Carotid blowout during attempted thrombectomy immediately after neck surgery

A 67 years-old male patient was submitted to total laryngectomy (no radiotherapy) due to laryngeal carcinoma. He woke up from the surgery with symptoms/signs of MCA infarction.

Non contrast CT revealed acute infarction at the insula and lateral frontal regions (ASPECTS 7)

CTA showed intracranial M2 (dominant branch) occlusion; at the neck there was cervical ICA occlusion (irregular tapering but without signs of acute transmural dissection).

Under general anesthesia, we tried to cross the cervical occlusion, to try to reopen the left dominant M2.

Materials in place: 8F Merci balloon guide catheter (BGC); 057 DAC; Trevo 18 microcatheter; 0.014'' Trasend microwire

Left CCA injection (lateral view) showed cervical ICA occlusion (pencil-like tapering, suggestive of dissection).

We were unable to cross the occlusion; after some attempts, control angiograms (lateral view) revealed massive contrast extravasation, in keeping with acute carotid rupture (blowout). The airway was protected since the patient was intubated; however, blood was oozing from the surgical sutures.

At this point, we inflated the BGC balloon and occluded the ICA with several coils; the last coil stretched and was (as much as possible) pushed to the external carotid artery.

Control CT (at 48h) revealed a large MCA infarction.

Retrospectively, perhaps the cervical ICA was injured during surgery; our subsequent endovascular manipulations must have created a full tear at the wall. Under those life threatening circumstances, acute occlusion was mandatory; we were unable to cross the occlusion, so no carotid-sparing approaches (namely, a covered stent) were considered.