Recurrent carotid blowout syndrome: Diagnostic and therapeutic challenges in a newly recognized subgroup of patients

BACKGROUND AND PURPOSE: To our knowledge, recurrent carotid blowout syndrom e (rCBS) has not been well described. Our purpose was to review our institu tion's recent experience with patients who presented with multiple episodes of carotid blowout syndrome (CBS), and who were referred for emergent diag nostic angiography and endovascular therapy. METHODS: We retrospectively reviewed the last 46 consecutive patients who h ad a clinical diagnosis of CBS, All patients were examined and treated pros pectively according to a standardized protocol. Most patients (43 of 46) ha d undergone extensive primary and salvage radical surgery with intraoperati ve brachytherapy or external beam radiation or both. The remaining three pa tients had either traumatic or iatrogenic CBS. RESULTS: Twelve patients (26%) in our series had more than one episode of C BS in which a total of 32 (20 recurrent) events were observed (average 2.7, range 2-4). Intervals of rCBS ranged from 1 day to 6 years. Thirteen (65%) of 20 recurrent events were attributed to progressive disease (PD), and se ven (35%) of 20 to treatment failures (TFs), In the PD group, seven (54%) o f 13 had recurrent ipsilateral disease, and six (46%) of 13 had recurrent c ontralateral disease. Etiologies of rCBS were as follows: seven exposed car otids; seven carotid pseudoaneurysms; eight small-branch pseudoaneurysms; f ive tumor hemorrhages; three hyperemic/ulcerated wounds; and one aortic arc h rupture. Twenty-seven of 32 events were treated with endovascular therapy , which included the following: nine carotid occlusions; 11 small-branch em bolizations; three transarterial tumor embolizations; one carotid stent; an d two direct-puncture embolizations. Four of six TFs were retreated success fully with endovascular therapy; the remaining two TFs were managed success fully by surgery. In the PD group, hemorrhagic complications of rCBS were m anaged successfully in all but one patient, who died. No permanent neurolog ic or ophthalmologic complications occurred. CONCLUSION: Recurrent CBS is a frequently encountered problem in which most cases are caused by PD resulting from both multifocal iatrogenic arteriopa thy and occasional wound complications that are characteristic of aggressiv ely managed head and neck surgical patients. Initial TFs are encountered of ten as well. Despite the diagnostic and therapeutic challenges of rCBS, mos t cases can be retreated effectively.