carotid blow - out syndrome is the most feared complication in head and neck surgery . the syndrome occurs in 3% to 4% of all head and neck cancer patients and is easy to happen following fistula formation , bad wound healing and tumor recurrence . carotid blow - out syndrome presents an average of 2.7 years after the initial diagnosis of cancer , usually occurs proximal to the carotid bifurcation , and is bilateral in 2% of cases . carotid blow - out syndrome occurred in a patient undergoing reoperation for recurrent thyroid cancer , and was repaired using the remaining carotid sheath , sterno - thyroid muscle , sterno - hyoid muscle and the harvested external jugular vein . local recurrence occurred on both sides 5 years and 6 months later , and the re - operation was done by an otolaryngologist ( fig . 1 ) . the sterno - hyoid muscle and sterno - thyroid muscle was severed and the tumor around the cricoid cartilage was removed . the tumor extended into the space between the right common carotid artery and internal jugular vein . the recurrent tumor was also located under the right common carotid artery and vagus nerve on the lateral side . enhanced cervical ct scan showed the recurred thyroid cancer in juxta - carotid regions of both sides . the tumor on the right side ( white arrowhead ) attached to the right common carotid artery ( white arrow ) . the carotid sheath of the right common carotid artery was hard and had no elasticity . the right common carotid artery had two layers , which were very fragile , so the direct suture or repair with a graft was impossible . the carotid artery could not be trapped with ligation because the cerebral vascular supply was not examined preoperatively . the carotid sheath was sutured to the carotid artery on the distal and proximal end of the lacerated portion ( fig . thereafter , the lacerated portion was covered with the remaining carotid sheath surrounding the carotid artery ( fig . fibrin glue was used to seal the space between the carotid artery and carotid sheath . however , re - bleeding occurred spontaneously at the proximal portion of the previous laceration during the dissection of the opposite side . fibrin glue with oxidized cellulose was initially used to seal the second small hole in this lesion ( fig . the ruptured section was then covered with the remaining sterno - thyroid muscle as the first layer and the sterno - hyoid muscle as the second layer ( fig . the proximal portion of the right common carotid artery was covered with the harvested external jugular vein because there were no vascularized tissues surrounding this artery ( fig . finally , the repaired right common carotid artery was widely covered with the sternomastoid muscle . blood pressure was strictly controlled after the operation , and no anti - platelet drugs were administered . the carotid sheath ( arrows ) was sutured to the right common carotid artery at the distal end of the lacerated portion ( arrowhead ) . the lacerated portion was covered with the remaining carotid sheath surrounding the right common carotid artery . re - bleeding occurred at the proximal portion ( black arrow ) of the previous laceration . fibrin glue with oxidized cellulose ( arrow head ) was initially used to seal the second small hole ( black arrow ) in this lesion . the ruptured section was then covered with the remaining sterno - thyroid muscle ( white arrow ) as the first layer . the ruptured section was then covered with the remaining sterno - hyoid muscle ( white arrow ) as the second layer . the proximal portion of right common carotid artery ( black arrow ) was covered with the harvested external jugular vein ( white arrow ) . three - dimensional ct angiography showed irregular stenosis in the right common carotid artery just after the re - operation ( fig . 3 ) . digital subtraction angiography also showed irregular stenosis in the right common carotid artery 5 days after the re - operation ( fig . however , the stenosis was found to recover on magnetic resonance angiography 11 days later . no cerebral infarction occurred after the operation and the patient s general condition was good . the pathological specimen revealed the papillary carcinoma which showed prominent invasion of the nervous system . the patient is in good condition without neurological complication , and recurrence of the tumor 22 months after the operation . the carotid sheath used for the repairment was partially pushed into the arterial cavity ( white arrow ) . thyroid cancer frequently invades the recurrent laryngeal nerve , strap muscles and trachea , and it is followed by invasion of the esophagus , internal jugular vein and carotid artery . surgical resection is the primary treatment for locally advanced thyroid cancer , and the carotid sheath invaded by a tumor must be excised with the thyroid tumor . during this procedure , carotid blow - out syndrome patients present with sentinel bleeding , but 60% of patients will develop a life - threatening hemorrhage requiring emergent intervention . the incidence is higher due to the lack of supporting healthy tissues if there is a history of radical neck dissection . other risk factors for carotid blow - out syndrome include radiotherapy , flap necrosis , mucocutaneous fistula , wound infection , and recurrent tumor invasion . injury to the vasa vasorum and necrotizing vasculitis in all three layers is an important factor in the development of radiation - induced vasculopathy of large arteries . the carotid rupture in the current case was related to the previous radical neck dissection followed by the recurrent tumor invasion . over 90% of patients with carotid blow - out syndrome are treated with endovascular therapy ( embolization 56% , stenting 36% ) , and surgical ligation ( 7% ) is rarely indicated . carotid artery embolization has a 15% to 20% neurologic morbidity rate and a lower incidence of associated mortality . endovascular embolization can also help predict cerebrovascular complications with temporary balloon occlusion and collateral cerebral blood flow analysis . stent - grafts may be useful in the treatment of carotid blow - out syndrome and show a high procedural success rate in selected cases . however , stent placement has a higher risk of recurrent carotid blow - out syndrome ( 44% ) than embolization therapy ( 10% ) . other studies of carotid blow - out syndrome treated with surgical ligation report an average mortality rate of 40% and an average morbidity rate of 60% . although trapping with ligation was considered in the current case , trapping of the right common carotid artery was not done , because the cerebral vascular supply was not assessed preoperatively . instead fibrin glue was used to seal the space between the carotid artery and the surrounding covering flap . we thought that it was important to seal the ruptured portion in multiple layers using vital , vascularized tissue . thus , the reconstruction was reinforced by covering the common carotid artery with the harvested external jugular vein and sternocleidomastoid muscle . this surgical technique was an emergency measure following the sudden rupture of the common carotid artery . given the large diameter of the common carotid artery , obstruction could be avoided even after the thrombus was formed around the repaired sites . this procedure can be one option when an unexpected rupture of the carotid artery occurs .