged disease-free survival, is often regarded as the only viable chance for cure. However, the successful excision of lesions requires transient interruption of the carotid artery. Therefore, much preoperative information is required to evaluate the vascular tolerance to ischemia. The temporary balloon occlusion test is the most commonly conducted procedure to predict collateral blood flow. However, preoperative temporary occlusion is not always an accurate predictor of collateral blood flow [7]. In all, 5–20% of patients who did not present any neurologic deficits during the temporary balloon occlusion test experienced strokes after carotid artery resection. Thus, a more accurate preoperative examination is required. The objective of this surgery is to minimize the potential of a postoperative neurological deficit. The reconstruction materials include the great saphenous vein and artificial blood vessels. Biller et al. [8] reported patients with recurrent cervical cancer involving reverse saphenous vein reconstruction of the carotid artery; 7% of the patients experienced cerebral ischemia, and the mortality rate was 15%. Because the great saphenous vein was too small, it required expansion for end-to-end anastomosis. An expanded great saphenous vein exhibits a thin vein wall with reduced elasticity. Because the vein wall and valves are damaged during the vein graft preparation, intimal hyperplasia, smooth muscle dysfunction, and graft thrombosis are more likely to occur [9].
Additionally, a slightly longer time is required to anastomose the carotid artery and the graft due to differing diameter between the carotid artery and the graft. However, the mean diameter of the SFV is a little bigger than that of the carotid artery. It is significantly easier and quicker to anastomose the carotid artery and SFV when compared with the great saphenous vein. As a result, the reconstruction procedure using the SFV was useful for minimizing the brain ischemic time due to its optimal size and length for carotid artery replacement. Consequently, surgical complications are fewer than those previously reported. In recent years, artificial vascular materials have been investigated for great arterial reconstructions. Artificial vessels grafts such as expanded polytetrafluoroethylene (ePTFE) have been used effectively in various great arterial reconstructions [10]. However, anticoagulant drugs are needed during the intraoperative and postoperative periods. The risk of perioperative bleeding can also be increased. In our experience, we have often found that small artificial vascular reconstructions for internal carotid arteries have resulted in occlusion. As for predicting the safety of carotid artery resection, Ehrnefeld et al. [11] concluded that a systolic stump pressure of greater than 70 mmHg indicates the adequacy of the collateral circulation. They also noted that intermediate stump pressures of 55– 68 mmHg represent a genuine hazard and that pressure below 55 mmHg results in an unacceptable stroke rate. In our cases, there was no case of stump pressure greater than 70 mmHg. A stump pressure of 60–69 mmHg was recorded for eight patients, while a stump pressure below 55 mmHg was recorded for two
306
J. Yokoyama et al.
patients. While clamping the carotid artery, a bypass shunt tube was inserted between the common and internal carotid to establish collateral circulation for the only patient with stump pressure below 50 mmHg. In the remaining nine cases, reconstruction with the SFV was useful for minimizing the brain ischemic time due to its optimal size and length for carotid artery replacement. In this study, only one patient experienced slight hemiparesis due to the transient cerebral ischemia, while nine patients did not experience any cerebrovascular complications. There were no postoperative vascular graft complications in either recipient or donor sites. Radiation therapy is often used for the treatment of head and neck squamous cell carcinoma. Radiation therapy can result in poor blood supply to the locoregional skin and muscle and low elasticity of the carotid artery wall [12]. As a result, pharyngocutaneous fistula could increase because of the radiation-induced delayed in wound healing [13]. Pharyngocutaneous fistula results in neck infection, and increases anastomotic rupture, especially in cases of artificial vascular reconstruction. To prevent pharyngocutaneous fistula, the design of a wound bed with sufficient blood supply for the vascular grafts is effective [14]. In the present study, the vascular grafts in 6 of 10 patients were encompassed by the wellvascularized muscle of the pectoralis major myocutaneous flap. Consequently, surgical site infections including the carotid grafts could be avoided. In long-term follow-up, many advanced head and neck cancers often metastasize to the other side neck lymph nodes involving the carotid artery. If the carotid artery reconstruction is performed in the initial side, the other side neck metastasis involving the carotid artery can be treated by surgical or radiation treatment. Conclusion Reconstruction of the carotid artery using SFV grafts is an effective procedure for patients with head and neck cancer involving the carotid artery. This is because of easy vessel acquisition and the optimal width and length of the superficial femoral vein for carotid artery replacement.
