Successful prevention of carotid artery rupture by placing a covered stent before salvage resection of advanced recurrent tongue cancer: a case report

Abstract

Background

Head and neck squamous cell carcinoma (HNSCC) is a common malignancy with a high recurrence rate, especially in locally advanced cases. Tumor invasion of the carotid artery is associated with poor prognosis and poses significant therapeutic challenges, with increased risks of fatal hemorrhage and stroke. Advances in endovascular and multidisciplinary approaches have expanded treatment options for such cases.

Case presentation

We report a 39-year-old man with recurrent tongue squamous cell carcinoma encasing the left internal carotid artery after surgery and adjuvant chemoradiotherapy. A staged strategy was adopted: endovascular placement of a covered stent as hemorrhage prophylaxis followed by salvage resection with pectoralis major myocutaneous flap reconstruction. Initial angiography demonstrated preserved antegrade flow through the stent; approximately 6 months later, follow-up digital subtraction angiography showed in-stent occlusion with robust collateral perfusion via the anterior and posterior communicating arteries, without neurologic deficits. The patient recovered uneventfully and resumed normal daily activity.

Conclusion

In carefully selected patients, a stent-as-bridge-to-surgery approach may mitigate perioperative hemorrhagic risk and enable definitive salvage resection. Given the potential for rebleeding, thrombosis, and infection, this strategy requires strict perioperative monitoring, infection control, tailored antithrombotic management, and individualized collateral assessment. As a single case, these observations warrant cautious interpretation.

Introduction

Head and neck squamous cell carcinoma (HNSCC) remains a major global malignancy. Even with multimodal treatment, locoregional relapse is common in locally advanced disease, occurring in up to 50% of patients within five years [1]. Salvage management is particularly challenging in T4b recurrence involving the skull base or major cervical vessels. Carotid artery invasion or circumferential encasement markedly increases operative complexity and the risks of carotid blowout syndrome (CBS) and ischemic stroke [2], and many patients therefore receive non-surgical treatment with limited long-term control.

Advances in systemic therapy and endovascular reconstruction have enabled new multidisciplinary strategies. Covered carotid stent-grafts can reduce hemorrhagic risk and create a safer window for salvage resection and reconstruction in selected patients [3]. Meanwhile, immune checkpoint inhibitors and other agents have improved outcomes in unresectable or metastatic recurrent disease [4]. We present a case of recurrent tongue squamous cell carcinoma with carotid involvement managed by staged covered stent-graft placement followed by salvage surgery, reported in accordance with the SCARE 2020 criteria.

Case presentation

A 39-year-old man without a history of tobacco or alcohol use presented in August 2022 with a left tongue ulcer and progressive pain. Biopsy at an outside hospital confirmed squamous cell carcinoma. He underwent extended resection of the primary lesion, left neck dissection, and reconstruction of the tongue and floor of mouth with a radial forearm free flap. Final pathology demonstrated moderately differentiated squamous cell carcinoma of the left ventral tongue with muscular invasion, lymphovascular invasion, perineural invasion, and a depth of invasion of approximately 6 mm. Nodal metastases were present in left level IIb (1/4 nodes; 0.9–2.0 cm) and level III (1/11 nodes; 0.4–3.1 cm), with all other dissected left cervical nodes negative. Extranodal extension (ENE) was present. The disease was staged as pT2N3bM0 (stage IVB) according to the AJCC/UICC 8th edition. A PET/CT scan in September 2022 showed no evidence of locoregional recurrence or distant metastasis. The patient received adjuvant radiotherapy with cisplatin-based chemotherapy and remained disease-free on routine follow-up.

In October 2023, the patient developed a progressively enlarging left cervical mass with mild pain and dysphagia. Contrast-enhanced CT and MRI demonstrated locoregional recurrence with cervical nodal disease, mandibular destruction, and encasement of the left internal carotid artery. A tracheostomy was performed on November 7, 2023. He then received two weekly cycles of combination systemic therapy consisting of pembrolizumab, cetuximab, albumin-bound paclitaxel, and cisplatin. Given ongoing progression, the regimen was modified on December 23, 2023. Nevertheless, the cervical mass ulcerated and continued to enlarge.

The patient was referred to our hospital in December 2023. Repeat CT and MRI demonstrated extensive tumor invasion with tight apposition to the left internal carotid artery, indicating a high risk of CBS. Following multidisciplinary discussion, a staged “bridge-to-surgery” strategy was selected. As the first stage, endovascular reconstruction with a covered stent-graft was performed in the left internal carotid artery to reduce hemorrhagic risk (Fig. 1A and B). A GORE^® Heparin-Bonded Vascular Endoprosthesis (VBHR070502W) was deployed, followed by planned salvage resection and reconstruction (Fig. 1C and D). Completion angiography demonstrated brisk antegrade flow without endoleak and < 10% residual stenosis by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method [5] (Fig. 2A). Two weeks after stent-graft placement, salvage resection was performed with reconstruction using a pectoralis major myocutaneous flap. No sentinel bleeding occurred during the bridging interval. The postoperative course was uneventful, and the patient was discharged three weeks after surgery.

