Is it safe to ligate the external carotid artery (ECA)?

External Carotid Artery Ligation: Safety and Clinical Context

Yes, external carotid artery (ECA) ligation can be safely performed in specific clinical scenarios, particularly for severe epistaxis and during oropharyngeal cancer surgery, with minimal risk of stroke or major complications.

Primary Indications for ECA Ligation

Severe Epistaxis Management

• ECA ligation is an effective treatment for persistent epistaxis not controlled by nasal packing or cauterization 1
• The American Academy of Otolaryngology recommends evaluating candidacy for surgical arterial ligation when bleeding persists despite conservative measures 1
• In a 9-year series, ECA ligation combined with ipsilateral anterior ethmoidal artery ligation controlled bleeding in 14 of 15 patients (93% success rate) with no deaths or significant complications 2
• The procedure can be performed under local anesthesia and does not require specialized equipment, making it accessible in urgent situations 2

Oropharyngeal Cancer Surgery

• Prophylactic ECA ligation during transoral oropharyngeal squamous cell carcinoma resection reduces severe postoperative bleeding 3
• Recent data (2025) shows no significant difference in bleeding rates between total ECA ligation (3.8%) versus selective branch ligation (3.7%) 3
• Stroke risk with total ECA ligation was minimal (1.9% in one series), with no significant difference compared to selective ligation 3

Critical Safety Considerations

When ECA Ligation Should Be AVOIDED

• Do NOT ligate the ECA in patients with internal carotid artery (ICA) occlusion 4, 5, 6
• The ECA provides critical collateral blood supply to the brain through connections between ECA branches and cranial branches of the ICA and vertebral arteries 5
• In patients with ICA occlusion, the ECA becomes the primary collateral pathway; ligation can precipitate cerebrovascular insufficiency 6
• If previous ECA ligation exists in patients with arteriovenous malformations, surgical reconstruction may be necessary to enable subsequent embolization therapy 4

Stroke Risk Context

• For epistaxis management, complications from embolization (the alternative approach) include stroke risk of 0.9% with embolization alone and 1.6% with combined embolization and surgical ligation, compared to 0.1% with surgical ligation alone 1
• This suggests ECA ligation may actually be safer than embolization in terms of stroke risk for epistaxis control 1

Clinical Algorithm for Decision-Making

Step 1: Assess cerebrovascular status

• Confirm patency of bilateral ICAs and vertebral arteries before considering ECA ligation 5, 6
• If ICA is occluded ipsilaterally, ECA ligation is contraindicated 4, 6

Step 2: Determine indication

• For severe epistaxis: ECA ligation is appropriate after failed packing/cauterization 1, 2
• For oropharyngeal cancer: Either total or selective ECA ligation is acceptable 3

Step 3: Consider patient factors

• Age and prior radiation exposure increase hemorrhage risk in cancer surgery patients 3
• Local anesthesia capability makes ECA ligation feasible even in high-risk surgical candidates 2

Important Caveats

• ECA ligation should no longer be used as primary treatment for cervicofacial arteriovenous malformations, as it complicates subsequent embolization therapy by preventing catheter access 4
• Economic analyses favor surgical arterial ligation (including ECA) over endovascular embolization for cost-effectiveness in epistaxis management 1
• The procedure's simplicity and ability to be performed under local anesthesia may make it preferable to more complex interventions in selected situations 2