Acknowledgment This study was partially supported by a research grant from the Ministry of Education, Science, and Culture of Japan (25462693)
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References [1] Németh Z, Dömötör G, Tálos M, Barabás J, Ujpál M, Szabó G. Resection and replacement of the carotid artery in metastatic head and neck cancer: literature review and case report. Int J Oral Maxillofac Surg 2003;32:645–50. [2] Brennan JA, Jafek BW. Elective carotid artery resection for advanced squamous cell carcinoma of the neck. Laryngoscope 1994;104:259–63. [3] Wright JG, Nicholson R, Schuller DE, Smead WL. Resection of the internal carotid artery and replacement with greater saphenous vein: a safe procedure for en bloc cancer resections with carotid involvement. J Vasc Surg 1996;23:775–80. [4] Mathis JM, Barr JD, Jungreis CA, Yonas H, Sekhar LN, Vincent D, et al. Temporary balloon test occlusion of the internal carotid artery: experience in 500 cases. Am J Neuroradiol 1995;16:749–54. [5] Uflacker R. Veins of the lower extremity. In Atlas of vascular anatomy – an angiographic approach. Williams and Wilkins. Baltimore: 1997. p 779–90. [6] Roh JL, Kim MR, Choi SH, Lee JH, Cho KJ, Nam SY, et al. Can patients with head and neck cancers invading carotid artery gain survival benefit from surgery? Acta Otolaryngol 2008;128:1370–4. [7] Chazono H, Okamoto Y, Matsuzaki Z, Horiguchi S, Matsuoka T, Horikoshi T, et al. Carotid artery resection: preoperative temporary occlusion is not always an accurate predictor of collateral blood flow. Acta Otolaryngol 2005; 125:196–200. [8] Biller HF, Urken M, Lawson W, Haimov M. Carotid artery resection and bypass for neck carcinoma. Laryngoscope 1988;98:181–3. [9] Osgood MJ, Hocking KM, Voskresensky IV, Li FD, Komalavilas P, Cheung-Flynn J, et al. Surgical vein graft preparation promotes cellular dysfunction, oxidative stress, and intimal hyperplasia in human saphenous vein. J Vasc Surg 2014;60:202–11. [10] Nichols MD, Choudhary R, Kodali S, Reichert WM. Coagulation-induced resistance to fluid flow in smalldiameter vascular grafts and graft mimics measured by purging pressure. J Biomed Mater Res B Appl Biomater 2013; 101:1367–76. [11] Ehrnefeld WK, Stoney RJ, Wylie EJ. Relation of carotid stump pressure to safety of carotid artery ligation. Surgery 1983;93:299–305. [12] Delanian S, Lefaix JL. The radiation-induced fibroatrophic process: therapeutic perspective via the antioxidant pathway. Radiother Oncol 2004;73:119–31. [13] Relic A, Scheich M, Stapf J, Voelter C, Hoppe F, Hagen R, et al. Salvage surgery after induction chemotherapy with paclitaxel/cisplatin and primary radiotherapy for advanced laryngeal and hypopharyngeal carcinomas. Eur Arch Otorhinolaryngol 2009;266:1799–805. [14] Fung K, Teknos TN, Vandenberg CD, Lyden TH, Bradford CR, Hogikyan ND, et al. Prevention of wound complications following salvage laryngectomy using free vascularized tissue. Head Neck 2007;29:425–30.
