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Yang Z, Chen L, Liu J, Zhuang H, Lin W, Li C, Zhao X. Short Peptide Nanofiber Biomaterials Ameliorate Local Hemostatic Capacity of Surgical Materials and Intraoperative Hemostatic Applications in Clinics. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2023; 35:e2301849. [PMID: 36942893 DOI: 10.1002/adma.202301849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/12/2023] [Indexed: 06/18/2023]
Abstract
Short designer self-assembling peptide (dSAP) biomaterials are a new addition to the hemostat group. It may provide a diverse and robust toolbox for surgeons to integrate wound microenvironment with much safer and stronger hemostatic capacity than conventional materials and hemostatic agents. Especially in noncompressible torso hemorrhage (NCTH), diffuse mucosal surface bleeding, and internal medical bleeding (IMB), with respect to the optimal hemostatic formulation, dSAP biomaterials are the ingenious nanofiber alternatives to make bioactive neural scaffold, nasal packing, large mucosal surface coverage in gastrointestinal surgery (esophagus, gastric lesion, duodenum, and lower digestive tract), epicardiac cell-delivery carrier, transparent matrix barrier, and so on. Herein, in multiple surgical specialties, dSAP-biomaterial-based nano-hemostats achieve safe, effective, and immediate hemostasis, facile wound healing, and potentially reduce the risks in delayed bleeding, rebleeding, post-operative bleeding, or related complications. The biosafety in vivo, bleeding indications, tissue-sealing quality, surgical feasibility, and local usability are addressed comprehensively and sequentially and pursued to develop useful surgical techniques with better hemostatic performance. Here, the state of the art and all-round advancements of nano-hemostatic approaches in surgery are provided. Relevant critical insights will inspire exciting investigations on peptide nanotechnology, next-generation biomaterials, and better promising prospects in clinics.
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Affiliation(s)
- Zehong Yang
- Department of Biochemistry and Molecular Biology, West China School of Basic Medical Sciences and Forensic Medicine, Sichuan University, Chengdu, Sichuan, 610041, China
- Institute for Nanobiomedical Technology and Membrane Biology, West China Hospital of Sichuan University, Chengdu, Sichuan, 610041, China
| | - Lihong Chen
- Department of Biochemistry and Molecular Biology, West China School of Basic Medical Sciences and Forensic Medicine, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Ji Liu
- Department of Biochemistry and Molecular Biology, West China School of Basic Medical Sciences and Forensic Medicine, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Hua Zhuang
- Department of Ultrasonography, West China Hospital of Sichuan University, No. 37 Guoxue Road, Wuhou District, Chengdu, Sichuan, 610041, China
| | - Wei Lin
- Department of Obstetrics and Gynecology, Key Laboratory of Birth Defects and Related Women and Children Diseases of the Ministry of Education, Sichuan University, No. 17 People's South Road, Chengdu, Sichuan, 610041, China
| | - Changlong Li
- Department of Biochemistry and Molecular Biology, West China School of Basic Medical Sciences and Forensic Medicine, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Xiaojun Zhao
- Institute for Nanobiomedical Technology and Membrane Biology, West China Hospital of Sichuan University, Chengdu, Sichuan, 610041, China
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Arraez MA, Arraez-Manrique C, Ros B, Ibañez G. Major Internal Carotid Artery Injury During Endoscopic Skull Base Surgery: Case Report. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 130:19-23. [PMID: 37548719 DOI: 10.1007/978-3-030-12887-6_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Major vascular structures are always at risk during complex skull base surgery, particularly with use of the endoscopic endonasal approach, and intraoperative damage of the internal carotid artery (ICA) can be a devastating complication. Herein, we report a case of a young patient who had a major injury of the left ICA during endoscopic resection of a recurrent petrous bone chordoma. Massive bleeding was controlled by a Foley balloon inserted and kept in the resection area. Urgent angiography revealed a persistent leak from the petrous segment of the left ICA, and the vessel was sacrificed with coiling, since a balloon occlusion test showed good collateral blood flow. The patient woke up from anesthesia without a neurological deficit. Salvage resection of recurrent skull base neoplasms deserves specific attention because of the possibility of major vascular damage. In cases of intraoperative ICA injury, its management requires immediate decisions, and the available possibilities for endovascular therapy should always be considered.
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Affiliation(s)
- Miguel A Arraez
- Department of Neurosurgery, Malaga University Hospital, University of Malaga, Malaga, Spain.
| | - Cinta Arraez-Manrique
- Department of Neurosurgery, Malaga University Hospital, University of Malaga, Malaga, Spain
| | - Bienvenido Ros
- Department of Neurosurgery, Malaga University Hospital, University of Malaga, Malaga, Spain
| | - Guillermo Ibañez
- Department of Neurosurgery, Malaga University Hospital, University of Malaga, Malaga, Spain
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Land T, Silva D, Paluzzi A, Tsermoulas G, Ahmed S. Endonasal skull base repair with a vascularised pedicled temporo-parietal myo-fascial flap. Laryngoscope Investig Otolaryngol 2022; 8:55-62. [PMID: 36846405 PMCID: PMC9948560 DOI: 10.1002/lio2.1000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 07/19/2022] [Accepted: 08/21/2022] [Indexed: 01/01/2023] Open
Abstract
Objective Expanded endonasal approaches (EEAs) to the skull base have increased the scope and extent of pathologies that can be treated endoscopically. The trade-off is creation of large skull base bone defects requiring reconstruction to re-establish barriers between the sino-nasal mucosa and subarachnoid space to prevent CSF leak and infection. A popular reconstructive technique is the local vascularized pedicled naso-septal flap, an option that may not always be possible when there is disruption of the vascular pedicle from multiple previous surgeries, adjuvant radiotherapy or extensive tumor infiltration. An alternative is the regional temporo-parietal fascial flap (TPFF) transposed via the trans-pterygoid route. We implemented a modification of this technique incorporating contralateral temporalis muscle at the tip of this flap and deeper vascularised pericranial layers within the pedicle to provide a more robust flap in selected cases. Study design/methods A retrospective review of two cases is presented with both patients having undergone multiple EEAs to resect skull base tumors with adjuvant radiotherapy, their postoperative courses complicated by recalcitrant CSF leaks resistant to multiple surgeries. Results Our patients had their persistent CSF fistulae repaired using infra-temporal transposition of the TPFF modified to include some of the contralateral temporalis muscle with optimisation of a vascular pedicle: a temporo-parietal temporalis myo-fascial flap (TPTMFF). Both CSF leaks resolved without further complication. Conclusion In situations where local flap repair to reconstruct skull-base defects following EEA may not be viable or has failed, a modified regional flap incorporating temporo-parietal fascia with a preserved vascular pedicle along with attached temporalis muscle plug may provide a robust alternative option.
