RAPID

OCCLUSION OF THE INTERNAL CAROTID

ARTERY WITH AMPLATZER VASCULAR PLUG
AFTER INJURY
Resident(s): Salim Abboud1, MD; Sasan Partovi1, MD1, and Sunil
Manjila, MD2
Attending(s): Kristine Blackham MD1,2, Jeffrey L Sunshine MD PhD1,2
Program/Dept(s): Department of Radiology1,
Department of Neurosurgery2

CHIEF COMPLAINT & HPI

Chief Complaint and/or reason for consultation

Severe bleeding from left internal carotid artery (ICA) during oropharyngeal
abscess debridement.

History of Present Illness

The patient has history of oropharyngeal squamous cell carcinoma (SCC) treated
with chemoradiation. Patient was transferred from an outside hospital for
management of left-sided pharyngocutaneous fistula with associated neck
oropharyngeal abscess.
Under general anesthesia, laryngoscope was introduced into the oropharynx.
Forceps were used to debride a large amount of necrotic tissue when significant
arterial bleeding was encountered. Further examination of that area revealed a
tear in proximal left ICA.
Bleeding could be controlled with pressure with the laryngoscope, however
attempts to pass a Fogarty catheter into arterial tear were unsuccessful.
Bleeding was temporarily controlled with intra-oral digital pressure.

RELEVANT HISTORY
Past Medical History

Primary squamous cell carcinoma (SCC) of the tonsils

Chemoradiation therapy for tonsillar SCC
Recurrent oropharyngeal abscess following surgical
debridement (image is immediately prior to most recent
debridement)
Pharyngocutaneous fistula

ICA

Past Surgical History:

Left anterior neck debridement for oropharyngeal and

sternocleidomastoid abscess

Medications: Piperacillin + tazobactam

Allergies: None

Axial contrast enhanced CT performed

immediately prior to most recent debridement
of tonsillar SCC (circle).

DIAGNOSTIC WORKUP
Patient taken emergently to neurointerventional A
suite.
No active extravasation while holding digital
pressure (Image A). Gauze metallic marker
overlies site of injury.
With transient release of intra-oral digital
pressure, no active contrast extravasation or
pseudoaneurysm noted on DSA. There was focal
narrowing at C-3-4 level (Image B).
Reflux of contrast was noted into the left
vertebral artery (not shown).
Vascular measurements performed: left
proximal ICA 5.5 mm and the distal ICA 5.3 mm.

DIAGNOSIS
Iatrogenic injury to the proximal left internal carotid artery

INTERVENTION
A

4 mm x 6 mm Amplatzer II vascular
plug (AVP, see arrow) initially deployed
distal to the ICA injury (box).
Diminished but persistent antegrade
flow was noted (Image A).
6 mm x 6 mm AVP placed immediately
proximal to the first AVP (arrows). Both
AVPs are distal to the injury site (box).
Antegrade flow is further reduced but
persistent (Image B).

INTERVENTION (CONT.)
A third AVP II (8 mm x 7 mm) was placed
immediately proximal to the bleeding site (arrow)
for proximal control of bleeding (Image A).
The AVP was intentionally over-sized relative to
vessel lumen (5.6 mm) in order to prevent distal
migration.
There is minimal, persistent antegrade flow
(Image B).
A fourth AVP (6 mm x 6 mm ) was deployed in the
distal left common carotid artery (not shown) with
subsequent stasis of contrast.

CLINICAL FOLLOW UP
A

DSA following left vertebral artery injection shows filling of left middle cerebral
artery via patent left posterior communicating artery (Images A , B)
Coronal CT image demonstrates stacked configuration of the 4 AVP in the left CCA
and ICA (Image C) .

QUESTION
1) Following embolization of the left ICA, perfusion of the left MCA was noted via a
patent left posterior communicating artery following left vertebral artery injection.
In what percentage of patients is there a complete Circle of Willis?
A: > 90%
B: 50-80%
C: 20-50%
D: <10%

CORRECT!
1) Following embolization of the left ICA, perfusion of the left MCA was noted via a
patent left posterior communicating artery following left vertebral artery injection.
In what percentage of patients is there a complete Circle of Willis?
A: > 90%
B: 50-80%
C: 20-50% The reported incidence of a complete Circle of Willis is highly variable,
but reports generally range from between 20 and 50%.
D: <10%

CONTINUE WITH CASE

SORRY, THATS INCORRECT!

1) Following embolization of the left ICA, perfusion of the left MCA was noted via a
patent left posterior communicating artery following left vertebral artery injection.
In what percentage of patients is there a complete Circle of Willis?
A: > 90%
B: 50-80%
C: 20-50% The reported incidence of a complete Circle of Willis is highly variable,
but reports generally range from between 20 and 50%.
D: <10%

CONTINUE WITH CASE

SUMMARY & TEACHING POINTS

Complete occlusion of the common carotid artery (CCA), internal carotid artery
(ICA) or external carotid artery (ECA) has several indications including fistula
closure, reducing bleeding risk during surgery, and control of arterial bleeding.
Amplatzer Vascular Plugs (AVPs) were initially developed and currently approved
for rapid occlusion of large peripheral vessels.
This case demonstrates that AVPs can be used effectively for CCA and ICA
occlusion to control bleeding.
Oversizing of AVPs may minimize the risk of inadvertent distal migration.
AVPs allow rapid, permanent vessel embolization, and use of relatively few AVPs
may represent a more cost effective solution than use of multiple vascular coils.

REFERENCES & FURTHER READING

Gneyli S, inar C, Bozkaya H, Parldar M, Oran . Applications of the Amplatzer Vascular Plug to
various vascular lesions. Diagn Interv Radiol. 2014 Mar-Apr;20(2):155-9.
Macht S, Mathys C, Schipper J, Turowski B. Initial experiences with the Amplatzer Vascular Plug 4 for
permanent occlusion of the internal carotid artery in the skull base in patients with head and neck
tumors. Neuroradiology. 2012 Jan;54(1):61-4.
Mihlon F, Agrawal A, Nimjee SM1, Ferrell A, Zomorodi AR, Smith TP, Britz GW. Enhanced, Rapid
Occlusion of Carotid and Vertebral Arteries Using the AMPLATZER Vascular Plug II Device: The Duke
Cerebrovascular Center Experience in 8 Patients with 22 AMPLATZER Vascular Plug II Devices. World
Neurosurg. 2013 Aug 3. pii: S1878-8750(13)00898-X.
"AmplatzerTM Vascular Plug II; Instructions for Use." St. Jude Medical Product Manuals. 1 July 2014.
Web. 31 Dec. 2014. http://professional.sjm.com/professional/resources/ifu/vas/peripheral-vascular-
embolization.
K. Ranil D. De Silva, Rukmal Silva,1 W. S. L Gunasekera,2 and R. W. Jayesekera3 Prevalence of typical
circle of Willis and the variation in the anterior communicating artery: A study of a Sri Lankan
populationAnn Indian Acad Neurol. 2009 Jul-Sep; 12(3): 157161.