Bleeding is a most common complication during head and neck surgical procedure but major tumour site bleed or acute CBS warrants emergency care to prevent immediate mortality. Acute and torrential bleed in head and neck cancer patients requires ECA ligation if the bleed is in tumour site and region supplied by ECA or CCA ligation if it is CBS. Over all incidence of CBS in head and neck surgery patients is between 3-4.5%.5 Based on literature, its incidence varies based on patients clinical scenario, post-operatively its incidence increases to 4.5–21.1% in previously irradiated patients, while in radiotherapy naïve patients, its 0–2.4%.6,7
Various causes have been attributed for CBS, one of them being considered as radiotherapy. Radiation has proven to generate free radicals which lead to obliteration of vasa vasorum of the arterial adventitial layer by forming thrombosis thereby fibrosis and weakening of arterial wall. Due to the focal ischemia, there’s formation of pseudoaneurysms, radiation induced necrosis and spontaneous rupture of the artery.8 Studies have shown that previously irradiated patients increases CBS by 7.6 fold post-operatively.9 Also studies by Gall et al. and Krause et al. concluded that pre-operative radiotherapy when given in moderate doses(< 45 Gy) increases possibility of CBS by 2.7-3%.6 It has also been reported that 80–90% of patients with CBS, has a prior radiotherapy history giving a precedence that radiotherapy is the main predisposing factor for CBS and possibility increases further during salvage surgery.10 Studies have shown that tumour infiltration of the carotid wall together with surrounding inflammation or tumour encasement of > 180° circumference of carotid wall, have more possibilities of developing CBS. As these disease condition requires higher radiation it ends up with weakening of carotid wall as disease responds to radiation making it prone for CBS.11,12 Patients receiving hypofractionated stereotactic radiotherapy(hSRT) and stereotactic radiosurgery(SRS) modalities of therapy have a higher risk of CBS when compared to intensity-modulated radiation therapy(IMRT) which may be due to increased biological efficacy of higher radiation doses per fraction while on the contrary fractionation schedule did not have an influence on the development of CBS with 16% chances of CBS on daily basis and 12.5% on alternate days.13,14
Surgically stripping of the carotid sheath during neck dissection compromises the nutrition of the carotid artery and renders the carotid artery more prone for CBS on a later date due to lack of supporting healthy tissues.11 Bacterial infection secondary to surgical site infection (SSI) increases the effects of local inflammatory mediators and also induces thrombosis of vasa vasorum. When coupled with oro-cutaneous/pharyngo-cutaneous fistula communicating to neck, it leads to digestion and dissection of adventitia and gradual erosion.15 Surgical complications like surgical site infection(SSI) and fistula needs to be dealt the earliest to avoid immediate post op CBS.
60–70% CBS occurs in predominantly at the bifurcation of CCA and in fewer cases in ICA usually 40–90 days after surgery or radiation. 2% of cases it can occur bilaterally. In our study, all the patients who underwent CCA ligation had CBS at CCA bifurcation. CBS can be classified into acute, impending and threatened. Threatened (type I) CBS are characterized by exposure of carotid artery on examination or imaging. Impending (type II) blowouts are the conditions where there are sentinel bleeding episodes which controlled with compressions and regular dressings. Acute carotid hemorrhage (type III) is sudden give away of the carotid wall secondary to infection/necrosis is associated with high rates of mortality. Study by Liang et al. reported that 8%, 24% and 68% presented with threatened, impending and acute CBS resptively.16 Recurrent CBS refers to repeated episodes of bleeding occuring in the same vessel which had been previously intervened and can be considered as treatment failure if occurred in the same site or progressive disease if occurred in different site of the same arterial segment. Recurrent CBS incidence can be 35–65% with duration varies from 1–6 months of previous ligation.16,17 In our study, all the patients presented with acute bleed which necessitated immediate surgical intervention to avoid mortality. Of the 8 patients who underwent CCA ligation, 3 patients mortality due to recurrent CBS at their hometown. Surgical wound dehiscence, radiation-induced arteriopathy, musculocutaneous flap necrosis or tumor invasion into the vessel are considered as the possible causes for recurrent CBS.17
Acute CBS is an oncological emergency where patient presents with torrential hemorrhage secondary due to loss of CCA wall and would result in mortality in 40% of cases if not surgically interwined.18 10–20% of patients develop permanent neurological sequelae and 30–40% remain asymptomatic.19 8 patients in our study underwent emergency CCA ligation and post-operatively didn’t have any neurological sequelae. This could be due to development of collateral blood flow by contralateral CCA or by ipsilateral ECA/vertebral arteries to the Circle of Willis.20 Risk of morbidity increases if the patient is in hypotension, so its pertinent to address the blood pressure with adequate resuscitation and further delay the neurological sequelae by substituting low dose heparin 8 hours after ligation.6
Endovascular management in CBS has received precedence in recent years for control of bleed and reconstructing damaged arteries in threatened, impending and stable acute bleeds. Gold standard for diagnosing threatened and impending CBS is digital subtraction angiography (DSA) for assessing arterial wall irregularity/rupture, luminal stenosis, pseudoaneurysm and contrast leak.21 Embolisation of ECA for the stable local tumour bleeds can be performed by deploying materials like microparticles or microcoils through mircocatheters.22 But for CCA bleed either endovascular occlusion or endovascular repair with covered stents is done. Endovascular occlusion by Amplatzer Vascular Plug is done in patients with complete circle of Willis and adequate contralateral flow which is ascertained by prior DSA and Balloon Occlusion Test for 30 minutes where neurological assessment is done for every 3–5 minutes.23 Patients who fall short of these tests and with deficient carotid wall are planned for Polytetrafluoroethylene-covered nitinol stent grafts.24 Patients who undergo endovascular procedure would receive lifelong antiplatelet drugs. As per study by Chang et al., neurological sequelae associated with endovascular embolisation is 8–14%, rebleeding rates with embolisation and covered stents are 11–21% and 25–85% respectively.24
11 patients were operated during covid-19 period (March 2020 – October 2020). All of these patients underwent RT-PCR test for Covid-19.
Since our center is marked as Red Zone hospital, all the necessary universal precautions with minimal handling like compression packing to the bleeding site was followed.
Considering the possibility of 1 in 5 false negative rate of the test, universal precautions with PPE kit and usage of PAPR was done in all emergency cases.
25 Open tracheostomy was preferred in a negative pressure, reverse laminar flow operation theatre as it is an aerosol generating procedure with minimal personnel in the theatre.
26 Cautery usage was discouraged and bloodless field was tired to be achieved during the procedures. Since 4 patients turned out to be positive, medical personnel involved in those cases were quarantined but on further testing none of personnel turned positive.