Vascular resection and reconstruction

When head and neck cancer invades or surrounds the carotid artery, oncologic principles of surgery demand that the vessel be resected with the tumor. Unfortunately, significant morbidity can occur with the loss of blood flow to the brain. Advances in invasive angiographic techniques have made preoperative balloon test occlusion (BTO) the standard of care in the preoperative work-up of these patients. Recent studies demonstrated the utility of single photon emission tomography and other nuclear studies to augment the capability of BTO to predict the collateral cerebral bloodflow. If adequate stumps of the artery remain post resection, arterial reconstruction appears to be preferable to reduce early and delayed stroke rates regardless of collateral circulation. When the carotid stump is too short for anastamosis, ligation and permanent balloon occlusion of the artery are acceptable alternatives in patients with confirmed adequate collateral circulation. Intracranial bypass surgery is an exciting possibility that awaits a large series to determine efficacy.