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ORIGINAL ARTICLE
Advantages of superficial femoral vein grafts for carotid artery reconstruction following carotid artery resection in the treatment of head and neck cancer
JUNKICHI YOKOYAMA1,5, MASAKI YAZAWA2, HITOSHI YOSHIMOTO3, SEIGO MATSUO4 & SHINICHI OHBA1 1
Department of Otolaryngology, Head and Neck Surgery, Juntendo University School of Medicine, Tokyo, Japan, Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan, 3Second Department of Oral and Maxillofacial Surgery, Osaka Dental University, Osaka, Japan, 4Department of Neurosurgery, Moriyama Memorial Hospital, Tokyo, Japan and 5Department of Otolaryngology, Head and Neck Surgery, Kyorin University School of Medicine, Tokyo, Japan
2
Abstract Conclusion: Reconstruction of the carotid artery using the superficial femoral vein (SFV) is very effective due to the ease in harvesting the vessel and its optimal size and length for carotid artery replacement. Objectives: To evaluate the effectiveness of carotid artery reconstruction using the SFV. Methods: Ten patients with malignant tumors involving the carotid artery underwent carotid artery resection followed by reconstruction with the SFV. The SFV between the deep femoral vein and branches to the great saphenous vein and deep femoral vein at the popliteal region was used as a reconstructive vessel. Results: The mean length and diameter of the grafted SFVs were 13.9 cm and 11.2 mm, respectively. The mean time for acquisition of SFV was 18 min. Ultrasonography measurements indicated that the mean lumen diameter of the common carotid artery was 8.37 mm. None of the patients experienced any permanent neurologic complications. The 2-year and 5-year overall survival rates were 60% and 40%, respectively. En bloc resection of the cancer and involved carotid artery followed by reconstruction with the SFV provides effective locoregional control. Our results indicated no postoperative vascular graft thrombosis and no donor site complications.
Keywords: Surgical complications, vein graft, en bloc resection, revascularization
Introduction In the treatment of recurrent head and neck squamous cell carcinoma (HNSCC) and radiationineffective malignant tumors involving the carotid artery the management of the tumor remains a challenging problem. This is particularly the case when carrying out the operative therapy. Resection of the carotid artery has been advocated for local control of advanced head and neck carcinoma [1]. However, resection alone without revascularization usually results in neurologic complications [2]. Carotid artery reconstruction is
superior to resection and ligation in reducing serious complications [3]. In this study, we evaluated the effectiveness of reconstructing the carotid artery using superficial femoral vein (SFV) grafts in patients with carotid artery invasion. Material and methods From January 2000 to December 2009, 10 patients with head and neck malignant tumors involving the carotid artery underwent resection and reconstruction of the carotid artery using SFV. The patient
Correspondence: Junkichi Yokoyama MD PhD, 113-8421, 2-1-1, Hongo, Bunkyo-ku, Tokyo, Japan. Tel: +81 3 3813 3111. Fax: +81 3 5802 1095. E-mail: [email protected]
(Received 7 July 2014; accepted 12 August 2014) ISSN 0001-6489 print/ISSN 1651-2251 online Ó 2015 Informa Healthcare DOI: 10.3109/00016489.2014.956336
Carotid artery reconstructed with femoral vein
303
Table I. Patient characteristics.
Site
Age Neurologic (years) New/recurrent Shunt Reconstruction complications
Ischemic Length of time femoral vein (min) (cm) Patency
Prognosis
Oropharynx
60
Recurrent
No
CCA-ICA
Temporary
20
12
Patent
Distant metastasis
Cervical esophageal cancer
60
Recurrent
Yes
CCA-ICA
No
5
12
Patent
Locoregional recurrence
Thyroid
72
New
No
CCA-CCA
No
20
11
Patent
NED
Tongue
35
Recurrent
No
CCA-ICA
No
29
14
Patent
Locoregional recurrence
Thyroid
70
New
No
CCA-CCA
No
19
13
Patent
NED
Hypopharynx
67
Recurrent
No
CCA-ICA
No
33
16
Patent
Locoregional recurrence
Larynx
71
Recurrent
No
CCA-ICA
No
28
15
Patent
NED
Larynx
68
Recurrent
No
CCA-ICA
No
30
15
Patent
Distant metastasis
Tongue
45
Recurrent
No
CCA-ICA
No
25
16
Patent
Distant metastasis
Malignant carotid body tumor
76
New
No
CCA-ICA
No
25
14
Patent
NED
CCA, common carotid artery; ICA, internal carotid artery; NED, no evidence of disease.
