Emergency endovascular stent graft and coil placement for internal carotid artery injury during transsphenoidal surgery

Carotid artery injury in endoscopic endonasal surgery: Risk factors, prevention, and management

Objective

Endoscopic approaches for sinus and skull base surgery are increasing in popularity. The objective of this narrative review is to characterize risk factors for internal carotid artery injury in endoscopic endonasal surgery (EES), highlight preventative measures, and illustrate key management principles.

Data Sources

Comprehensive literature review.

Methods

Relevant literature was reviewed using PubMed/MEDLINE.

Results

Carotid artery injury in EES is rare, with most studies reporting an incidence below 0.1%. Anatomic aberrancies, wide dissection margins, as well as specific provider and hospital factors, may increase the risk of injury. Multidisciplinary teams, comprehensive preoperative imaging, patient risk assessment, and formal training in vascular emergencies may reduce the risk. Management protocols should emphasize proper visualization of the injury site, fluid replacement, rapid packing, angiography, and endovascular techniques to achieve hemostasis.

Conclusions

While EES is a relatively safe procedure, carotid artery injury is a devastating complication that warrants full consideration in surgical planning. Important preventative measures include identifying patients with notable risk factors and obtaining preoperative imaging. Multidisciplinary teams and management protocols are ultimately necessary to reduce morbidity and mortality.

Internal carotid artery (ICA) injury is a rare complication of endoscopic endonasal surgery.

Risk factors for ICA injury may include vascular anatomic variants, invasive pathology, and prior radiation therapy.

Surgical team preparation and experience are key to successful management of operative complications.

Identifying Best Practices for Managing Internal Carotid Artery Injury During Endoscopic Endonasal Surgery by Consensus of Expert Opinion

BACKGROUND

Injury to the internal carotid artery (ICA) is a potentially devastating complication of endoscopic endonasal surgery (EES) that as many as 20% of skull base surgeons will experience at least once during their careers. Managing these injuries is difficult given the small operative field and poor visibility created by high-flow hemorrhage, and, at present, there is no consensus regarding best practices.

OBJECTIVE

This study seeks to consolidate the practices and opinions of experienced skull base surgeons from high-volume tertiary care centers into a single consensus statement regarding the best practices for managing ICA injuries during EES.

METHODS

A panel of 23 skull base surgeons (15 neurosurgeons and 8 otolaryngologists) completed a 3-round Delphi survey that assessed experiences and opinions regarding various aspects of ICA injury management. Mean (SD) years since fellowship completion was 15.6 (8.1) and all but 3 surgeons had experienced an ICA injury at least once.

RESULTS

The final consensus statement included 36 guidelines all of which were grouped under 1 of 4 categories: 11 statements concerned preoperative management and equipment for high-risk patients; 14 statements concerned hemorrhage control; 4 statements concerned definitive management; 7 statements concerned pharmacologic treatment, blood pressure, and neurophysiologic monitoring.

CONCLUSIONS

There are numerous decisions that a surgeon must make when facing a carotid artery injury. In our estimation, many questions can be grouped under 1 of the 4 categories outlined in our consensus statement and can be addressed by these findings.

Recurrent epistaxis from inflamed granulated tissue and an associated pseudoaneurysm of the internal carotid artery: case report

BACKGROUND

Chronic inflamed tissue in nasal cavity is a rare complication of transsphenoidal approach (TSA). Inflamed tissue is rich in blood vessels, which can lead to frequent nosebleeds. In addition, chronic inflammation can cause pseudoaneurysm, whose rupture results in massive epistaxis. There have been few reported cases of pseudoaneurysm of ICA occurring more than 10 years after TSA surgery.

CASE PRESENTATION

We report a case of a patient who had recurrent epistaxis for over a decade after TSA surgery, and analyzed the causes of the nosebleeds. The aspect of occurrence of the nosebleeds and the result of biopsy and imaging tests suggest that the nosebleeds were due to chronic inflamed tissue and an associated pseudoaneurysm. The rupture of pseudoaneurysm recurred after treatment with stent placement, and brain abscess was developed. After removing the inflamed tissue by endoscopic resection, the patient no longer had recurrence of ruptured pseudoaneurysm or nosebleeds.

CONCLUSIONS

In patients with recurrent nosebleeds, the possibility of intranasal inflammation and subsequent pseudoaneurysm should be considered. Therefore, people who consistently have epistaxis after TSA, even if the bleeding is not in large amount, should be actively screened and treated for nasal chronic inflammation.

Inadvertent internal carotid artery (ICA) injury during transsphenoidal surgery: review of literature

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.

