|Year : 2019 | Volume
| Issue : 3 | Page : 46-49
Current application of endovascular interventions in surgical management of carotid body tumor
Guangchao Gu, Yuehong Zheng
Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
|Date of Submission||30-May-2020|
|Date of Decision||05-Jul-2020|
|Date of Acceptance||16-Jul-2020|
|Date of Web Publication||25-Aug-2020|
Dr. Yuehong Zheng
Department of Vascular Surgery, Peking Union Medical College Hospital, Shuaifuyuan 1, Dongcheng District, Beijing 100730
Source of Support: None, Conflict of Interest: None
Carotid body tumors (CBTs) are rare neoplasms at the carotid bifurcation. Surgical excision is currently the only curable treatment for CBTs but is associated with high incidence of morbidities and mortality, due to the hyper-vascularity and proximity to carotid vessels and cranial nerves of the tumors. In the last decades, endovascular interventions, including preoperative trans-arterial embolization and carotid stents, have been utilized in surgical excision of CBTs with the attempt to reduce perioperative complications and improve surgical outcomes. However, controversial results have been reported with regard to the efficacy of such techniques. This review summarized the current application of endovascular interventions in surgical treatment of CBTs, with emphasis on their impacts on surgical conducting and perioperative complications.
Keywords: Carotid body tumor, carotid stents, preoperative embolization, surgery
|How to cite this article:|
Gu G, Zheng Y. Current application of endovascular interventions in surgical management of carotid body tumor. Transl Surg 2019;4:46-9
| Introduction|| |
Carotid body tumor (CBT) is a rare neoplasm originating from the neural crest tissues at the carotid bifurcation and it accounts for 60%–70% of head and neck paragangliomas. Most patients present gradually enlarging painless masses at the neck, with some individuals complaining of local pain, headache, dizziness, tinnitus, hoarseness, coughing when drinking or tongue deviations due to tumor invasion to carotid artery or cranial nerves. 1 Surgical excision is the preferable treatment for CBTs due to the risk of severe invasion to carotid arteries, cranial nerves, and also the potential of developing metastasis that is associated with poor prognosis. 2 Currently, the Shamblin grading system, which is based on the extent of tumor encasement to carotid arteries, is used to estimate a patient's surgical difficulties and to predict the risk of intraoperative bleeding as well as vascular morbidities. 3 With the advancement of surgical techniques and the development of medical devices, the diagnosis and treatment of CBT have obtained significant improvement, but the overall surgical complications were still high, particularly with regard to cranial nerve injury. 4 According to a systemic review composed of 4418 patients with 4743 CBTs, the 30-day stroke, mortality and cranial nerve injury rate in surgical excision of CBTs were reported to be 2.3%, 3.5%, and 25.4%, respectively. 5 The high surgical morbidity and mortality is owing to the high vascularity, local involvement of adjacent neurovascular structures, and risk of stroke during carotid artery reconstruction.
The application of adjuvant endovascular interventions, including preoperative embolization and placement of vascular stents, is shedding light to improving the clinical outcomes attached to the purely surgical treatment of Shamblin II to III CBTs. However, controversial results have been reported by different researchers and standard guidelines are still lacking with regard to which tumors should receive the adjuvant interventions. 6 In this review, we focused on the current application of endovascular interventions in surgical treatment of CBTs.
| Surgical Procedures|| |
Surgical excision of CBTs is usually performed under general anesthesia, and tumor dissection should be performed along the subadventitial plane to reduce bleeding. The external carotid artery (ECA) might be ligated to reduce the tumor size and to control intraoperative bleeding. If the tumor is small and has little adhesion to adjacent nerves and vessels (Shamblin I CBTs), it can often be removed directly from the carotid arteries without injuring the nerve and carotid arteries. If the tumor is large in volume and has severe adhesion to carotid arteries and cranial nerves (Shamblin II and III CBTs), dissection will be difficult and some nerves and involved carotid arteries will have to be injured. When internal carotid artery (ICA) is injured, revascularization is required to restore cerebral perfusion, which could be conducted by great saphenous vein transplantation, end-to-end anastomosis, and carotid artery patch angioplasty. Carotid shunt might be used to aid the tumor dissection and ICA reconstruction because it helps to maintain the cerebral perfusion while clamping the carotid arteries for vessel anastomosis or tumor dissection.
| Preoperative Embolization|| |
Preoperative embolization was first reported in the 1980s. Angiography is first performed to determine the feeding arteries of the tumors, a micro-catheter is advanced into the main arterial feeders, and embolization agents mixed with contrast were injected through the micro-catheter to achieve embolization. All feeding vessels, when enough for accommodating the micro-catheter, should be embolized to achieve satisfactory devascularisation. A completion angiogram is needed to confirm the efficacy of embolization and patency of ICA. Injections should be repeated until a significant blood flow reduction was obtained. Surgical excision of CBTs is usually performed at 0–3 days after embolization to prevent the formation of aseptic inflammation and collateral circulation.
