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Carotid Artery Resection in Head and Neck Cancer Treatment

last modified on: Thu, 10/05/2023 - 08:39

GENERAL CONSIDERATIONS

  1. Indications
    1. The contention that resection of the common or internal carotid artery due to invasion by malignant disease is a "subject of considerable study and debate in the literature" (as cited in this protocol in the 1990's) remains relevant today (Orlandi 2021)
    2. Patients with cancer involving the carotid artery deserve attention to the complex clinical decisions that must be tailored to the individual clinical situation. Many physicians would regard this intervention as a palliative procedure and approach its utilization from that standpoint. In selected cases, with an otherwise dismal prognosis, the procedure may be viewed as offering a small chance at prolonged survival. Regardless of the perspective, carotid resection in the head and neck cancer patient population is associated with significant morbidity and mortality and, in many cases, limited demonstrable benefit. The following indications and contraindications should be viewed as general guidelines, and the goals and indications for the procedure must be individualized for each specific case.
    3. Localized tumor invasion of the carotid artery with no evidence of unresectable skull base or vertebral invasion
    4. No evidence of distant metastasis
    5. Patient demonstrates good candidacy for carotid resection based on preoperative work-up (see below)
  2. Contraindications
    1. Clear evidence of unresectable tumor elsewhere in the head and neck
    2. Evidence on preoperative work-up that the patient is at severe risk for neurovascular ischemic event with even extremely brief carotid occlusion
  3. Pertinent Anatomy
    1. Due to their proximity to the carotid artery, the lower cranial nerves and sympathetic chain may also have tumor invasion (IX, X, XI, XII). Patients should be aware of the potential need to resect these structures in the course of carotid resection.
    2. The carotid artery courses through the neck in the direction of "carotid line", starting inferiorly at the sternoclavicular joint, extending superiorly to the midpoint between the angle of the mandible and the mastoid process.
    3. The right common carotid artery is derived from the brachiocephalic artery, while the left common carotid artery arises directly off of the aortic arch. 
      1. The carotid artery bifurcates at the superior edge of the thyroid cartilage.
        1. The internal carotid artery has no branches in the neck, and continues in the carotid sheath to the skull base.
        2. The external carotid artery has 8 branches, including:
          1. Superior thyroid (superior laryngeal usually a branch of)
          2. Ascending pharyngeal
          3. Lingual
          4. Facial
          5. Occipital (flanks digastric)
          6. Posterior auricular (flanks digastric)
          7. Maxillary 
          8. Superficial temporal - the terminal branch
    4. The Carotid sheath contains three structures, including the carotid artery (medially), the internal jugular vein (laterally), and the vagus nerve (posteriorly). The sympathetic chain is directly posterior to the carotid sheath.

PREOPERATIVE PREPARATION (as per 1990's protocol at the U of Iowa)

  1. Evaluation
    1. Complete head and neck examination
    2. Head and neck cancer work-up per protocol
    3. CT with contrast from base of skull to clavicles, special attention to skull base and thoracic inlet. The CT or MRI of the head and neck are often unreliable regarding the extent or location of carotid involvement. In many cases, the final decision to resect the carotid must be made at the time of surgical exploration.
    4. Test balloon occlusion study
    5. Post-balloon occlusion Tc99 HMPAO SPECT scan; consider supplementing with post-occlusion MRI with gadolinium
    6. Radiation oncology consultation to discuss alternatives to surgery as well as role for postoperative treatment
    7. Vascular surgery consultation and mapping of saphenous veins
      1. Operative plan for carotid ligation without reconstruction, reconstruction without shunt, or reconstruction with shunt will depend upon the vascular work-up.
      2. In general, if the carotid can be reconstructed, it is preferred to do so even if the preoperative work-up indicates that the patient will likely tolerate permanent occlusion without neurovascular sequelae.
    8. Intraoperative EEG monitoring should be arranged preoperatively to plan for placement of leads the AM of surgery.
  2. Potential Major Complications
    1. Lethal neurovascular event either during or following surgery
    2. Nonlethal but permanently disabling neurovascular event
    3. Severe infection compromising vascular repair
    4. Severe bleeding intraoperatively or postoperatively
    5. Anticipate the need to resect lower cranial nerves and probable Horner's syndrome postoperatively; resection of lower cranial nerves may result in significant problems with dysphagia, aspiration, and decreased voice strength

NURSING CONSIDERATIONS

  1. Room Setup
    1. See Basic Soft Tissue Room Setup
  2. Instrumentation and Equipment
    1. Standard
      1. Major Instrument Tray 1, Otolaryngology
      2. Major Instrument Tray 2, Otolaryngology
      3. Bipolar Forceps Trays
      4. Arterial Graft Instrument Tray
    2. Special
      1. Tracheotomy Tray (available only)
      2. Varidyne vacuum suction controller
      3. Nerve stimulator control unit and instrument
  3. Medications (specific to nursing)
    1. 2% lidocaine
    2. Papaverine 30 mg/ml
    3. Antibiotic ointment
    4. 1% lidocaine with 1:100,000 epinephrine
  4. Prep and Drape
    1. Standard prep, 10% providone iodine
    2. Drape
      1. Head drape
      2. Long sheet to body, disposable
      3. Split sheet
  5. Drains and Dressings
    1. Antibiotic ointment
    2. Varidyne vacuum suction drain: 7 mm or 10 mm
  6. Special Considerations
    1. Blood loss may be rapid, double suction may be needed immediately
    2. Vascular instruments should be available.
    3. If the carotid artery is to be reconstructed using a saphenous vein, draping and prepping should be modified accordingly.

