Dealing with a challenging carotid body tumor Shu-jie Yan, MD, Xiao-jun Song, MD, Chang-wei Liu, MD, and Yue-hong Zheng, MD, Beijing, China
A 30-year-old woman presented with a painless swelling in her right neck for 1 year. On physical examination, a large pulsatile and nontender mass (w15 10 cm in size) was present in the right anterolateral neck region. Selective carotid arteriography and computed tomography angiography confirmed an intensely enhancing mass at the bifurcation of the internal (ICA) and external carotid arteries (ECA), extending from the base of the skull and almost reaching the clavicle bone (A). The lesion encased the ICA, ECA, common carotid artery (CCA), and the regional nerves, although no symptoms of cranial neuropathy were detected. A temporary balloon occlusion test showed open collateral vessels through the anterior communicans artery. The operation was undertaken by a team of vascular surgeons and otolaryngologists. A 25-cm-long, S-shaped incision was made along the posterior border of the sternocleidomastoid muscle. We removed the mastoid and styloid processes to facilitate adequate skull base exposure. A large, hypervascular tumor (15 10 cm) was visualized extending from the level of the sternoclavicular joint to the base of the skull. As expected, the ICA and CCA were wholly enclosed in the tumor. The vascular walls were infiltrated without a dissection plane between the tumor and the vessel adventitia (white line of Gordon-Taylor). An autologous saphenous vein graft was indicated. After we obtained control of the petrous carotid artery and proximal CCA with vessel loops, the saphenous vein was anastomosed in an end-toside fashion into the CCA in 8 minutes, followed by the end-to-end anastomosis to the petrous portion of the ICA in 11 minutes (B). Finally, the tumor was removed, together with the ICA, after artery reconstruction. The ECA was ligated. The VII and XI cranial nerves were identified and well protected. The X and XII nerves were resected due to direct tumor involvement. Operative blood loss was 600 mL. Histologic analysis showed findings typical of a carotid body paraganglioma. The patient’s postoperative course was uneventful, with a slight XII cranial nerve deficit and temporary hoarseness. No recurrence or any further complications were noted at the 10-month follow-up. DISCUSSION Safe resection of this large carotid body tumor (CBT) required a complete preoperative evaluation, skull base exposure techniques, identification and protection of cranial nerves, immediate vascular control, and ICA reconstructive approaches. ICA reconstruction is recommended for Shamblin III CBTs completely encasing or infiltrating the ICA. Salvador et al1 described the procedure of ICA reconstruction using the saphenous vein after total removal of the CBT with the involved ICA segment. An intraluminal shunt was used during the operation for adequate cerebral perfusion.1 This has been a standard procedure for resection of a large Shamblin III CBT.2 Artificial grafts are also used. In this patient, we used an alternative approach to manage ICA reconstruction. First a bypass was made, followed by resection of the tumor and the involved artery. The amount of blood loss and the operation time were comparable to or even less than that of the standard procedure in our institute. We have also successfully applied this procedure in the management of an ICA aneurysm.3
From the Department of Vascular Surgery, Peking Union Medical College Hospital. Author conflict of interest: none. E-mail: [email protected]. The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2014;59:1709-10 0741-5214/$36.00 Copyright Ó 2014 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2013.06.094
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JOURNAL OF VASCULAR SURGERY June 2014
REFERENCES 1. Salvador JT, Tarnoff J, Feinhandler E. Difficult lesions of the carotid arteries and their surgical management. Angiology 1977;28:500-14. 2. Patetsios P, Gable DR. Management of carotid body paragangliomas and review of a 30-year experience. Ann Vasc Surg 2002;16:331-8. 3. Ren H, Song X, Shao J, Liu C, Zheng Y. Revascularisation of internal carotid artery aneurysm near the skull base. Eur J Vasc Endovas Surg Extra 2012;24:e25-6. Submitted Mar 2, 2013; accepted Jun 30, 2013.
A 30-year-old woman presented with a painless swelling in her right neck for 1 year. On physical examination, a large pulsatile and nontender mass (w15 10 cm in size) was present in the right anterolateral neck region. Selective carotid arteriography and computed tomography angiography confirmed an intensely enhancing mass at the bifurcation of the internal (ICA) and external carotid arteries (ECA), extending from the base of the skull and almost reaching the clavicle bone (A). The lesion encased the ICA, ECA, common carotid artery (CCA), and the regional nerves, although no symptoms of cranial neuropathy were detected. A temporary balloon occlusion test showed open collateral vessels through the anterior communicans artery. The operation was undertaken by a team of vascular surgeons and otolaryngologists. A 25-cm-long, S-shaped incision was made along the posterior border of the sternocleidomastoid muscle. We removed the mastoid and styloid processes to facilitate adequate skull base exposure. A large, hypervascular tumor (15 10 cm) was visualized extending from the level of the sternoclavicular joint to the base of the skull. As expected, the ICA and CCA were wholly enclosed in the tumor. The vascular walls were infiltrated without a dissection plane between the tumor and the vessel adventitia (white line of Gordon-Taylor). An autologous saphenous vein graft was indicated. After we obtained control of the petrous carotid artery and proximal CCA with vessel loops, the saphenous vein was anastomosed in an end-toside fashion into the CCA in 8 minutes, followed by the end-to-end anastomosis to the petrous portion of the ICA in 11 minutes (B). Finally, the tumor was removed, together with the ICA, after artery reconstruction. The ECA was ligated. The VII and XI cranial nerves were identified and well protected. The X and XII nerves were resected due to direct tumor involvement. Operative blood loss was 600 mL. Histologic analysis showed findings typical of a carotid body paraganglioma. The patient’s postoperative course was uneventful, with a slight XII cranial nerve deficit and temporary hoarseness. No recurrence or any further complications were noted at the 10-month follow-up. DISCUSSION Safe resection of this large carotid body tumor (CBT) required a complete preoperative evaluation, skull base exposure techniques, identification and protection of cranial nerves, immediate vascular control, and ICA reconstructive approaches. ICA reconstruction is recommended for Shamblin III CBTs completely encasing or infiltrating the ICA. Salvador et al1 described the procedure of ICA reconstruction using the saphenous vein after total removal of the CBT with the involved ICA segment. An intraluminal shunt was used during the operation for adequate cerebral perfusion.1 This has been a standard procedure for resection of a large Shamblin III CBT.2 Artificial grafts are also used. In this patient, we used an alternative approach to manage ICA reconstruction. First a bypass was made, followed by resection of the tumor and the involved artery. The amount of blood loss and the operation time were comparable to or even less than that of the standard procedure in our institute. We have also successfully applied this procedure in the management of an ICA aneurysm.3
From the Department of Vascular Surgery, Peking Union Medical College Hospital. Author conflict of interest: none. E-mail: [email protected]. The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2014;59:1709-10 0741-5214/$36.00 Copyright Ó 2014 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2013.06.094
1709
1710 Yan et al
JOURNAL OF VASCULAR SURGERY June 2014
REFERENCES 1. Salvador JT, Tarnoff J, Feinhandler E. Difficult lesions of the carotid arteries and their surgical management. Angiology 1977;28:500-14. 2. Patetsios P, Gable DR. Management of carotid body paragangliomas and review of a 30-year experience. Ann Vasc Surg 2002;16:331-8. 3. Ren H, Song X, Shao J, Liu C, Zheng Y. Revascularisation of internal carotid artery aneurysm near the skull base. Eur J Vasc Endovas Surg Extra 2012;24:e25-6. Submitted Mar 2, 2013; accepted Jun 30, 2013.