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Affiliation(s)
- Thomas Land
- Department of Neurosurgery and Skull Base SurgeryQueen Elizabeth University Hospital BirminghamBirminghamUK
| | - Dulanka Silva
- Department of Neurosurgery and Skull Base SurgeryQueen Elizabeth University Hospital BirminghamBirminghamUK
| | - Alessandro Paluzzi
- Department of Neurosurgery and Skull Base SurgeryQueen Elizabeth University Hospital BirminghamBirminghamUK
| | - Georgios Tsermoulas
- Department of Neurosurgery and Skull Base SurgeryQueen Elizabeth University Hospital BirminghamBirminghamUK
| | - Shahzada Ahmed
- Department of ENT Skull Base SurgeryQueen Elizabeth University Hospital BirminghamBirminghamUK
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Matoušek P, Krejčí T, Misiorzová E, Lipina R, Procházka V, Lubojacký J, Čábalová L, Komínek P. Internal Carotid Injury during Skull Base Surgery-Case Report and a Review of the Literature. Brain Sci 2022; 12:brainsci12091254. [PMID: 36138989 PMCID: PMC9497109 DOI: 10.3390/brainsci12091254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/12/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022] Open
Abstract
Iatrogenic injury of the internal carotid artery (ICA) is a rare, and probably underreported, complication of transnasal endoscopic skull base surgery. Although treatment algorithms have been suggested, there is no definite consensus or guideline for the management of this severe complication. We describe a case of ICA injury that occurred during a transsphenoidal biopsy of a tumor in the cavernous sinus and we present a treatment algorithm for managing this complication. We reviewed the articles published from 1998 to 2021, reporting on major vascular injury during transnasal endoscopic skull base surgery and endonasal endoscopic surgery, and we compare the methods and results of ICA injury management reported in the literature with the presented case. The most promising treatment for ICA injury might be packing with a muscle graft initially, then performing an endovascular intervention.
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Affiliation(s)
- Petr Matoušek
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Ostrava, 708 52 Ostrava, Czech Republic
- Department of Craniofacial Surgery, Faculty of Medicine, University of Ostrava, 701 03 Ostrava, Czech Republic
| | - Tomáš Krejčí
- Department of Neurosurgery, University Hospital Ostrava, 708 52 Ostrava, Czech Republic
- Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, 701 03 Ostrava, Czech Republic
| | - Eva Misiorzová
- Department of Neurosurgery, University Hospital Ostrava, 708 52 Ostrava, Czech Republic
- Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, 701 03 Ostrava, Czech Republic
| | - Radim Lipina
- Department of Neurosurgery, University Hospital Ostrava, 708 52 Ostrava, Czech Republic
- Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, 701 03 Ostrava, Czech Republic
| | - Václav Procházka
- Department of Radiology, University Hospital Ostrava, 708 52 Ostrava, Czech Republic
- Department of Imaging Methods, Faculty of Medicine, University of Ostrava, 701 03 Ostrava, Czech Republic
| | - Jakub Lubojacký
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Ostrava, 708 52 Ostrava, Czech Republic
- Department of Craniofacial Surgery, Faculty of Medicine, University of Ostrava, 701 03 Ostrava, Czech Republic
| | - Lenka Čábalová
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Ostrava, 708 52 Ostrava, Czech Republic
- Correspondence: ; Tel.: +420-5973-75812
| | - Pavel Komínek
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Ostrava, 708 52 Ostrava, Czech Republic
- Department of Craniofacial Surgery, Faculty of Medicine, University of Ostrava, 701 03 Ostrava, Czech Republic
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Hamour AF, Laliberte F, Padhye V, Monteiro E, Agid R, Lee JM, Witterick IJ, Vescan AD. Development of a management protocol for internal carotid artery injury during endoscopic surgery: a modified Delphi method and single-center multidisciplinary working group. J Otolaryngol Head Neck Surg 2022; 51:30. [PMID: 35902904 PMCID: PMC9331087 DOI: 10.1186/s40463-022-00582-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 05/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intra-operative internal carotid artery (ICA) injury during transnasal endoscopic surgery is a potentially catastrophic event. Such an injury is life-threatening in the immediate setting, with a reported peri-operative mortality rate of 10%. Nasal packing, muscle patches, direct vessel closure, and endovascular techniques have been described as useful strategies for managing ICA bleeds. The objective of this study was to develop a formalized management protocol for intra-operative ICA injury through engagement with a multi-disciplinary panel. METHODS A modified Delphi method including literature review, iterative rounds of stakeholder feedback, and expert panel discussions was used to develop a management protocol for ICA injury during transnasal endoscopic surgery. The 10-person multi-disciplinary panel included otolaryngologists, neurosurgeons, interventional neuroradiologists, anesthesiologists, and operating room nursing staff. RESULTS After three rounds of stakeholder engagement with the expert panel, consensus was reached on important elements to include within the protocol. The protocol was divided in three categories: Alert, Control, and Transfer. 'Alert' focusses on early communication with anesthesia and nursing staff. 'Control' focusses on techniques to expose the injury and obtain hemostasis or adequate tamponade. Lastly, 'Transfer' describes the process of contacting neuro-interventional radiology and safely transferring the patient. A one-page handout of the protocol was developed for placement in operating theatres. CONCLUSION Due to the life-threatening nature of ICA injury, it is imperative that endoscopic sinus and skull base surgeons are prepared to manage this complication. Using a modified Delphi method with a multidisciplinary expert panel, a protocol for management of intra-operative ICA injury was developed.
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Affiliation(s)
- Amr F Hamour
- Department of Otolaryngology - Head and Neck Surgery, Temerty Faculty of Medicine, University of Toronto, Mount Sinai Hospital, 600 University Ave, Suite 401, Toronto, ON, M5G 1X5, Canada
| | - Frederick Laliberte
- Department of Otolaryngology - Head and Neck Surgery, Temerty Faculty of Medicine, University of Toronto, Mount Sinai Hospital, 600 University Ave, Suite 401, Toronto, ON, M5G 1X5, Canada
| | - Vikram Padhye
- Department of Otolaryngology - Head and Neck Surgery, Temerty Faculty of Medicine, University of Toronto, Mount Sinai Hospital, 600 University Ave, Suite 401, Toronto, ON, M5G 1X5, Canada
| | - Eric Monteiro
- Department of Otolaryngology - Head and Neck Surgery, Temerty Faculty of Medicine, University of Toronto, Mount Sinai Hospital, 600 University Ave, Suite 401, Toronto, ON, M5G 1X5, Canada.,Department of Otolaryngology - Head and Neck Surgery, Sinai Health System, Toronto, ON, Canada
| | - Ronit Agid
- Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - John M Lee
- Department of Otolaryngology - Head and Neck Surgery, Temerty Faculty of Medicine, University of Toronto, Mount Sinai Hospital, 600 University Ave, Suite 401, Toronto, ON, M5G 1X5, Canada.,Department of Otolaryngology - Head and Neck Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Ian J Witterick
- Department of Otolaryngology - Head and Neck Surgery, Temerty Faculty of Medicine, University of Toronto, Mount Sinai Hospital, 600 University Ave, Suite 401, Toronto, ON, M5G 1X5, Canada.,Department of Otolaryngology - Head and Neck Surgery, Sinai Health System, Toronto, ON, Canada
| | - Allan D Vescan
- Department of Otolaryngology - Head and Neck Surgery, Temerty Faculty of Medicine, University of Toronto, Mount Sinai Hospital, 600 University Ave, Suite 401, Toronto, ON, M5G 1X5, Canada. .,Department of Otolaryngology - Head and Neck Surgery, Sinai Health System, Toronto, ON, Canada.
