Internal carotid artery (ICA) injuries during endoscopic endonasal surgery (EES) are catastrophic complications. Alongside the advancements in medical instrumentation and material, there is a need to modify previous treatment modalities and principles.
A retrospective review of 3658 patients who underwent EES performed at the authors’ institution between January 2012 and December 2017 was conducted. Ultimately, 20 patients (0.55%) with ICA injury following EES were enrolled for analysis. Data collection included demographic data, preoperative diagnosis, injury setting, repair method, and immediate and follow-up angiographic and clinical outcomes.
Among the 20 patients, 11 received immediate endovascular therapy and 9 were treated only with packing. Of the 11 patients who received endovascular treatment, 6 were treated by covered stent and 5 by parent artery occlusion (PAO). The preservation rate of injured ICA increased from 20.0% (1 of 5) to 83.3% (5 of 6) after the Willis covered stent graft became available in January 2016. Of the 20 patients in the study, 19 recovered well and 1 patient—who had a pseudoaneurysm and was treated by PAO with a detachable balloon—suffered epistaxis after the hemostat in her nasal cavity was removed in ward, and she died later that day. The authors speculated that the detachable balloon had shifted to the distal part of ICA, although the patient could not undergo a repeat angiogram because she quickly suffered shock and could not be transferred to the catheter room. After the introduction of a hybrid operating room (OR), one patient whose first angiogram showed no ICA injury was found to have a pseudoaneurysm. He received endovascular treatment when he was brought for a repeat angiogram 5 days later in the hybrid OR after removing the hemostat in his nasal cavity. Of the 4 surviving patients treated with PAO, no external carotid artery–ICA bypass was required. The authors propose a modified endovascular treatment protocol for ICA injuries suffered during EES that exploits the advantage of the covered stent graft and the hybrid OR.
The endovascular treatment protocol used in this study for ICA injuries during EES was helpful in the management of this rare complication. Willis stent placement improved the preservation rate of injured ICA during EES. It would be highly advantageous to manage this complication in a hybrid OR or by a mobile C-arm to get a clear intraoperative angiogram.
ABBREVIATIONSCCF = carotid cavernous fistula; DSA = digital subtraction angiography; ECA = external carotid artery; EES = endoscopic endonasal surgery; ICA = internal carotid artery; mRS = modified Rankin Scale; OR = operating room; PAO = parent artery occlusion.
Correspondence Yazhuo Zhang: Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China. firstname.lastname@example.org.INCLUDE WHEN CITING Published online January 25, 2019; DOI: 10.3171/2018.8.JNS181048.
Yisen Zhang and Zhongbin Tian contributed equally to this work.
Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
AlQahtaniACastelnuovoPNicolaiPPrevedelloDMLocatelliDCarrauRL: Injury of the internal carotid artery during endoscopic skull base surgery: prevention and management protocol. Otolaryngol Clin North Am49:237–2522016
AlQahtaniA, CastelnuovoP, NicolaiP, PrevedelloDM, LocatelliD, CarrauRL: Injury of the internal carotid artery during endoscopic skull base surgery: prevention and management protocol. 49:237–252, 201610.1016/j.otc.2015.09.00926614841)| false
CappabiancaPBrigantiFCavalloLMde DivitiisE: Pseudoaneurysm of the intracavernous carotid artery following endoscopic endonasal transsphenoidal surgery, treated by endovascular approach. Acta Neurochir (Wien)143:95–962001
CappabiancaP, BrigantiF, CavalloLM, de DivitiisE: Pseudoaneurysm of the intracavernous carotid artery following endoscopic endonasal transsphenoidal surgery, treated by endovascular approach. 143:95–96, 20011134572510.1007/s007010170144)| false
CiricI, RaginA, BaumgartnerC, PierceD: Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. 40:225–237, 199710.1097/00006123-199702000-000019007854)| false
