Carotid stenting and "extarterectomy" in the management of head and neck cancer involving the internal carotid artery: Technical case report

OBJECTIVE AND IMPORTANCE: Head and neck cancer that invades the internal carotid artery (ICA) represents a significant management challenge. We describe a novel technique that allows for aggressive tumor removal without disrupting blood flow through the affected ICA. CLINICAL PRESENTATION: A 62-year-old man was referred to our institution for management of a neck malignancy involving the ICA. Cerebral angiography suggested that there was good collateral flow from the opposite hemisphere, but the patient reported visual loss in the ipsilateral eye during balloon test occlusion of the ICA. INTERVENTION: A self-expanding stent was deployed in the ICA; it spanned the entire length of the artery involved by tumor. One month later, the patient underwent tumor resection. During surgery, a long ICA arteriotomy was performed directly down to the mesh of the stent. A neoendothelium had formed within the stent, which prevented arterial bleeding. The carotid wall was dissected from the stent without difficulty and removed en bloc with the surrounding tumor. The exposed stent was wrapped circumferentially with a synthetic patch material. The patient tolerated the procedure well, and postoperative angiography demonstrated normal filling of the ICA. CONCLUSION: We describe a novel approach to a patient with head and neck cancer involving the cervical ICA. Preliminary stenting, which allows time for endothelialization before surgery, may permit aggressive tumor resection without interrupting flow through the ICA. This technique obviates the need for complicated carotid reconstruction procedures and avoids the risk of delayed ischemia from carotid sacrifice.