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Kahilogullari G, Bahadır B, Bozkurt M, Akcalar S, Balci S, Arat A. Carotid Artery-Cavernous Segment Injury during an Endoscopic Endonasal Surgery: A Case Report and Literature Review of the Overlooked Option for Surgical Trapping in the Hyperacute Phase. J Neurol Surg Rep 2021; 82:e53-e62. [PMID: 34917447 PMCID: PMC8670996 DOI: 10.1055/s-0041-1740511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 09/20/2021] [Indexed: 10/26/2022] Open
Abstract
Internal carotid artery (ICA) injury is a catastrophic complication of endoscopic endonasal surgery (EES). However, its standard management, emergent endovascular treatment, may not always be available, and the transnasal approach may be insufficient to achieve hemostasis. A 44-year-old woman with pituitary adenoma underwent EES complicated with the ICA cavernous segment injury (CSI). In urgent intraoperative angiogram, a good collateral flow from the contralateral carotid circulation was observed. Due to the unavailability of intraoperative embolization, emergent surgical trapping was performed by combined transcranial and cervical approach. The patient recovered but later developed a giant cavernous pseudoaneurysm. During the pseudoaneurysm embolization, ICA was directly accessed via a 1.7-F puncture hole using a bare microcatheter technique. Then, both the aneurysm and parent artery were obliterated with coils. At the 4-year follow-up, the patient was asymptomatic without a residual tumor. To our knowledge, this is the first case of ICA-CSI during EES successfully treated with ICA trapping as a lifesaving urgent surgery that achieved a complete recovery after a pseudoaneurysm embolization. Although several studies reported that EES-related ICA-CSIs with percutaneous carotid artery access, neither our surgical salvage technique nor our carotid access and tract embolization techniques were previously described.
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Affiliation(s)
| | - Burak Bahadır
- Department of Neurosurgery, Ankara University, Ankara, Turkey
| | - Melih Bozkurt
- Department of Neurosurgery, Ankara University, Ankara, Turkey
| | - Seray Akcalar
- Department of Radiology, Ankara University, Ankara, Turkey
| | - Sinan Balci
- Department of Radiology, Hacettepe University, Ankara, Turkey
| | - Anil Arat
- Department of Radiology, Hacettepe University, Ankara, Turkey
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Donoho DA, Pangal DJ, Kugener G, Rutkowski M, Micko A, Shahrestani S, Brunswick A, Minneti M, Wrobel BB, Zada G. Improved surgeon performance following cadaveric simulation of internal carotid artery injury during endoscopic endonasal surgery: training outcomes of a nationwide prospective educational intervention. J Neurosurg 2021; 135:1347-1355. [PMID: 33740764 DOI: 10.3171/2020.9.jns202672] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 09/10/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Internal carotid artery injury (ICAI) is a rare, life-threatening complication of endoscopic endonasal approaches that will be encountered by most skull base neurosurgeons and otolaryngologists. Rates of surgical proficiency for managing ICAI are not known, and the role of simulation to improve performance has not been studied on a nationwide scale. METHODS Attending and resident neurosurgery and otorhinolaryngology surgeons (n = 177) were recruited from multicenter regional and national training courses to assess training outcomes and validity at scale of a prospective educational intervention to improve surgeon technical skills using a previously validated, perfused human cadaveric simulator. Participants attempted an initial trial (T1) of simulated ICAI control using their preferred technique. An educational intervention including personalized instruction was performed. Participants attempted a second trial (T2). Task success (dichotomous), time to hemostasis (TTH), estimated blood loss (EBL), and surgeon heart rate were measured. RESULTS Participant rating scales confirmed that the simulation retained face and construct validity across eight instructional settings. Trial success (ICAI control) improved from 56% in T1 to 90% in T2 (p < 0.0001). EBL and TTH decreased by 37% and 38%, respectively (p < 0.0001). Postintervention resident surgeon performance (TTH, EBL, and success rate) was superior to preintervention attending surgeon performance. The most improved quartile of participants achieved 62% improvement in TTH and 73% improvement in EBL, with trial success improvement from 25.6% in T1 to 100% in T2 (p < 0.0001). Baseline surgeon confidence was uncorrelated with T1 success, while posttraining confidence correlated with T2 success. Tachycardia was measured in 57% of surgeon participants, but was attenuated during T2, consistent with development of resiliency. CONCLUSIONS Prior to training, many attending and most resident surgeons could not manage the rare, life-threatening intraoperative complication of ICAI. A simulated educational intervention significantly improved surgeon performance and remained valid when deployed at scale. Simulation also promoted the development of favorable cognitive skills (accurate perception of skill and resiliency). Rare, life-threatening intraoperative complications may be optimal targets for educational interventions using surgical simulation.
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Affiliation(s)
| | | | | | | | - Alexander Micko
- Departments of1Neurosurgery and
- 2Department of Neurosurgery, Medical University Vienna, Austria; and
| | - Shane Shahrestani
- Departments of1Neurosurgery and
- 3Department of Medical Engineering, California Institute of Technology, Pasadena, California
| | | | | | - Bozena B Wrobel
- 5Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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Lucke-Wold B, Gillham HE, Baskerville M, Cameron WE, Dillman D, Haley CA, Noles M, Spight D, Ciporen JN. Establishing a Multidisciplinary Cavernous Carotid Injury Simulation to Train Neurosurgical, Otolaryngology, and Anesthesia Residents. J Vis Exp 2021:10.3791/56403. [PMID: 34542530 PMCID: PMC8462993 DOI: 10.3791/56403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Carotid artery injuries are serious complications of endoscopic endonasal surgery. As these occur rarely, simulation training offers an avenue for technique and algorithm development in resident learners. This study develops a realistic cadaveric model for the training of crisis resource management in the setting of cavernous carotid artery injury. An expanded endonasal approach and right cavernous carotid injury is performed on a cadaveric head. The cadaver's right common carotid artery is cannulated and connected to a perfusion pump delivering pressurized simulated blood. A simulation mannequin is incorporated into the model to allow for vital sign feedback. Surgical and anesthesia resident learners are tasked with obtaining vascular control with a muscle patch technique and medical management over the course of 3 clinical scenarios with increasing complexity. Crisis management instructions for an endoscopic endonasal approach to the cavernous carotid artery and blood pressure control were provided to the learners prior to beginning the simulation. An independent reviewer evaluated the learners on communication skills, crisis management algorithms, and implementation of appropriate skill sets. After each scenario, residents were debriefed on how to improve technique based on evaluation scores in areas of situational awareness, decision-making, communications and teamwork, and leadership. After the simulation, learners provided feedback on the simulation and this data was used to improve future simulations. The benefit of this cadaveric model is ease of set-up, cost-effectiveness, and reproducibility.