Embolization agents are generally composed of mechanical devices, particles, and liquids. Gelfoam, cyanoacrylate, coils, vinyl alcohol, ethylene, and polyvinyl alcohol have so far been used with variable embolization efficacy, with polyvinyl alcohol particles being the most commonly used agents and most particles used are 150–500 μm in diameter. Endovascular access may be gained from the brachial or the femoral arteries, most commonly through the later. Direct percutaneous intratumoral injection of a liquid embolic is an alternative access that was proved successful and safe in cases where trans-arterial endovascular embolization was insufficient, potentially dangerous or difficult to perform due to presence of small-caliber arterial feeders and arteriovenous shunts within the tumor, which might be performed alone or adjuvant to transarterial embolization and should be performed under the guidance of angiographic road map and ultrasonography to prevent distal embolization.,
Preoperative embolization has been advocated to aid in surgical resection by decreasing intraoperative blood loss and operative time. Some authors have investigated the impact of embolization on surgical complications including vascular and nerve damages. However, controversial findings have been reported in the literature. Power et al. reported 33 CBTs with preoperative embolization and 71 CBTs without embolization, and found that preoperative embolization might reduce the intraoperative bleeding (mean estimated blood loss, 263 vs. 599 mL, P = 0.002) and simplify the conduct of the operation (simple excision without vascular morbidities in 97% vs. 82%, P = 0.03), but had no impact on the incidence of cranial nerve injury (52% vs. 38%, P = 0.21), postoperative length of stay (4.1 vs. 4.2 days, P = 0.91), mortality (0% vs. 0%, P > 0.99), and stroke (0% vs. 1%, P > 0.99). Liu et al. compared the surgical outcomes of 31 CBTs with preoperative embolization and 27 CBTs without preoperative embolization, and found that preoperative embolization can significantly reduce the amount of bleeding (140.32 ± 57.12 mL vs. 396.43 ± 272.82 mL, P < 0.01), the operation time (110.65 ± 35.77 min vs. 188.33 ± 66.44 min, P < 0.01), the number of blood transfusion (0% vs. 29.63%, P = 0.004) and the overall rate of perioperative complications (9.7% vs. 33.3%, P = 0.03), however, no significant difference was found with regard to cranial nerve injury rate (6.45% vs. 14.81%, P > 0.05), stroke (3.23% vs. 7.41%, P > 0.05), incision infection (0% vs. 0%, P > 0.99), incision hematoma (0% vs. 0%, P > 0.99), and mortality (0% vs. 3.7%, P > 0.05) between the embolization group and nonembolization group of patients. Zhang et al. proved that preoperative embolization can significantly reduce the median blood loss (median bleeding 80 mL vs. 200 mL, P = 0.001) and shorten operative time (median time, 120 min vs. 169 min, P = 0.006), but it has no impact on rate of cranial never injury (36.4% vs. 22.2%, P = 0.433). A systemic review and meta-analysis published by Texakalidis et al. included a total of 25 studies with 1326 CBT patients, and concluded that preoperative embolization appears to decrease estimated blood loss (weighted mean difference, −135.32; 95% confidence interval (CI), −224.58–−46.06; I = 78.6%) and operative time (weighted mean difference, −38.61; 95% CI, −65.61–−11.62; I = 71.9%). While another meta-analysis published by Abu-Ghanem found no significant difference in estimated blood loss (mean difference − 176.07; 95% CI − 360.63–8.49; P = 0.06), operative time (mean difference − 0.85; 95% CI − 2.53–0.83; P = 0.32), length of hospital stay (−0.3; 95% CI − 2.44–1.85; P = 0.78), or risks of cranial nerve injury (odds ratio [OR] =1.37; 95% CI 0.81–2.3; P = 0.24, vascular injury (OR = 0.6; 95% CI 0.33–1.1; P = 0.1), and stroke (OR = 0.89; 95% CI 0.31–2.58; P = 0.82) between the embolization group and nonembolization group.