Fig. 1.

Pre- and postoperative CT images of the patient undergoing pectoralis major myocutaneous flap reconstruction. (A) Coronal CT scan before reconstruction. (B) Sagittal CT scan before reconstruction. (C) Coronal CT scan after reconstruction. (D) Sagittal CT scan after reconstruction. The red arrow indicates the location of the covered stent

Fig. 2.

Covered stent placement in the patient. (A) Placement of a covered stent prior to pectoralis major flap reconstruction to prevent carotid artery rupture. (B) Anterior cerebral circulation supplied by the right internal carotid artery via the anterior communicating artery. (C) Patent left posterior communicating artery. The red arrow indicates the location of the covered stent

To balance early stent-graft thrombosis risk against surgical bleeding, the patient received urgent enteral loading with aspirin 300 mg and clopidogrel 300 mg before transfer to the angiography suite. After vascular access was obtained, intravenous unfractionated heparin (80 U/kg) was administered, with additional boluses titrated to maintain an activated clotting time of 250–300 s throughout the procedure. Following stent-graft deployment, dual antiplatelet therapy (DAPT) with aspirin 100 mg plus clopidogrel 75 mg once daily was initiated. Because salvage resection was planned within two weeks, clopidogrel was withheld 5 days preoperatively and restarted 24 h after surgery once hemostasis was secured. DAPT was continued to complete a total of 6 weeks from stent-graft placement, followed by long-term aspirin monotherapy.

At approximately six months after stent-graft placement, follow-up digital subtraction angiography revealed complete in-stent occlusion of the left internal carotid artery. Cerebral perfusion was preserved by robust collateral flow through the anterior communicating artery (Fig. 2B) and posterior communicating artery (Fig. 2C). The right carotid circulation opacified normally, and the left vertebrobasilar system remained patent (Fig. 2C). No parenchymal perfusion defects were observed, venous outflow was unimpeded, and the patient remained neurologically intact.

At follow-up in April 2025, the patient had returned to work, remained physically active, and could run 5 km without limitation.

Discussion

In recurrent oral cavity squamous cell carcinoma with carotid artery involvement, conventional salvage options typically include carotid artery sacrifice (with or without reconstruction) or temporary carotid clamping during resection. Although carotid sacrifice with reconstruction may be undertaken when CBS is anticipated, it is associated with substantial morbidity, including ischemic stroke, rebleeding, and non-trivial procedure-related mortality. Carotid clamping can be used as a temporizing maneuver in carefully selected patients, but the risk remains considerable, particularly in previously irradiated fields and in the setting of circumferential carotid encasement. Consequently, these strategies often demand meticulous preoperative planning and may require complex vascular reconstruction or grafting. Beyond open surgical approaches, electrochemotherapy has also been explored as a locoregional salvage modality in selected oral cavity/oropharyngeal squamous cell carcinoma, and contemporary systematic reviews provide outcome benchmarks for heavily pretreated recurrent disease [6].

In our patient, the recurrent tumor circumferentially encased ≥ 270° of the left internal carotid artery, rendering immediate resection without vascular protection unacceptably high-risk. Such an approach would have carried a substantial likelihood of catastrophic hemorrhage consistent with acute CBS. Historically, carotid involvement has been managed by ligation or segmental resection with reconstruction; however, simple proximal ligation is associated with a high risk of ischemic stroke, and mortality in CBS has been reported to reach 28.6%, compared with approximately 10% for endovascular strategies [7]. Covered stent-grafts can exclude arterial wall defects while maintaining flow, offering an endovascular reconstructive option. In this case, covered stent-graft placement promptly mitigated hemorrhagic risk and created a safer window for definitive oncologic resection.

Covered stent-grafts are effective for immediate hemorrhage control, but they are associated with clinically meaningful delayed complications; therefore, our experience should be interpreted in the context of the broader literature. Early series of CBS in HNSCC reported high rates of immediate hemostasis after reconstructive stent-grafting, but late adverse events were frequent, including rebleeding, stent thrombosis, and infection-related complications such as brain abscess and cutaneous stent exposure. Although technical success was uniformly high, stent-graft reconstruction was associated with higher technical complication (≈ 50%) and rebleeding rates (≈ 39%) than deconstructive embolization (≈ 24% and ≈ 13%, respectively) in comparative cohorts [8]. Consistent with these observations, interventional reviews describe covered stent-grafts as an important option for patients who cannot tolerate carotid sacrifice, while emphasizing the non-trivial risk of delayed failure and neurologic events [9].