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Al-Shami H, Alnemare AK. Inadvertent internal carotid artery (ICA) injury during transsphenoidal surgery: review of literature. EGYPTIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1186/s41984-021-00100-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Internal carotid artery (ICA) injury is a hazardous catastrophe for the skull base surgery team. We aimed to illustrate the vital joints in this hazardous event during endoscopic surgery.
Main text
The condition is rare (1.1%) but fatal per se. Working in the field of endoscopic surgery is not free of charges. It demands a thorough knowledge of anatomy, variations, and pathoanatomy to expect what can be seen thereafter. Once the injury occurs, one must have a quite clear plan to proceed. Marvelous bleeding is confusing not only in the field but also in the mind process.
Conclusion
Endoscope teams when expose to this event should think in a stepwise manner. In our review, we explained the pathoanatomy of the field after an injury, pre-conditions of injury, and how to avoid certain drawbacks during management.
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Endoscopic technology and repair techniques. HANDBOOK OF CLINICAL NEUROLOGY 2021; 170:217-225. [PMID: 32586493 DOI: 10.1016/b978-0-12-822198-3.00042-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
In this chapter, we describe advances in endoscopic endonasal surgery that have impacted skull base meningioma surgery. After reviewing the technical innovations in endoscopy, we describe the advances as they relate to each surgical step. We discuss preoperative planning and approach and the utility of neuronavigation and neuromonitoring. We then discuss endoscopic instrumentation, technology for tumor debulking (ultrasonic aspirators, radiofrequency ablators, suction debriders), and hemostatic agents as they relate to tumor resection and hemostasis. In the end, we discuss techniques of skull base reconstruction and closure (nasoseptal flap, gasket seal and bilayer button).
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Fustero de Miguel D, López López LB, Avedillo Ruidíaz A, Orduna Martínez J, Casado Pellejero J, Moles Herbera JA. Repair of internal carotid artery injury with aneurysm clip during endoscopic endonasal surgery: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE2098. [PMID: 36045935 PMCID: PMC9394176 DOI: 10.3171/case2098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 11/18/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUNDOne of the most feared and dangerous scenarios that can appear during an endoscopic endonasal surgery (EES) is the iatrogenic injury of the internal carotid artery (ICA). Several methods, along with a variety of outcomes, have been described to deal with this complication. To the authors’ knowledge, this is the first report on the use of a Yasargil-type aneurysm clip to solve an ICA injury, preserving the artery’s patency and having a long-term follow-up. The authors discuss the advantages and disadvantages of other vessel preservation techniques compared with clipping.OBSERVATIONSA visually impaired 56-year-old woman was diagnosed with a giant nonfunctional pituitary tumor that invaded the sphenoidal sinus, anterior and posterior ethmoidal cells, and both cavernous sinuses, with suprasellar extension and optochiasmatic compression. The patient underwent EES, and during the final resection phase her left ICA was injured, with massive hemorrhage.LESSONSICA injury during endoscopic skull base surgery carries high mortality and morbidity; it is essential to maintain carotid flow when possible to avoid short-term and long-term consequences. There are several techniques depicted in the literature to deal with this situation. The authors report the use of a Yasargil mini-clip to deal with the injury for a positive outcome: primary hemostasis, vessel preservation, and no postoperative complications.
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Li L, Carrau RL, Prevedello DM, Yang B, Rowan N, Han D, London NR. Intercarotid artery distance in the pediatric population: Implications for endoscopic transsphenoidal approaches to the skull base. Int J Pediatr Otorhinolaryngol 2021; 140:110520. [PMID: 33261860 DOI: 10.1016/j.ijporl.2020.110520] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/22/2020] [Accepted: 11/22/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Comprehensive quantitative evaluation of the intercarotid artery distance (ICD) in the pediatric population has not been sufficiently explored. This study aims to measure the minimal ICDs at multiple levels of the skull base to assess changes in the ICD during development. METHODS Measurement of the ICDs between the paired paraclival, parasellar, and paraclinoid segments of the internal carotid artery (ICA) was performed on coronal MRI from 540 patients ranging from 0 to 17 years old (n = 30 for each age). Comparison of these indices in the very young (0-5 years, Group 1) and young (6-17 years, Group 2) patients, and assessment of the degree of sphenoid sinus pneumatization was employed. RESULTS The narrowest ICD was located at the paraclinoid ICAs in the vast majority of cases (89.44%). When comparing the ICDs in very young age patients with the ICDs of 17 years old subjects, a statistically significant difference was found at the paraclival (ages 0-5), parasellar (ages 0-2), and paraclinoid (ages 0-4) ICDs (p < 0.05). Comparison of the ICDs between the intergroups (Group 1 and 2) also demonstrated a statistically significant difference (p < 0.0001). Pneumatization of the sphenoid sinus was initially noted to start at 3 years of age, and there were no patients with a non-pneumatized sphenoid sinus identified after 7 years of age in our cohort. CONCLUSION Measurement of ICDs at multiple levels provides a valuable reference for EEA procedures in the pediatric population. While the ICD may be largely stable in the pediatric population after 5 years of age, additional anatomic factors may restrict transsphenoidal access in very young patients (0-5 years).
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Affiliation(s)
- Lifeng Li
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Ricardo L Carrau
- Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University, Columbus, OH, USA; Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University, Columbus, OH, USA
| | - Daniel M Prevedello
- Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University, Columbus, OH, USA; Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University, Columbus, OH, USA
| | - Bentao Yang
- Department of Radiology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Nicholas Rowan
- Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Demin Han
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Nyall R London
- Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
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Senthamarai Siddharthan YP, Bata A, Anetakis K, Crammond DJ, Balzer JR, Snyderman C, Gardner P, Thirumala PD. Role of Intraoperative Neurophysiologic Monitoring in Internal Carotid Artery Injury During Endoscopic Endonasal Skull Base Surgery. World Neurosurg 2020; 148:e43-e57. [PMID: 33301995 DOI: 10.1016/j.wneu.2020.11.154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/26/2020] [Accepted: 11/27/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE In the present study, we investigated the role of intraoperative neuromonitoring (IONM) in internal carotid artery (ICA) injury during endoscopic endonasal skull base surgery (EESBS). METHODS The study group included all 13 patients who had experienced an ICA injury during EESBS with IONM from 2004 to 2017. The medical records were reviewed for the perioperative data. The IONM reports were reviewed to evaluate the baseline somatosensory evoked potentials (SSEP), electroencephalography (EEG), and brainstem auditory evoked potentials (BAEP) and their significant changes related to ICA injury and/or the subsequent surgical/endovascular interventions. RESULTS All 13 patients had undergone SSEP and 7 patients had BAEP monitoring during surgery. EEG was added during emergent angiography following the surgery for 5 patients. Two patients showed significant SSEP changes, and one showed significant SSEP and EEG changes, indicating cerebral hypoperfusion. Of these 3 patients, patient 1 had experienced irreversible SSEP loss with postoperative stroke. Patients 2 and 3 had SSEP and/or EEG changes that had recovered to baseline after interventions without postoperative deficits. Despite ICA injury, 10 patients showed no significant SSEP and/or EEG changes, and all 7 patients with BAEP monitoring showed no significant BAEP changes, indicating adequate cerebral and brainstem perfusion, respectively. The injured ICA was sacrificed in 4 patients, of whom 3 showed stable SSEP and 1 had experienced irreversible SSEP loss. IONM correlated with the postoperative neurologic examination findings in all cases, adequately predicting the neurologic outcomes after ICA injury. CONCLUSION SSEP and EEG monitoring can accurately detect cerebral hypoperfusion and provide real-time feedback during surgery. SSEP and EEG changes predicted for neurologic outcomes and guide surgical decisions regarding the preservation or sacrifice of the ICA. Comprehensive multimodality monitoring according to the surgical risks can serve to detect and guide the management of ICA injury in EESBS.
