Internal carotid artery ligation for excision of a huge Carotid Body Tumor – Report of a Case –
Panagiotis G. TheodoridisV. ArgitisNikolaos IatrouIlias DodosAnastasios G. PotouridisKonstantinos Dervisis
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Abstract:
Paragangliomas (PGLs) are rare neuroendocrine tumors. About 50% of PGLs develop in the head and neck region, of which approximately 50% originate from the carotid body, and classified as Carotid body tumors (CBTs). Proper management and therapeutic options for CBTs have not yet been clearly determined, to date. We hereby report a case of a huge transected CBT treated by ligation of internal carotid artery (ICA), resulting to an unexpected ipsilateral embolic stroke despite an anticoagulation therapy.Keywords:
Surgical excision
External carotid artery
Bilateral external carotid arteries ligation is a rare practice in cases of extensive maxilla-facial injuries. Defining indication criteria in the management of such cases is highly demanded in emergency surgery.Reported case presents a male patient 67 years old man with a gunshot to the face. The whole face was macerated. Patient was operated surgically performing bilateral external carotid artery ligation, tracheostomy, pharyngostomy, gastrostomy and pressure dressing to face and head.The procedure of bilateral external carotid artery ligation has no defined role in the management of maxillofacial trauma. The current status of such procedure in maxillofacial trauma needs revision.
External carotid artery
Facial trauma
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The authors were the first ones who obtained the established collateral vascular anatomy after external carotid artery embolization and ligation with angiography, vascular transparent specimen filled with ink, microvessel casting and scanning electronic microscope. The results indicated that the rich collateral circulation would be established after external carotid artery ligation. Ligation itself could not cut off blood supply to lesion area. Embolization, in turn, can effectively obstruct blood supply by reducing collateral branches. So we suggest that it is better to use external carotid embolization rather than external carotid ligation for those oral maxillofacial lesions with rich blood supply.
External carotid artery
Collateral circulation
Blood supply
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Epistaxis which is not controlled by anterior and posterior nasal packing is usually treated by ligation or embolization of the arterial supply to the nose. Transantral ligation of the maxillary artery, or embolization of its branches, have recently been considered the treatments of choice. Ligation of the external carotid artery has the advantage of being a short procedure which can be readily performed under local anesthesia, and does not require particular surgical expertise or the use of specialized equipment. This procedure, in combination with ligation of the ipsilateral anterior ethmoidal artery, controlled the bleeding in 14 of 15 patients over a nine-year period. There were no deaths and no significant complications. Although ligation and embolization of the maxillary artery are of proven efficacy, ligation of the external carotid artery is similarly effective and its simplicity may still make it the procedure of choice in some situations.
External carotid artery
Maxillary artery
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Objective:To investigate whether the external carotid artery which has been ligated can get repatency through the ligation or the ramus anastomosis of collateral circulation above and below the ligation position.Methods:From September 1988 to April 1995, the external carotid artery had been ligated in 9 patients with severe epistaxis. Among them, 2 patients had recurrence epistaxis in the side of the ligation,of whom 1 recurred on the 5 years after ligation and 1 recurred on the 7 years after ligation.Digital subtraction angiography on the external carotid artery which had been ligated was performed in order to confirm the relation between the ligated external carotid artery and the recurrence epistaxis in the 2 patients.Result: The external carotid artery which had been ligated could not get repatency through the ligation or the ramus anastomosis of collateral circulation above and below the ligation position,and the ramus anastomosis of collateral circulation above and below the ligation couldn′t had formed. The external carotid artery which had been ligated had no relation with the recurrence of epistaxis.Conclusion: The external carotid artery which have been ligated can not get repatency as time goes on.
External carotid artery
Collateral circulation
Digital subtraction angiography
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Although intracranial obliteration or detachable balloon occlusion of the proximal artery has been recommended for treatment of unruptured aneurysms of the cavernous sinus, carotid artery ligation continues to be used by many neurosurgeons. This study compares the long term outcome after carotid ligation with that following conservative treatment. Nine of 13 patients treated by common carotid ligation improved, two were unchanged but two patients subsequently needed internal carotid ligation (mean FU 8.2 years). Ten patients were managed conservatively. Three improved, six were unchanged and one patient died following intracranial haemorrhage (mean FU 6.9 years). The authors conclude that carotid ligation remains an acceptable method for treating these difficult lesions.