characteristics are shown in Table I. All patients were males, with an average age of 62.4 years. Preoperative evaluations included neurologic physical examination, temporary balloon occlusion test, color Doppler imaging of carotid vessels, and computed tomography (CT). A balloon occlusion test for the internal carotid artery was performed on all patients. A balloon catheter was brought into position in the internal carotid artery above bifurcation and inflated for 15 min. Patients were evaluated continuously for development of neurologic deficits such as extremity numbness and myodynamia decrease [4]. In addition, rSO2 (regional cerebral oxygen saturation) monitoring was used during surgical procedures. The diameters of the SFV and carotid artery were measured preoperatively by ultrasonography. With regard to surgical treatment, neck dissection was conducted until the invaded artery was exposed. The internal and common carotid segments were exposed 2 cm on the proximal and distal sides of the invaded artery. Before resecting the involved internal carotid artery, the length of artery to be resected and reconstructed was measured. As regards the harvesting method for SFV, the SFV communicates with the great saphenous vein and deep femoral vein at the level of the inguinal ligament and also has many perforator branches to the great saphenous vein and deep femoral vein in the popliteal region [5]. Between the deep femoral vein and the perforator branches to the great saphenous vein or deep femoral vein at the popliteal region, we can use the SFV safely
as a reconstructive vessel without reconstruction (Figure 1). After harvesting the SFV for reconstruction, resection of the internal carotid artery was performed as the last procedure in the en bloc resection of the whole cancer. The carotid stump pressure was measured in all cases. In cases when the carotid stump pressure was below 50 mmHg, a bypass shunt tube was inserted between the common and internal carotid to establish collateral circulation during reconstruction. The tumor was resected with the segment of the invaded artery, and a clear surgical margin was confirmed by intraoperative frozen section assessment. Head b a c
d
Figure 1. Anatomic findings of superficial femoral vein. Between the deep femoral vein behind the saphenous vein (a) and perforator branches (c), we can use the superficial femoral vein (b) safely as a reconstructive vessel without reconstruction (between two white arrowheads); d, femoral artery.
304
J. Yokoyama et al.
A distal SFV was anastomosed to the proximal common carotid artery. A proximal SFV was anastomosed to the distal internal carotid artery. Then the resected carotid was reconstructed with the SFV by end-to-end anastomosis (Figure 2). Color Doppler imaging of the vascular grafts was performed on postoperative days 3 and 7. CT was performed to evaluate recurrence and the patency of the grafts every 3 months. Results During a balloon occlusion test, one patient indicated slight contralateral upper extremity numbness. The balloon was deflated and the patient recovered from the neurologic deficits immediately. The other nine patients did not experience any neurologic deficits during the occlusion period. The mean length of the grafted SFV was 13.9 cm (range 11–16 cm). Preoperative ultrasonography indicated that the mean diameter of the grafted SFV was 11.2 mm (range 10.5–12.0 mm). Ultrasonography measurements also indicated that the mean lumen diameters of the common carotid artery and internal carotid artery were 8.37 mm and 6.87 mm, respectively. The mean time for acquiring SFV was 18 min. The blood supply to the brain was blocked for a short period of time (mean 23.1 min, ranging from 5 to 30 min). Measurements of the carotid stump pressures indicated a pressure of 60–70 mmHg for three patients, 50–60 mmHg for six patients, and 40–50 mmHg for one patient. Donor site complications did not occur. There was no postoperative vascular graft thrombosis, and no lower limb swelling. There was no need for any special treatment such as compression stockings or anticoagulation. In the following discussion, we describe a representative case in which a patient’s malignant carotid body tumor resulted in frequent syncope. The patient
had bilateral carotid body tumors (Figure 2A). Preoperative neurological examination indicated that the right carotid body tumor caused syncope. We resected the right carotid body tumor with the carotid artery and conducted neck dissection with reconstruction of the carotid artery. The preoperative syncope was significantly cured following surgery. The postoperative 5-year CT confirmed the patency of the reconstructed carotid artery (Figure 2B). Figure 3 demonstrates the reconstruction of the carotid artery with the SFV. The resected specimen of vagal nerve is swollen from the invasion of the malignant carotid body tumor. Pathological findings of the vagal nerve indicated tumor invasion. With regard to postoperative complications, one patient temporarily experienced slight hemiparesis in the immediate postoperative period. After 1 week, the patient recovered without any permanent neurologic deficit. While rSO2 monitoring was employed, it did not effectively indicate that the patient suffered from ischemia during the surgical procedure. The remaining nine patients did not experience any vascular or neurologic complications. Patients with preoperative dysphagia or extreme pain achieved complete remission after surgery. The 2-year and 5-year overall survival rates were 60% and 40%, respectively (Figure 4). Discussion The optimal treatment for patients with head and neck carcinoma involving the carotid artery remains controversial. Since the majority of patients with tumor invasion of the carotid artery are either cases of recurrence after radiation therapy, or cases in which
a
Head a
b
Figure 2. Malignant carotid body tumor. (A) Preoperative CT; (B) postoperative CT. The right carotid body tumor was resected and the right reconstructed carotid artery maintained good blood flow after 5 years (arrow).