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Affiliation(s)
| | - Ammar Bata
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Katherine Anetakis
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeffrey R Balzer
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Carl Snyderman
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Paul Gardner
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Parthasarathy D Thirumala
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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14
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Wang WH, Lieber S, Lan MY, Wang EW, Fernandez-Miranda JC, Snyderman CH, Gardner PA. Nasopharyngeal muscle patch for the management of internal carotid artery injury in endoscopic endonasal surgery. J Neurosurg 2020; 133:1382-1387. [PMID: 31628289 DOI: 10.3171/2019.7.jns191370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 07/12/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Injury to the internal carotid artery (ICA) is the most critical complication of endoscopic endonasal skull base surgery. Packing with a crushed muscle graft at the injury site has been an effective management technique to control bleeding without ICA sacrifice. Obtaining the muscle graft has typically required access to another surgical site, however. To address this concern, the authors investigated the application of an endonasally harvested longus capitis muscle patch for the management of ICA injury. METHODS One colored silicone-injected anatomical specimen was dissected to replicate the surgical access to the nasopharynx and the stepwise dissection of the longus capitis muscle in the nasopharynx. Two representative cases were selected to illustrate the application of the longus capitis muscle patch and the relevance of clinical considerations. RESULTS A suitable muscle graft from the longus capitis muscle could be easily and quickly harvested during endoscopic endonasal skull base surgery. In the illustrative cases, the longus capitis muscle patch was successfully used for secondary prevention of pseudoaneurysm formation following primary bleeding control on the site of ICA injury. CONCLUSIONS Nasopharyngeal harvest of a longus capitis muscle graft is a safe and practical method to manage ICA injury during endoscopic endonasal surgery.
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Affiliation(s)
- Wei-Hsin Wang
- Departments of1Neurological Surgery and
- Departments of3Neurosurgery and
| | | | - Ming-Ying Lan
- 4Otolaryngology, Taipei Veterans General Hospital, National Yang-Ming University, Taipei, Taiwan
| | - Eric W Wang
- 2Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | | | - Carl H Snyderman
- 2Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
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15
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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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16
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Fastenberg JH, Garzon‐Muvdi T, Hsue V, Reilly EK, Jabbour P, Rabinowitz MR, Rosen MR, Evans JJ, Nyquist GN, Farrell CJ. Adenosine‐induced transient hypotension for carotid artery injury during endoscopic skull‐base surgery: case report and review of the literature. Int Forum Allergy Rhinol 2019; 9:1023-1029. [DOI: 10.1002/alr.22381] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/28/2019] [Accepted: 06/20/2019] [Indexed: 01/10/2023]
Affiliation(s)
- Judd H. Fastenberg
- Department of Otolaryngology–Head & Neck SurgeryThomas Jefferson University Hospitals Philadelphia PA
| | - Tomas Garzon‐Muvdi
- Department of Neurosurgery and Neurological SciencesThomas Jefferson University Hospitals Philadelphia PA
| | | | - Erin K. Reilly
- Department of Otolaryngology–Head & Neck SurgeryThomas Jefferson University Hospitals Philadelphia PA
| | - Pascal Jabbour
- Department of Neurosurgery and Neurological SciencesThomas Jefferson University Hospitals Philadelphia PA
| | - Mindy R. Rabinowitz
- Department of Otolaryngology–Head & Neck SurgeryThomas Jefferson University Hospitals Philadelphia PA
| | - Marc R. Rosen
- Department of Otolaryngology–Head & Neck SurgeryThomas Jefferson University Hospitals Philadelphia PA
| | - James J. Evans
- Department of Neurosurgery and Neurological SciencesThomas Jefferson University Hospitals Philadelphia PA
| | - Gurston N. Nyquist
- Department of Otolaryngology–Head & Neck SurgeryThomas Jefferson University Hospitals Philadelphia PA
| | - Christopher J. Farrell
- Department of Neurosurgery and Neurological SciencesThomas Jefferson University Hospitals Philadelphia PA
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17
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18
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Deng D, Du J, Liu F, Zhong B, Qiao Y, Liu Y. Clinical characteristics of internal carotid artery pseudoaneurysms in the sphenoid sinus. Am J Otolaryngol 2019; 40:106-109. [PMID: 30472125 DOI: 10.1016/j.amjoto.2018.09.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 09/17/2018] [Accepted: 09/19/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Internal carotid artery (ICA) pseudoaneurysms are associated with high mortality if lack of proper management. Patients with ICA pseudoaneurysms in the sphenoid sinus often visit a hospital's ear, nose and throat (ENT) department due to nasal bleeding. In such cases, simple examination and therapy will lead to misdiagnosis. OBJECTIVE This study sought to investigate the clinical characteristics, diagnostic methods and treatment of ICA pseudoaneurysms in the sphenoid sinus. METHODS Various data, including clinical features, imaging examination results, and treatment and prognosis information, were collected and analyzed for 8 patients who visited the Department of Otolaryngology, Head & Neck Surgery of West China Hospital from March 2008 to January 2017. RESULTS The patients included 6 males and 2 females (ages 16 to 56 years). Repeated epistaxis was a common symptom in six of the eight patients (6/8), whereas monocular blindness and binocular blindness were observed in the other two patients. Head trauma was found to play a role in the induction of ICA pseudoaneurysms, given that five patients (5/8) exhibited a specific history of head injury. CT examination tended to result in misdiagnosis, whereas MRI and digital subtraction angiography (DSA) were helpful for obtaining a definite diagnosis with all diagnoses were confirmed via DSA. Coated stent intervention was performed in five patients, while carotid artery ligation was performed in two patients in emergency situations: one of whom exhibited paraplegia, but recovery was ultimately observed after rehabilitation. Moreover, failure of coated stent intervention in one patient was resolved via additional unilateral common carotid artery ligation. Furthermore, one patient with vision loss experienced vision restoration. One patient discontinued treatment for personal reasons and was lost to follow-up. No recurrence was observed in the other 7 patients. CONCLUSION ICA pseudoaneurysms in the sphenoid sinus are uncommon. To accurately identify ICA pseudoaneurysms, collaboration between otolaryngologists and imaging specialists is essential. On the other hand, both surgical and interventional treatments can achieve good results; therefore, otolaryngologists should enhance their cooperation with neurosurgery and intervention departments. Accurate diagnosis and rapid treatment are keys to managing ICA pseudoaneurysms.
