2007 Abstracts: The Emergent Use of Endografts in the Carotid Circulation to Control Hemorrhage in Potentially Contaminated Fields

Background: Carotid blowout and tracheo-innominate fistula are two erosive vascular emergencies in the carotid circulation with exceedingly high morbidity and mortality. Endografts provide a minimally invasive option to control hemorrhage in these pathologies while maintaining cerebral blood flow. However, the technique involves the placement of a foreign body in a potentially contaminated field. The purpose of this paper is to report our experience with four cases and review the world literature regarding this approach.
Methods: A retrospective review at our institution identified two patients who underwent endograft placement to control active hemorrhage due to carotid blowout and two for tracheo-innominate fistula. To this cohort, an additional 16 cases of carotid blowout and 3 tracheo-innominate fistulae treated with endografts were added from a literature search using PubMed. Outcomes evaluated included survival as well as infectious, ischemic, hemorrhagic, and wound complications (i.e., exposure of endograft).
Results: For carotid blowout, 8 of the 18 patients died from their cancer between 2 and 7 months after endograft placement. Two others died from late ischemic complications after coiling was performed for rebleeding (at 6 weeks and "several months" after endograft placement.) There were four other cases of rebleeding (two immediate, one at 11 days, one at 6 weeks). There were two other strokes (both perioperative) that resolved. Despite late exposure of the endograft being noted in 6 patients, only one case of systemic infectious complication was noted (brain abscess four months after endograft placement.) Anti-biotic protocols were rarely documented, but were not used peri-operatively in the case with the brain abscess. One case of a local peri-graft infection resolved with anti-biotics. Of the 8 survivors, the longest follow-up was 5 months.
For tracheo-innominate fistula, one patient died of anaplastic thyroid cancer 4 weeks after endograft placement. The patient also had immediate rebleeding requiring a second endograft extending into the common carotid for control and suffered a watershed stroke perioperatively. A second patient died after open conversion for rebleeding and erosion of the endograft into the trachea 6 weeks after endograft placement. Of note, the patient had a tracheo-innominate fistula from metastatic salivary gland cancer and irradiation. The patient, in fact, did not receive a tracheostomy until after the initial herald bleed. The three patients with tracheo-innominate fistulae from non-cancerous causes have survived from 14 to 19 months without evidence of infection. Two of these three patients had documented prolonged peri-operative anti-biotics (4-6 weeks.)
Conclusions: The use of endografts to control hemorrhage in carotid blow-out and tracheo-innominate fistula appears to provide improved early results compared to traditional open techniques. Overall survival is often limited by cancer and the goal should be palliation in these cases. Re-bleeding is common and likely secondary to the erosive nature of the lesions, suggesting a benefit for longer treatment zones. Infectious complications are relatively uncommon, but do occur. Consideration for prolonged peri-operative anti-biotics may be justified in patients with reasonable life expectancy.