Figure 3. Intraoperative findings. Carotid artery reconstruction with superficial femoral vein (black arrow). An arrowhead indicates the ideal anastomosis between the graft and the common carotid artery.
Carotid artery reconstructed with femoral vein
305
Overall survival rate 100 Nonsquamous cell carcinoma
90 80 Survival rate
70 60 50
Total cases
40 30 20 10 Recurrent squamous cell carcinoma 0 0
10
20
30
40
50
60
70
Months Figure 4. Overall survival rate.
radiation therapy has been ineffective for malignant tumors such as thyroid cancers, nonsurgical treatment with radiation and chemotherapy cannot achieve a satisfactory curative outcome [6]. En bloc resection, which can provide locoregional control and the possibility of prolonged disease-free survival, is often regarded as the only viable chance for cure. However, the successful excision of lesions requires transient interruption of the carotid artery. Therefore, much preoperative information is required to evaluate the vascular tolerance to ischemia. The temporary balloon occlusion test is the most commonly conducted procedure to predict collateral blood flow. However, preoperative temporary occlusion is not always an accurate predictor of collateral blood flow [7]. In all, 5–20% of patients who did not present any neurologic deficits during the temporary balloon occlusion test experienced strokes after carotid artery resection. Thus, a more accurate preoperative examination is required. The objective of this surgery is to minimize the potential of a postoperative neurological deficit. The reconstruction materials include the great saphenous vein and artificial blood vessels. Biller et al. [8] reported patients with recurrent cervical cancer involving reverse saphenous vein reconstruction of the carotid artery; 7% of the patients experienced cerebral ischemia, and the mortality rate was 15%. Because the great saphenous vein was too small, it required expansion for end-to-end anastomosis. An expanded great saphenous vein exhibits a thin vein wall with reduced elasticity. Because the vein wall and valves are damaged during the vein graft preparation, intimal hyperplasia, smooth muscle dysfunction, and graft thrombosis are more likely to occur [9].
Additionally, a slightly longer time is required to anastomose the carotid artery and the graft due to differing diameter between the carotid artery and the graft. However, the mean diameter of the SFV is a little bigger than that of the carotid artery. It is significantly easier and quicker to anastomose the carotid artery and SFV when compared with the great saphenous vein. As a result, the reconstruction procedure using the SFV was useful for minimizing the brain ischemic time due to its optimal size and length for carotid artery replacement. Consequently, surgical complications are fewer than those previously reported. In recent years, artificial vascular materials have been investigated for great arterial reconstructions. Artificial vessels grafts such as expanded polytetrafluoroethylene (ePTFE) have been used effectively in various great arterial reconstructions [10]. However, anticoagulant drugs are needed during the intraoperative and postoperative periods. The risk of perioperative bleeding can also be increased. In our experience, we have often found that small artificial vascular reconstructions for internal carotid arteries have resulted in occlusion. As for predicting the safety of carotid artery resection, Ehrnefeld et al. [11] concluded that a systolic stump pressure of greater than 70 mmHg indicates the adequacy of the collateral circulation. They also noted that intermediate stump pressures of 55– 68 mmHg represent a genuine hazard and that pressure below 55 mmHg results in an unacceptable stroke rate. In our cases, there was no case of stump pressure greater than 70 mmHg. A stump pressure of 60–69 mmHg was recorded for eight patients, while a stump pressure below 55 mmHg was recorded for two