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Affiliation(s)
- Di Deng
- Department of Otorhinolaryngology Head & Neck surgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Jintao Du
- Department of Otorhinolaryngology Head & Neck surgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China.
| | - Feng Liu
- Department of Otorhinolaryngology Head & Neck surgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Bing Zhong
- Department of Otorhinolaryngology Head & Neck surgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Yixin Qiao
- Department of Otorhinolaryngology Head & Neck surgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Yafeng Liu
- Department of Otorhinolaryngology Head & Neck surgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China.
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19
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Jukes A, Miljkovic D, Wormald PJ, Psaltis AJ. Platelet activation by crushed and uncrushed muscle: a flow cytometry analysis. Int Forum Allergy Rhinol 2017; 7:916-919. [PMID: 28658522 DOI: 10.1002/alr.21977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 05/11/2017] [Accepted: 05/23/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND Crushed autologous muscle is used in skull base surgery in the acute phase of major arterial hemorrhage to stop bleeding. The mechanism of this is not yet clear, but is thought to involve the formation of a platelet plug, which seals the vessel wall defect but still allows ongoing blood flow to the brain. METHODS In this study we use flow cytometry to replicate the in-vivo actions of crushed muscle on platelets in whole blood. We compare the ratio of activation of platelets exposed to crushed and uncrushed muscle supernatant in control patients and in patients on antiplatelet agents. RESULTS Crushed muscle activated platelets to a higher degree than uncrushed muscle: 5.18-fold greater in control blood (p = 0.002); 6.53-fold greater in aspirin-exposed blood (p < 0.0001); and 9.4-fold greater in clopidogrel-exposed blood (p < 0.0001). CONCLUSION Crushed muscle caused a consistently increased ratio of platelet activation when compared with uncrushed muscle across all groups, adding to the evidence that at least part of its clinical effect is the result of platelet activation.
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Affiliation(s)
- Alistair Jukes
- Department of Otolaryngology, Head and Neck Surgery, Queen Elizabeth Hospital, Woodville South, Adelaide, SA, Australia.,Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, SA, Australia.,Department of Medicine, University of Adelaide, Queen Elizabeth Hospital, Woodville South, Adelaide, SA, Australia
| | - Dijana Miljkovic
- Department of Otolaryngology, Head and Neck Surgery, Queen Elizabeth Hospital, Woodville South, Adelaide, SA, Australia.,Department of Medicine, University of Adelaide, Queen Elizabeth Hospital, Woodville South, Adelaide, SA, Australia
| | - P J Wormald
- Department of Otolaryngology, Head and Neck Surgery, Queen Elizabeth Hospital, Woodville South, Adelaide, SA, Australia.,Department of Medicine, University of Adelaide, Queen Elizabeth Hospital, Woodville South, Adelaide, SA, Australia
| | - Alkis J Psaltis
- Department of Otolaryngology, Head and Neck Surgery, Queen Elizabeth Hospital, Woodville South, Adelaide, SA, Australia.,Department of Medicine, University of Adelaide, Queen Elizabeth Hospital, Woodville South, Adelaide, SA, Australia
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20
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Jukes A, Murphy J, Vreugde S, Psaltis A, Wormald PJ. Nano-hemostats and a Pilot Study of Their Use in a Large Animal Model of Major Vessel Hemorrhage in Endoscopic Skull Base Surgery. J Neurol Surg B Skull Base 2017; 78:215-221. [PMID: 28593108 DOI: 10.1055/s-0036-1597277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 10/25/2016] [Indexed: 10/20/2022] Open
Abstract
Nano-hemostats are synthetic amino acid chains that self-assemble into a scaffold under certain conditions. These have been shown to be effective in stopping bleeding in small animal models of hemorrhage. Proposed mechanisms for their effect are that they form a mesh analogous to the fibrin plug in native hemostasis and that they may potentiate both platelet activation and the coagulation cascade. These may potentially become valuable adjuncts to endoscopic skull base surgery where there is the potential for both major vessel injury and smaller perforator injury to eloquent areas where bipolar cautery may not be suitable. We present a summary of the clinical studies to date and a small pilot study of nano-hemostat in an endoscopic sheep model of major vessel hemorrhage to determine its efficacy in stopping bleeding in this potentially catastrophic complication.
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Affiliation(s)
- Alistair Jukes
- Department of Otolaryngology, Head and Neck Surgery, Queen Elizabeth Hospital, Adelaide, Australia.,Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, Australia
| | - Jae Murphy
- Department of Otolaryngology, Head and Neck Surgery, Queen Elizabeth Hospital, Adelaide, Australia.,Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, Australia
| | - Sarah Vreugde
- Department of Otolaryngology, Head and Neck Surgery, Queen Elizabeth Hospital, Adelaide, Australia.,Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, Australia
| | - Alkis Psaltis
- Department of Otolaryngology, Head and Neck Surgery, Queen Elizabeth Hospital, Adelaide, Australia.,Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, Australia
| | - P J Wormald
- Department of Otolaryngology, Head and Neck Surgery, Queen Elizabeth Hospital, Adelaide, Australia.,Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, Australia
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21
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Jukes AK, Mascarenhas A, Murphy J, Stepan L, Muñoz TN, Callejas CA, Valentine R, Wormald P, Psaltis AJ. Stress response and communication in surgeons undergoing training in endoscopic management of major vessel hemorrhage: a mixed methods study. Int Forum Allergy Rhinol 2017; 7:576-583. [DOI: 10.1002/alr.21941] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 03/04/2017] [Accepted: 03/14/2017] [Indexed: 12/27/2022]
Affiliation(s)
- Alistair K. Jukes
- Department of Otolaryngology; Head and Neck Surgery; Queen Elizabeth Hospital; Adelaide Australia
- Department of Neurosurgery; Royal Adelaide Hospital; Adelaide Australia
| | - Annika Mascarenhas
- Department of Otolaryngology; Head and Neck Surgery; Queen Elizabeth Hospital; Adelaide Australia
| | - Jae Murphy
- Department of Otolaryngology; Head and Neck Surgery; Queen Elizabeth Hospital; Adelaide Australia
| | - Lia Stepan
- Department of Otolaryngology; Head and Neck Surgery; Queen Elizabeth Hospital; Adelaide Australia
| | - Tamara N. Muñoz
- Department of Otolaryngology; Pontificia Universidad Católica de Chile; Santiago Chile
| | - Claudio A. Callejas
- Department of Otolaryngology; Pontificia Universidad Católica de Chile; Santiago Chile
| | - Rowan Valentine
- Department of Otolaryngology; Head and Neck Surgery; Queen Elizabeth Hospital; Adelaide Australia
- Department of Otolaryngology; Royal Adelaide Hospital; Adelaide Australia
| | - P.J. Wormald
- Department of Otolaryngology; Head and Neck Surgery; Queen Elizabeth Hospital; Adelaide Australia
- Department of Medicine; University of Adelaide; Queen Elizabeth Hospital; Adelaide Australia
| | - Alkis J. Psaltis
- Department of Otolaryngology; Head and Neck Surgery; Queen Elizabeth Hospital; Adelaide Australia
- Department of Medicine; University of Adelaide; Queen Elizabeth Hospital; Adelaide Australia
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22
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Simulation Training for Vascular Emergencies in Endoscopic Sinus and Skull Base Surgery. Otolaryngol Clin North Am 2017; 49:877-87. [PMID: 27267032 DOI: 10.1016/j.otc.2016.02.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Carotid artery injury during endonasal surgery is a feared and potentially catastrophic complication. Simulation training provides the opportunity for a realistic experience with management of major vascular injuries. The sheep model of carotid artery injury reproduces the challenges of dealing with vascular emergencies during endoscopic sinus and skull base surgery, which include working in narrow nasal confines, high-flow/high-pressure vascular injury, and the immediately challenging surgical field. Simulated vascular emergencies allow for research and development; training using various surgical techniques to control the field, including hemostatic products or direct vascular closure techniques; and consequently improved patient care and outcomes.