Conservative Treatment
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Not many instances of ligation of the external carotid artery for severe nasal hemorrhage are given in the literature. Hyde1reported a case of what he terms idiopathic nasal hemorrhage which was ultimately controlled by ligation of the external carotid artery. This appears to be the only case in which the external carotid artery was tied for essential nasal hemorrhage. There are, however, many reports of the ligation of the common carotid artery. Bartlett and McKittrick2presented a paper on a case of secondary hemorrhage in which the common carotid artery was ligated. A review of their references shows that many cases of hemorrhage from the nose and throat, either spontaneous or postoperative, could have been controlled by a less formidable procedure than ligation of the common carotid artery; namely, by ligation of the external carotid artery. Spontaneous hemorrhage from inoperable malignant conditions of the jaw, antrum
External carotid artery
Ligature
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Skull base tumors, in addition to blood supply from the external carotid artery, frequently receive a portion of their blood supply from the cavernous portion of the internal carotid artery, especially when the cavernous sinus is invaded by tumor. Preoperative embolization routinely includes obliteration of the supply to the tumor from the external carotid system. However, a variety of strategies are available that enable preoperative embolization of supply from the internal carotid artery as well. These include direct catheterization of cavernous branches of the internal carotid artery, temporary occlusion of the internal carotid artery during external carotid embolization, embolization of the internal carotid artery supply during temporary or permanent occlusion of the internal carotid artery, and internal carotid artery sacrifice. The angiographic anatomy in any particular case dictates these options.
External carotid artery
Sinus (botany)
Blood supply
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Patterns of collateral vascularization were investigated by SEM evaluation of microvascular corrosion casts following either ligation or embolization of the external carotid artery in the rabbit. Results indicated that rich collateral channels were established soon after ligation of this artery, and blood supply to the lesional area was never cut off. In contrast, embolization effectively obstructed blood supply by reducing collateral branches. We concluded that for purposes of controlling blood loss, it is more helpful to employ external carotid embolization rather than ligation for oral maxillofacial lesions with a rich blood supply.
External carotid artery
Blood supply
Collateral circulation
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Ligation of the external carotid artery is not infrequent operation now, and every surgeon today has performed or has had been acquainted with the surgery of this vessel.It is commonly believed that the peripherial blood flow after the ligation of external carotid artery is reduced or ceased for a long time, but concerning this, only a few experiments about reestablishment of the blood flow after the ligation have been made.Therefore, the re-establishment of blood flow was observed in man by using a plethysmograph and sphygmo-manometer and by using the three dimensional cast model of the blood vessel in the dog.1) Re-establishment of the blood flowThe plethysmograph at the ear lobe showed that in 11 of the 18 cases (61%) the blood flow was recovered in 5 days, that is, in 4 of 11 immediately after the ligation, 3 in 1 day, 1 in 3 days, 3 in 5 days. And also immediately after the ligation low but regular waves were noted.2) Blood pressureBlood pressure of the external carotid artery was messured befor and after the ligation in 4 cases in man and 6 cases in dog, and arterial pressure was maintained on the same level as venous pressure.3) AnastomosisThree dimensional cast model in dogs showed the most important channel of collateral circulation to the external carotid artery were the external ophthalmic artery and middle meningial artery and following this the free communication between the external carotid arteries of both sides and the vertebral artery into the occipital artery. Moreover, the route of the ophthalmic artery to the external ophthalmic artery and the ethmoidal artery to the external ophthalmic artery were recognized, but it is thought that the route does not contribute to the blood flow because of its narrowness.Results.The re-establishment of the blood flow was much earlier than it was thought and the arterial pressure was maintained on the same level as the venous pressure, so one should not rely too much on the ligation of the external carorid artery for control of hemorrhage.
External carotid artery
Plethysmograph
Collateral circulation
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Citations (1)
Paragangliomas (PGLs) are rare neuroendocrine tumors. About 50% of PGLs develop in the head and neck region, of which approximately 50% originate from the carotid body, and classified as Carotid body tumors (CBTs). Proper management and therapeutic options for CBTs have not yet been clearly determined, to date. We hereby report a case of a huge transected CBT treated by ligation of internal carotid artery (ICA), resulting to an unexpected ipsilateral embolic stroke despite an anticoagulation therapy.
Surgical excision
External carotid artery
Cite
Citations (0)