306
J. Yokoyama et al.
patients. While clamping the carotid artery, a bypass shunt tube was inserted between the common and internal carotid to establish collateral circulation for the only patient with stump pressure below 50 mmHg. In the remaining nine cases, reconstruction with the SFV was useful for minimizing the brain ischemic time due to its optimal size and length for carotid artery replacement. In this study, only one patient experienced slight hemiparesis due to the transient cerebral ischemia, while nine patients did not experience any cerebrovascular complications. There were no postoperative vascular graft complications in either recipient or donor sites. Radiation therapy is often used for the treatment of head and neck squamous cell carcinoma. Radiation therapy can result in poor blood supply to the locoregional skin and muscle and low elasticity of the carotid artery wall [12]. As a result, pharyngocutaneous fistula could increase because of the radiation-induced delayed in wound healing [13]. Pharyngocutaneous fistula results in neck infection, and increases anastomotic rupture, especially in cases of artificial vascular reconstruction. To prevent pharyngocutaneous fistula, the design of a wound bed with sufficient blood supply for the vascular grafts is effective [14]. In the present study, the vascular grafts in 6 of 10 patients were encompassed by the wellvascularized muscle of the pectoralis major myocutaneous flap. Consequently, surgical site infections including the carotid grafts could be avoided. In long-term follow-up, many advanced head and neck cancers often metastasize to the other side neck lymph nodes involving the carotid artery. If the carotid artery reconstruction is performed in the initial side, the other side neck metastasis involving the carotid artery can be treated by surgical or radiation treatment. Conclusion Reconstruction of the carotid artery using SFV grafts is an effective procedure for patients with head and neck cancer involving the carotid artery. This is because of easy vessel acquisition and the optimal width and length of the superficial femoral vein for carotid artery replacement.
Acknowledgment This study was partially supported by a research grant from the Ministry of Education, Science, and Culture of Japan (25462693)
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References [1] Németh Z, Dömötör G, Tálos M, Barabás J, Ujpál M, Szabó G. Resection and replacement of the carotid artery in metastatic head and neck cancer: literature review and case report. Int J Oral Maxillofac Surg 2003;32:645–50. [2] Brennan JA, Jafek BW. Elective carotid artery resection for advanced squamous cell carcinoma of the neck. Laryngoscope 1994;104:259–63. [3] Wright JG, Nicholson R, Schuller DE, Smead WL. Resection of the internal carotid artery and replacement with greater saphenous vein: a safe procedure for en bloc cancer resections with carotid involvement. J Vasc Surg 1996;23:775–80. [4] Mathis JM, Barr JD, Jungreis CA, Yonas H, Sekhar LN, Vincent D, et al. Temporary balloon test occlusion of the internal carotid artery: experience in 500 cases. Am J Neuroradiol 1995;16:749–54. [5] Uflacker R. Veins of the lower extremity. In Atlas of vascular anatomy – an angiographic approach. Williams and Wilkins. Baltimore: 1997. p 779–90. [6] Roh JL, Kim MR, Choi SH, Lee JH, Cho KJ, Nam SY, et al. Can patients with head and neck cancers invading carotid artery gain survival benefit from surgery? Acta Otolaryngol 2008;128:1370–4. [7] Chazono H, Okamoto Y, Matsuzaki Z, Horiguchi S, Matsuoka T, Horikoshi T, et al. Carotid artery resection: preoperative temporary occlusion is not always an accurate predictor of collateral blood flow. Acta Otolaryngol 2005; 125:196–200. [8] Biller HF, Urken M, Lawson W, Haimov M. Carotid artery resection and bypass for neck carcinoma. Laryngoscope 1988;98:181–3. [9] Osgood MJ, Hocking KM, Voskresensky IV, Li FD, Komalavilas P, Cheung-Flynn J, et al. Surgical vein graft preparation promotes cellular dysfunction, oxidative stress, and intimal hyperplasia in human saphenous vein. J Vasc Surg 2014;60:202–11. [10] Nichols MD, Choudhary R, Kodali S, Reichert WM. Coagulation-induced resistance to fluid flow in smalldiameter vascular grafts and graft mimics measured by purging pressure. J Biomed Mater Res B Appl Biomater 2013; 101:1367–76. [11] Ehrnefeld WK, Stoney RJ, Wylie EJ. Relation of carotid stump pressure to safety of carotid artery ligation. Surgery 1983;93:299–305. [12] Delanian S, Lefaix JL. The radiation-induced fibroatrophic process: therapeutic perspective via the antioxidant pathway. Radiother Oncol 2004;73:119–31. [13] Relic A, Scheich M, Stapf J, Voelter C, Hoppe F, Hagen R, et al. Salvage surgery after induction chemotherapy with paclitaxel/cisplatin and primary radiotherapy for advanced laryngeal and hypopharyngeal carcinomas. Eur Arch Otorhinolaryngol 2009;266:1799–805. [14] Fung K, Teknos TN, Vandenberg CD, Lyden TH, Bradford CR, Hogikyan ND, et al. Prevention of wound complications following salvage laryngectomy using free vascularized tissue. Head Neck 2007;29:425–30.
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