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23
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Shen J, Wrobel BB, Zada G. Management of Vascular Injuries During Endoscopic Skull Base Surgery: Current Strategies and Simulation-Based Educational Paradigms. CURRENT OTORHINOLARYNGOLOGY REPORTS 2017. [DOI: 10.1007/s40136-017-0146-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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24
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Management of arterial injury during endoscopic sinus and skull base surgery. Curr Opin Otolaryngol Head Neck Surg 2016; 24:170-4. [PMID: 26959844 DOI: 10.1097/moo.0000000000000239] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The most feared complication during endonasal surgery is a carotid artery injury. The sheep model of carotid injury provides training for this event by giving a realistic endoscopic experience of major vascular injuries and tissue hemostasis. RECENT FINDINGS The sheep model of carotid artery injury recreates the narrow nasal confines and high-flow/high-pressure vascular injury accurately reproducing the endoscopic challenges seen in such vascular emergencies. This has led to the development of surgical techniques that quickly and effectively control the field of bleeding and achieve reliable hemostasis including the crushed muscle patch new direct vascular closure technologies. Vascular emergency simulation training is achieving better outcomes for our patients. SUMMARY All skull base surgeons are at risk of the unexpected carotid artery injury and recently, the sheep model not only effectively recreates this situation but has identified clinically tried and tested techniques at managing this situation and is improving patient outcomes.
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25
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R Baylis J, Finkelstein-Kulka A, Macias-Valle L, Manji J, Lee M, Levchenko E, Okpaleke C, Al-Salihi S, Javer A, J Kastrup C. Rapid hemostasis in a sheep model using particles that propel thrombin and tranexamic acid. Laryngoscope 2016; 127:787-793. [PMID: 27861945 DOI: 10.1002/lary.26408] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 10/04/2016] [Accepted: 10/10/2016] [Indexed: 12/27/2022]
Abstract
OBJECTIVES/HYPOTHESIS Bleeding during endoscopic sinus surgery and open surgeries can easily obstruct the surgeons' field of view and increase morbidity and risk of intraoperative complications. Intraoperative bleeding could potentially be addressed by a hemostatic agent that safely disperses itself through the escaping blood. We tested the safety and efficacy of a self-propelling formulation of thrombin and tranexamic acid (SPTT) in stopping bleeding in a paranasal sinus injury and in an open surgical carotid injury sheep model. STUDY DESIGN Interventional animal study. METHODS SPTT was tested in the sinonasal space following endoscopic injury to the inferior turbinate of six sheep, and to the common carotid artery following open surgical injury in eight sheep. In the nasal cavity, bleeding time and local inflammation were measured and compared to plain gauze. Following carotid arteriotomy, successful hemostasis and markers of thrombosis and coagulopathy were compared to Floseal. RESULTS SPTT significantly decreased bleeding times in the sinonasal space compared to plain gauze (mean difference = 3.8 minutes, P = .002). All of the carotid bleeds (100%) were successfully controlled with SPTT after 10 minutes of application under pressure, compared to 25% with Floseal. No adverse events were noted, and there was no evidence of thromboembolism. CONCLUSIONS SPTT significantly reduced bleeding time in a sheep model of surgical sinus bleeding and successfully stopped bleeding following catastrophic carotid artery injury, with no adverse events observed. LEVEL OF EVIDENCE NA Laryngoscope, 127:787-793, 2017.
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Affiliation(s)
- James R Baylis
- Michael Smith Laboratories and Department of Biochemistry and Molecular Biology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andres Finkelstein-Kulka
- St. Paul's Sinus Center, St. Paul's Hospital, Vancouver, British Columbia, Canada.,Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Luis Macias-Valle
- St. Paul's Sinus Center, St. Paul's Hospital, Vancouver, British Columbia, Canada.,Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile.,Hospital Espñol de México, Facultad Mexicana de Medicina, Universidad La Salle, Mexico City, Mexico
| | - Jamil Manji
- St. Paul's Sinus Center, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Michael Lee
- Michael Smith Laboratories and Department of Biochemistry and Molecular Biology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Elina Levchenko
- Michael Smith Laboratories and Department of Biochemistry and Molecular Biology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher Okpaleke
- St. Paul's Sinus Center, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Salahuddin Al-Salihi
- St. Paul's Sinus Center, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Amin Javer
- St. Paul's Sinus Center, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Christian J Kastrup
- Michael Smith Laboratories and Department of Biochemistry and Molecular Biology, University of British Columbia, Vancouver, British Columbia, Canada
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26
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Gardner PA, Snyderman CH, Fernandez-Miranda JC, Jankowitz BT. Management of Major Vascular Injury During Endoscopic Endonasal Skull Base Surgery. Otolaryngol Clin North Am 2016; 49:819-28. [DOI: 10.1016/j.otc.2016.03.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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27
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Chin OY, Ghosh R, Fang CH, Baredes S, Liu JK, Eloy JA. Internal carotid artery injury in endoscopic endonasal surgery: A systematic review. Laryngoscope 2015; 126:582-90. [PMID: 26525334 DOI: 10.1002/lary.25748] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2015] [Indexed: 12/22/2022]
Abstract
OBJECTIVES/HYPOTHESIS Internal carotid artery (ICA) injury during endoscopic endonasal surgery (EES) is a known and feared complication of paranasal sinus and skull base procedures. These ICA injuries can result in stroke, cranial nerve palsies, and death. This review examines the setting of injury along with the treatment approaches, and patient outcomes. STUDY DESIGN Systematic review using PubMed/MEDLINE and EMBASE. METHODS The databases were searched for articles reporting cases of ICA injury during EES. Variables analyzed included patient demographics, operative approach, preoperative diagnosis, setting of injury, repair method, imaging studies, patient outcomes, and follow-up. RESULTS Twenty-five articles with 50 cases were included in this review. The EES approach was used for skull base procedures in 34 cases and for inflammatory disease in 16 cases. The most commonly injured ICA segment was the cavernous (34 cases), followed by the ophthalmic (three cases). Injuries occurred more commonly on the left (1.3:1). Injury occurred in the setting of various steps during EES with instruments. Stereotactic image guidance was reported in two cases. Initial hemostasis was achieved with packing in 35 cases, endoscopic clip sacrifice in four cases, bipolar coagulation with the intent to seal defect in three cases, and bipolar coagulation with the intent to sacrifice the ICA in one case. Intraoperative or immediate postoperative angiography was reported in 27 cases. CONCLUSIONS The incidence of reported cases of ICA injury during EES remains low. Left-sided injuries to the cavernous segment of the ICA occurred more frequently than injuries on the right. LEVEL OF EVIDENCE NA Laryngoscope, 126:582-590, 2016.