More recent series and case–control studies in nasopharyngeal carcinoma and other high-risk CBS populations suggest that protective or prophylactic stenting may preserve carotid patency and reduce ischemic stroke compared with endovascular occlusion; however, asymptomatic in-stent occlusion and occasional rebleeding remain concerns, highlighting the need for careful patient selection and close surveillance [10]. Contemporary multicenter data similarly confirm rapid bleeding control with stent-graft treatment but report clinically relevant rates of rebleeding and stent-related complications, supporting the view that stent-grafts are best deployed as a temporizing measure or when reconstructive alternatives are limited [11].

In contrast to many reports in which stenting serves as definitive management in patients with poor oncologic prognosis, our case illustrates a “stent-graft as a bridge to surgery” strategy. Early salvage resection with well-vascularized flap coverage was performed after stent-graft placement, and no recurrent hemorrhage or neurologic sequelae occurred during follow-up.

Covered stent-grafts are associated with both early and delayed complications, including recurrent bleeding (13–44%), in-stent thrombosis, embolic events, stroke, infection, and stent exposure [12]. Ongoing infection and residual tumor burden may further undermine durability. Although immediate hemostasis is commonly achieved, rebleeding within the ensuing weeks has been reported in 50–86% of cases, particularly when infection is uncontrolled or resection is incomplete [13]. Hemorrhage often arises at the stent edges or from adjacent diseased tissues rather than through the covered segment itself. Accordingly, when covered stent-grafts are deployed as a temporary bridge, definitive salvage surgery should proceed as early as clinically feasible, with aggressive debridement of tumor and infected/necrotic tissue and coverage using a well-vascularized flap. In our patient, radical debridement and pectoralis major myocutaneous flap coverage performed two weeks after stent-graft placement likely mitigated early rebleeding risk and created a safer window for definitive resection while preserving carotid perfusion in a carefully selected setting.

After emergency covered stent-graft placement, antithrombotic therapy required balancing the risk of early stent-graft thrombosis against perioperative bleeding. Consistent with carotid stenting practice and perioperative guidance, we administered urgent enteral loading with aspirin 300 mg and clopidogrel 300 mg [14], intraprocedural unfractionated heparin with an activated clotting time target of 250–300 s [15], and short-term DAPT (aspirin 100 mg plus clopidogrel 75 mg once daily) [14]. Because salvage surgery was unavoidable within two weeks, aspirin was maintained, clopidogrel was withheld 5 days preoperatively and restarted 24 h after surgery once hemostasis was secured [16]. DAPT was continued to complete six weeks from the date of stent-graft placement, followed by single-agent antiplatelet therapy per local practice. Notably, the heparin-bonded stent surface does not obviate the need for systemic antithrombotic therapy [17]. In our patient, this regimen was associated with no sentinel bleeding during the bridging interval and an uncomplicated postoperative course [14].

Finally, collateral cerebral circulation via the circle of Willis is critical in this setting. A complete circle can maintain cerebral perfusion through cross-flow from the contralateral carotid and vertebrobasilar systems when unilateral carotid inflow is compromised, thereby mitigating ischemic risk. Because vascular anatomy and collateral reserve vary substantially among individuals, treatment decisions should be individualized. In our case, in-stent occlusion at approximately six months was asymptomatic, likely reflecting robust collateralization through the anterior and posterior communicating arteries. This finding highlights the importance of assessing collateral pathways when considering a stent-as-bridge strategy.

This report describes a single case from a tertiary center and cannot determine comparative effectiveness relative to alternative strategies. Outcomes after covered stent-graft placement in previously irradiated or potentially contaminated fields may be influenced by infection, thrombosis, and residual tumor burden. The antithrombotic regimen and the interval between stent-graft placement and surgery were individualized and should not be extrapolated without multidisciplinary assessment. Larger, preferably multicenter studies are needed to refine patient selection, peri-interventional management, and best practices.

Conclusion

In this patient with recurrent HNSCC involving the carotid artery, a staged covered stent-graft bridge facilitated salvage resection without hemorrhagic or neurologic complications. This strategy may be considered when upfront resection is unsafe, provided that infection is controlled, antithrombotic therapy is carefully managed, and collateral cerebral circulation is sufficient.

Authors’ contributions

Lijuan Zhou and Huanyu Jiang wrote the manuscript and collected the patient’s medical history and data. Zhenkun Yu, Haidong Zhang, Lijuan Zhou and Xianjun Lv performed the surgical procedures for the patient.

Funding

No specific funding was received for this work.

Data availability

Data sharing is not applicable to this article as no new datasets were generated or analyzed.

Declarations

Ethics approval and consent to participate

This case report was reviewed and approved by the Ethics Committee of BenQ Medical Center affiliated with Nanjing Medical University.

Consent for publication

Written informed consent for publication of this case report and the accompanying images was obtained from the patient.

Competing interests

The authors declare no competing interests.