Despite that preoperative embolization appears to reduce the blood loss and operative time, many authors proved that large CBTs can be safely removed without the need of preoperative embolization., Some authors also pointed out the complications associated preoperative embolization, including puncture site complications, fever, local pain, cranial nerve deficits, and distal embolization. Currently, there is no guideline for which patients should receive embolization prior surgery and the application of this technique varies in different centers. 9
| External Carotid Artery Stenting|| |
ECA stenting with covered stents have been reported as an alternative method for preoperative devascularization of the CBTs. ECA stenting might have advantages over traditional embolization in that incomplete occlusion in embolization will be prevented with covered stent exclusion, and theoretically, small feeding branches that are not apparent on angiograms are more likely to be excluded with a covered stent. However, ECA stenting cannot prevent inflow from collateral branches, and it has flaws due to the need of life-long anti-platelet therapy and also the risk of stent related complications such as arterial dissection, rupture, graft migration, and endoleak. Currently, the application of ECA stenting is only reported in small case reports and its efficacy and safety remain to be investigated.,,
| Internal Carotid Artery Stenting|| |
Preservation of ICA is of paramount importance in surgical excision of CBTs to avoid devastating cerebral ischemic complications caused by ICA occlusion. For CBTs with advanced Shamblin classification, ICA injury is sometimes inevitable to achieve radical tumor excision due to severe tumor adhesion and encasement to the vessels. Small carotid vessel injuries can be repaired by primary suturing, whereas larger defects require vascular grafting or carotid artery ligation if the bleeding is beyond control. ICA ligation was associated with high rate of mortality and stroke, especially for patients with an unfavorable anatomy of the Circle of Willis and ICA stenosis. ICA reconstruction, on the other hand, requires expertise and is associated with massive bleeding and high risk of cranial nerve injuries. Besides, temporary clamping of both the proximal and distal ends of the ICA during anastomosis also carries risk of ischemic stroke.
ICA stents have been utilized in surgical excision of head and neck paragangliomas with the primary aim of reinforcing the arterial walls, which was believed to provide a robust dissection plane that allows a safer sub-adventitial dissection with easier arterial manipulation, thus reduce the risk of ICA injury and rate of vascular reconstruction. Paolo Piazza presented the utilization of preoperative ICA stenting in surgical treatment of 21 head and neck paragangliomas, who showed total tumor removal from the ICA in 95.2% cases and long-term stent patency was obtained in 95.2% cases during a mean follow-up duration of 53.8 months. Konishi et al. reported the successful preservation of ICAs in the excision of large bilateral CBTs in a staged fashion with the use of uncovered ICA stents. Ong et al. descried the radical excision of a complicated Shamblin III CBT with the use of preoperative embolization and ICA stenting and ICA was preserved. McDougall et al. presented the use of ICA stenting in surgery of two CBT patients due to the presence of bilateral disease or failure to balloon occlusion test, and obtained complete excision of both tumors with minimal blood loss and well preservation of ipsilateral ICAs. For CBTs extending distally to the skull base, surgical reconstruction of ICA is challenging due to the limited operating space and lack of an enough length of distal ICA left for control. For this instance, Alqaim et al. applied a ICA stent before surgery, and a subsequent resection of CBT was performed with the ICA wall en bloc, leaving the exposed stent graft as a bridge between the proximal and distal end of ICA.
The greatest risk is a potential injury at the transition point of the stented and nonstented artery and minimization of traction is essential at this point. To reduce the possibility of injuring the ICA at the stent-tumor interface, stent is usually deployed up to at least 1 cm beyond the tumor edge both proximally and distally in the ICA. Surgery is recommended to be performed after an interval of at least 4–6 weeks' poststenting so as to allow the formation of a stabilized neo-intimal lining on the luminal surface of the stent. Suggested indications for ICA stenting included bilateral CBTs, absence of contralateral ICA, severe tumor encasement of ICA, and involvement of the intra-petrous ICA. ICA stenting also has risks, with the potential for stent-restenosis, distal embolization, thrombosis, dissection, and the lifelong requirement for antiplatelet therapy, in addition to the risk associated with the endovascular procedure itself.
Although ICA stenting is promising in preventing the ICA from injury and aiding the subadventitial dissection of CBTs, the current utilization of such technique is reported mainly by case reports or small case series.,, The long-term efficacy and safety of ICA stenting remains to be investigated in future studies involving large number of patients.
| Conclusion|| |
Surgical excision of CBTs is challenging due to the high risk of massive bleeding and injuries of carotid artery and cranial nerves. Preoperative embolization of arterial feeders of tumors has been applied in many centers to simplify the conduct of surgery, which, although controversial results have been reported, appears to reduce the surgical time and intraoperative bleeding, but has little impact on surgical complications including vascular injury and cranial nerve deficits. ECA stenting was reported to be an alternative method for tumor devascularization. ICA stenting has shown promising values in reinforcing the arterial wall and reducing the risk of ICA injury, however, both ECA and ICA stents are currently described in case reports or small case series, thus long-term efficacy and safety of carotid stents remain to be investigated in future studies with more clinical cases and comparative designs.
Financial support and sponsorship
This work was supported by grant from the Major Research Program of Natural Science Foundation of China (51890892).
Conflicts of interest
There are no conflicts of interest.
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