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Affiliation(s)
- Oliver Y Chin
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Ritam Ghosh
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Christina H Fang
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Soly Baredes
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - James K Liu
- Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
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Padhye V, Valentine R, Wormald PJ. Management of carotid artery injury in endonasal surgery. Int Arch Otorhinolaryngol 2015; 18:S173-8. [PMID: 25992141 PMCID: PMC4399584 DOI: 10.1055/s-0034-1395266] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction Carotid artery injury (CAI) is the most feared and potentially catastrophic intraoperative complication an endoscopic skull base surgeon may face. With the advancement of transnasal endoscopic surgery and the willingness to tackle more diverse pathology, evidence-based management of this life-threatening complication is paramount for patient safety and surgeon confidence. Objectives We review the current English literature surrounding the management of CAI during endoscopic transnasal surgery. Data Synthesis The searched databases included PubMed, MEDLINE, Cochrane database, LILACS, and BIREME. Keywords included “sinus surgery,” “carotid injury,” “endoscopic skull base surgery,” “hemostasis,” “transsphenoidal” and “pseudoaneurysm.” Conclusions Review of the literature found the incidence of CAI in endonasal skull base surgery to be as high as 9% in some surgeries. Furthermore, current treatment recommendations can result in damage to critical neurovascular structures. Management decisions must be made in the preoperative, operative, and postoperative setting to ensure adequate treatment of CAI and the prevention of its complications such as pseudoaneurysm. Emphasis should be placed on surgical competency, teamwork, and technical expertise through education and training.
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Affiliation(s)
- Vikram Padhye
- Department of Surgery - Otolaryngology, Head & Neck Surgery, The University of Adelaide, South Australia, Australia
| | - Rowan Valentine
- Department of Surgery - Otolaryngology, Head & Neck Surgery, The University of Adelaide, South Australia, Australia
| | - Peter-John Wormald
- Department of Surgery - Otolaryngology, Head & Neck Surgery, The University of Adelaide, South Australia, Australia
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Rajiv S, Rodgers S, Bassiouni A, Vreugde S, Wormald PJ. Role of crushed skeletal muscle extract in hemostasis. Int Forum Allergy Rhinol 2015; 5:431-4. [DOI: 10.1002/alr.21489] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 12/13/2014] [Accepted: 12/23/2014] [Indexed: 11/08/2022]
Affiliation(s)
- Sukanya Rajiv
- Department of Surgery-Otorhinolaryngology, Head and Neck Surgery; University of Adelaide; Adelaide Australia
| | - Susan Rodgers
- Department of Haematology; SA Pathology; Adelaide Australia
| | - Ahmed Bassiouni
- Department of Surgery-Otorhinolaryngology, Head and Neck Surgery; University of Adelaide; Adelaide Australia
| | - Sarah Vreugde
- Department of Surgery-Otorhinolaryngology, Head and Neck Surgery; University of Adelaide; Adelaide Australia
| | - Peter-John Wormald
- Department of Surgery-Otorhinolaryngology, Head and Neck Surgery; University of Adelaide; Adelaide Australia
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30
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Padhye V, Valentine R, Sacks R, Ooi EH, Teo C, Tewfik M, Wang D, Wormald PJ. Coping with catastrophe: the value of endoscopic vascular injury training. Int Forum Allergy Rhinol 2014; 5:247-52. [DOI: 10.1002/alr.21471] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 11/04/2014] [Accepted: 11/11/2014] [Indexed: 11/10/2022]
Affiliation(s)
- Vikram Padhye
- Department of Otolaryngology-Head and Neck Surgery, The Queen Elizabeth Hospital and University of Adelaide; South Australia Australia
| | - Rowan Valentine
- Department of Otolaryngology-Head and Neck Surgery, The Queen Elizabeth Hospital and University of Adelaide; South Australia Australia
| | - Raymond Sacks
- Australian School of Advanced Medicine, Macquarie University and Concord General Hospital, University of Sydney; NSW Australia
| | - Eng H. Ooi
- Department of Otolaryngology-Head and Neck Surgery, Flinders Medical Centre, Flinders University; South Australia Australia
| | - Charlie Teo
- Centre for Minimally Invasive Surgery, Prince of Wales Hospital and University of New South Wales; NSW Australia
| | - Marc Tewfik
- Department of Otolaryngology-Head and Neck Surgery, McGill University Health Centre, Montreal; QC Canada
| | - Dehui Wang
- Department of ENT, Rhinology Division, Eye and ENT Hospital, Fudan University; Shanghai China
| | - Peter-John Wormald
- Department of Otolaryngology-Head and Neck Surgery, The Queen Elizabeth Hospital and University of Adelaide; South Australia Australia
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Padhye V, Murphy J, Bassiouni A, Valentine R, Wormald PJ. Endoscopic direct vessel closure in carotid artery injury. Int Forum Allergy Rhinol 2014; 5:253-7. [DOI: 10.1002/alr.21453] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 09/15/2014] [Accepted: 09/25/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Vikram Padhye
- Department of Surgery-Otolaryngology Head and Neck Surgery, University of Adelaide, The Queen Elizabeth Hospital; Woodville South SA Australia
| | - Jae Murphy
- Department of Surgery-Otolaryngology Head and Neck Surgery, University of Adelaide, The Queen Elizabeth Hospital; Woodville South SA Australia
| | - Ahmed Bassiouni
- Department of Surgery-Otolaryngology Head and Neck Surgery, University of Adelaide, The Queen Elizabeth Hospital; Woodville South SA Australia
| | - Rowan Valentine
- Department of Surgery-Otolaryngology Head and Neck Surgery, University of Adelaide, The Queen Elizabeth Hospital; Woodville South SA Australia
| | - Peter-John Wormald
- Department of Surgery-Otolaryngology Head and Neck Surgery, University of Adelaide, The Queen Elizabeth Hospital; Woodville South SA Australia
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Kennedy DW. The epidemic of allergy continues in westernized nations. Introduction. Int Forum Allergy Rhinol 2014; 4:607-8. [PMID: 25091509 DOI: 10.1002/alr.21403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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