ANESTHESIA CONSIDERATIONS

  1. General
    1. The patient should be on a Mayfield headrest, and the table turned 180°.
  2. Specific
    1. The anesthesiologist should be aware that disrupted carotid flow may occur in order to rapidly institute appropriate neurovascular anesthetic maneuvers.
    2. The anesthesiologist should be aware that brisk bleeding may occur at various points during the procedure and that blood should be immediately available.
    3. Intraoperative EEG monitoring should be arranged.

OPERATIVE PROCEDURE (as per 1990's protocol at the U of Iowa)

  1. The operative procedure will depend on the clinical situation. The following are general guidelines that should be followed during these cases.
    1. If there are suspected areas of tumor involvement that would preclude carotid resection, these should be initially identified and explored with biopsy employing frozen section evaluation.
    2. Resection of tumor in the neck should initially involve proximal and distal control of the carotid above and below the suspected area of carotid involvement.
      1. The resection specimen is "mobilized" toward the area of carotid involvement.
      2. Clearance of tumor with frozen section control should proceed as the specimen is mobilized toward the area of carotid involvement.
      3. The neck specimen is left attached to the carotid.
    3. After the saphenous vein has been harvested and the vascular team is in position to perform the carotid repair, the carotid is divided above and below the tumor attachment or infiltration. Frozen sections of the carotid ends are sent. A vascular shunt, IV Heparin, and Dextran 40 are used per the vascular service preference.
    4. The carotid graft is performed by the vascular service.
    5. With rare exception, the vascular graft should be covered with a pectoralis myofascial flap. This is necessary if there has been entry into the oral cavity or pharynx during tumor excision or if the skin flaps have been previously irradiated. In these cases, the pectoralis muscle is draped over the carotid and graft and sutured to the prevertebral fascia medially. This effectively creates a watertight closure around the graft, excluding it from the pharyngeal and skin closure.

POSTOPERATIVE CARE

  1. Neuro checks Q1 hr for 24 hours
  2. Drains out when less than 30 cc per 24 hours
  3. Carotid duplex scan at two to three weeks
  4. ASA, Dextran 40, Heparin per vascular service preference

REFERENCES

Atkinson DP, Jacobs LA, Weaver AW. Elective carotid resection for squamous cell carcinoma of the head and neck. Am J Surg. 1984;148:483-488.

Eckard DA, Purdy PD, Bonte FJ. Temporary balloon occlusion of the carotid artery combined with brain blood flow imaging as a test to predict tolerance prior to permanent carotid sacrifice. AJNR. 1992;13:1565-1569.

Ehrenfeld WK, Stoney RJ, Wylie EJ. Relation of carotid stump pressure to safety of carotid artery ligation. Surgery. 1983;93:299-305.

Enzmann DR, Miller DC, Olcott C, Mehigan JT. Carotid back pressures in conjunction with cerebral angiography. Radiology. 1980;134:415-419.

Meleca RJ, Marks SC. Carotid artery resection for cancer of the head and neck. Arch Otolaryngol Head Neck Surg. 1994;120:974-978.

Nayak UK, Donald PJ, Stevens D. Internal carotid artery resection for invasion of malignant tumors. Arch Otolaryngol Head Neck Surg. 1995;121:1029-1033.

Orlandi E, Ferrari M, Lafe E, Preda L, Benazzo M, Vischioni B, Bonora M, Rampinelli V, Schreiber A, Licitra L, Nicolai P. When Everything Revolves Around Internal Carotid Artery: Analysis of Different Management Strategies in Patients With Very Advanced Cancer Involving the Skull Base. Front Oncol. 2021 Nov 18;11:781205. doi: 10.3389/fonc.2021.781205. PMID: 34869033; PMCID: PMC8636461.

Peterman SB, Taylor A, Hoffman JC. Improved detection of cerebral hypoperfusion with internal carotid balloon test occlusion and 99mTc-HMPAO cerebral perfusion SPECT imaging. AJNR. 1991;12:1035-1041.

Reilly MK, Perry MO, Netterville JL, Meacham PW. Carotid artery replacement in conjunction with resection of squamous cell carcinoma of the neck: preliminary results. J Vasc Surg. 1992;15:324-30.

Woodburne RT, Burkel WE, Essentials of Human Anatomy. 9th edition. Oxford press. 1994;202-205

Yuh WTC, Crain MR, Loes DJ, et al. MR imaging of cerebral ischemia: findings in the first 24 hours. AJNR. 1991;12:621-629.