DolencVV, LipovsekM, SlokanS: Traumatic aneurysm and carotid-cavernous fistula following transsphenoidal approach to a pituitary adenoma: treatment by transcranial operation. 13:185–188, 19991061658910.1080/02688699943961)| false
GriauzdeJRavindraVMChaudharyNGemmeteJJMazurMDRoarkCD: Use of the Pipeline embolization device in the treatment of iatrogenic intracranial vascular injuries: a bi-institutional experience. Neurosurg Focus42(6):E92017
GriauzdeJ, RavindraVM, ChaudharyN, GemmeteJJ, MazurMD, RoarkCD, : Use of the Pipeline embolization device in the treatment of iatrogenic intracranial vascular injuries: a bi-institutional experience. 42(6):E9, 201710.3171/2017.3.FOCUS173528565993)| false
KocerNKizilkilicOAlbayramSAdaletliIKantarciFIslakC: Treatment of iatrogenic internal carotid artery laceration and carotid cavernous fistula with endovascular stent-graft placement. AJNR Am J Neuroradiol23:442–4462002
LiMHLiYDGaoBLFangCLuoQYChengYS: A new covered stent designed for intracranial vasculature: application in the management of pseudoaneurysms of the cranial internal carotid artery. AJNR Am J Neuroradiol28:1579–15852007
LiMH, LiYD, GaoBL, FangC, LuoQY, ChengYS, : A new covered stent designed for intracranial vasculature: application in the management of pseudoaneurysms of the cranial internal carotid artery. 28:1579–1585, 20071784621610.3174/ajnr.A0668)| false
NervaJDMortonRPLevittMROsbunJWFerreiraMJGhodkeBV: Pipeline Embolization Device as primary treatment for blister aneurysms and iatrogenic pseudoaneurysms of the internal carotid artery. J Neurointerv Surg7:210–2162015
RomeroADCBLal GangadharanJBanderEDGobinYPAnandVKSchwartzTH: Managing arterial injury in endoscopic skull base surgery: case series and review of the literature. Oper Neurosurg (Hagerstown)13:138–1492017
RomeroADCB, Lal GangadharanJ, BanderED, GobinYP, AnandVK, SchwartzTH: Managing arterial injury in endoscopic skull base surgery: case series and review of the literature. 13:138–149, 201728931251)| false
TanHQ, LiMH, LiYD, FangC, WangJB, WangW, : Endovascular reconstruction with the Willis covered stent for the treatment of large or giant intracranial aneurysms. 31:154–162, 20112113555110.1159/000321735)| false
TarrRW, JungreisCA, HortonJA, PenthenyS, SekharLN, SenC, : Complications of preoperative balloon test occlusion of the internal carotid arteries: experience in 300 cases. 1:240–244, 19911717084210.1055/s-2008-1057104)| false
ValentineR, BoaseS, Jervis-BardyJ, Dones CabralJD, RobinsonS, WormaldPJ: The efficacy of hemostatic techniques in the sheep model of carotid artery injury. 1:118–122, 20112228733010.1002/alr.20033)| false
WillinskyRATaylorSMTerBruggeKFarbRITomlinsonGMontaneraW: Neurologic complications of cerebral angiography: prospective analysis of 2,899 procedures and review of the literature. Radiology227:522–5282003
WillinskyRA, TaylorSM, TerBruggeK, FarbRI, TomlinsonG, MontaneraW: Neurologic complications of cerebral angiography: prospective analysis of 2,899 procedures and review of the literature. 227:522–528, 200310.1148/radiol.227201207112637677)| false
ZadaGCavalloLMEspositoFFernandez-JimenezJCTasiouADe AngelisM: Transsphenoidal surgery in patients with acromegaly: operative strategies for overcoming technically challenging anatomical variations. Neurosurg Focus29(4):E82010
ZadaG, CavalloLM, EspositoF, Fernandez-JimenezJC, TasiouA, De AngelisM, : Transsphenoidal surgery in patients with acromegaly: operative strategies for overcoming technically challenging anatomical variations. 29(4):E8, 20102088713310.3171/2010.8.FOCUS10156)| false
ZhuYQLiMHFangCTanHQWangWZhangPL: Application of the Willis covered stent in the treatment of aneurysm in the cisternal segment of the internal carotid artery: a pilot comparative study with midterm follow-up. J Endovasc Ther17:55–652010
ZhuYQ, LiMH, FangC, TanHQ, WangW, ZhangPL, : Application of the Willis covered stent in the treatment of aneurysm in the cisternal segment of the internal carotid artery: a pilot comparative study with midterm follow-up. 17:55–65, 20102019926810.1583/09-2688.1)| false