A 62-year-old man, who had known T3, N4, M0, Stage IVa squamous cell carcinoma of the middle esophagus, presented with dysphagia and was admitted to our institute. Regional radiotherapy extending from the supraclavicular fossa to the pericardial area, including the entire mediastinum, was planned. A total dose of 50.4 Gy of radiation therapy was delivered and systemic chemotherapy consisting of low-dose cisplatin and 5FU was concurrently performed. Eight months after the initial treatment, right supraclavicular lymph node enlargement was seen on follow-up computed tomography (CT). Although 20 Gy of additional irradiation were given to the right supraclavicular fossa, the metastatic lymph node enlarged and invaded the surrounding soft tissue. Left common carotid artery was confirmed to be intact on contrast enhanced CT.
Inspection of the neck confirmed the presence of a large mass in the right supraclavicular region with carotid sheath invasion. Necrotic skin caused by the irradiation was also observed within the tumor. As a result, direct pulsation of the common carotid artery was visualized in the cutaneous pocket on gross examination (Fig. 1).
It was determined that the patient’s condition was critical, and the decision was made to proceed with a percutaneous interventional approach (Fig. 2). It was decided that a covered nitinol stent graft could be placed to prevent rupture of the right carotid artery.
After obtaining written, informed consent from the patient, an 8-French (8-Fr) angiographic sheath was placed via the right femoral artery. Radiopaque markers were placed on the right neck surface as markers of the appropriate position planned for placing the stent by adhesive tape before the procedure. A 4-Fr headhunter catheter was then inserted into the right common carotid artery, and angiographic examination was performed.
An angiogram showed a pathologic condition located at the midpoint between the origin of the right common carotid artery and the carotid bifurcation. The radiopaque markers were placed on the neck surface to mark the appropriate position where it was planned to place the stent (Fig. 3).
A covered stent graft (Niti-S stent, Taewoong Medical, Seoul, Korea), with a body diameter of 10 mm and a length of 60 mm, was advanced along the stiff guide wire to the right carotid artery in a similar way reported by previous studies (Chang et al. 2007; Chaloupka et al. 1999).
The stent was deployed to fully cover the artery that the adjacent tumor had invaded and threatened to cause impending rupture, with reference to the body markers. The distal end of the stent was placed below the carotid bifurcation, and the proximal end was placed at the origin of the common carotid artery.
A carotid artery angiogram showed the full expansion and accurate positioning of the stent after stent placement (Fig. 4). The patient was asymptomatic and had no neurological problems related to the procedure. Antiplatelet was not administrated because of his poor general condition.
After 2 months, cervical contrast-enhanced CT revealed that the blood flow through the carotid artery was intact (Fig. 5). Despite subsequent palliative treatment, the patient died 7 months after stent placement due to a respiratory infection. Rupture of the carotid artery did not occur while the patient was alive.