A modified endovascular treatment protocol for iatrogenic internal carotid artery injuries following endoscopic endonasal surgery

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Magnetic Resonance Angiography-based Prediction of the Results of Balloon Test Occlusion

Precautious balloon test occlusion (BTO) is sometimes performed in cases of high-risk intraoperative internal carotid artery injury. We investigated whether magnetic resonance angiography (MRA) findings could predict BTO results to thus avoid the use of precautious BTO. This retrospective study, included 96 patients who underwent BTO, eight of whom underwent bilateral BTO. The relationship between the BTO results for 104 internal carotid arteries and the MRA findings obtained in 96 patients were retrospectively evaluated. On MRA, anterior cerebral artery (A1)–anterior communicating artery–A1 was defined as anterior collateral circulation (ACC), and posterior cerebral artery–posterior communicating artery was defined as posterior collateral circulation (PCC). BTO was tolerated in all 27 sides with thick ACC regardless of PCC thickness. In 31 of 44 cases with a thin ACC, the tested sides were BTO-tolerant (70.5%). Of these 44 tested sides, all five with a thick PCC were BTO-tolerant, but eight with a thin PCC and 31 with an invisible PCC showed results other than tolerance. Among cases with an invisible ACC, 10 of 33 tested sides were BTO-tolerant (30.3%). Among these 33 tested sides, outcomes other than tolerance were observed regardless of PCC thickness. Thick, thin, and invisible ACCs were assigned 3, 1, and 0 points, respectively; and thick, thin, and invisible PCCs were assigned 2, 1, and 0 points, respectively. A sum of 3 points in the ACC and PCC indicated that all sides were BTO-tolerant. In conclusion, a thick ACC or a thin ACC with a thick PCC indicates BTO-tolerance. The BTO prediction score is useful for predicting results of BTO.

Managing Arterial Injury in Endoscopic Skull Base Surgery: Case Series and Review of the Literature

BACKGROUND

The most feared complications following endoscopic endonasal skull base surgery are arterial vascular injuries. Previously published literature is restricted to internal carotid artery injuries. The ideal method for controlling arterial bleeding during this kind of procedure is debated, and a variety of techniques have been advocated.

OBJECTIVE

To evaluate the management and outcome following intraoperative arterial injury during endoscopic endonasal skull base surgery.

METHODS

We performed a retrospective review of a prospectively acquired database of consecutive endonasal endoscopic surgeries at the New York-Presbyterian Hospital/Weill Cornell Medical Center from December 2003 to June 2015 and identified all cases of arterial injury.

RESULTS

Of 800 cases, there were 4 arterial injuries (0.5%), of which only one involved the internal carotid artery (ICA), for a risk of 0.125%. The other 3 involved the ophthalmic artery, anterior communicating artery, and A1 segment of the anterior cerebral artery. In all cases, definitive treatment involved occlusion of the artery either through endovascular means (3 cases) or direct surgical ligation (1 case). Neurological examinations were unchanged after arterial repair with only 1 small asymptomatic stroke. Literature review identified 7336 patients, of which there were 25 arterial injuries, of which 19 were of the ICA. Hence, the total rate of arterial injury was 0.34% and the rate of ICA injury was 0.26%. Arterial sacrifice was the only reliable method for managing arterial injury.

CONCLUSION

Arterial injury is an uncommon event after endoscopic endonasal surgery. Attempts at arterial repair are rarely successful, and vessel sacrifice is the most reliable technique at this point.

Urgent cerebral revascularization bypass surgery for iatrogenic skull base internal carotid artery injury

BACKGROUND

When feasible, the management of iatrogenic internal carotid artery (ICA) injury during skull base surgery is mainly endovascular.

OBJECTIVE

To propose a cerebral revascularization procedure as a rescue option when endovascular treatment is not feasible.

METHODS

We retrospectively reviewed all extracranial-intracranial (EC-IC) bypass procedures performed between July 2007 and January 2014.

RESULTS

From 235 procedures, we identified 8 consecutive patients with iatrogenic ICA injury managed with an EC-IC bypass. Injury to the ICA occurred during an endoscopic transsphenoidal surgery (n=3), endoscopic transfacial-transmaxillary surgery (n=1), myringotomy (n=1), cavernous sinus meningioma resection (n=1), posterior communicating artery aneurysm clipping (n=1), and cavernous ICA aneurysm coiling (n=1). Endovascular management was considered first-line treatment but was not successful. All patients received a high-flow EC-IC bypass. At a mean clinical/radiographic follow-up of 19 months (range, 3-36 months), all patients had a modified Rankin Scale score of 0 or 1. All bypasses remained patent.

CONCLUSION

Iatrogenic injury of the skull base ICA is uncommon but can lead to lethal consequences. Many injuries can be treated with endovascular techniques. However, certain cases may still require a cerebral revascularization procedure.

Flow diversion in the treatment of carotid injury and carotid-cavernous fistula after transsphenoidal surgery

We describe a case of iatrogenic carotid injury with secondary carotid-cavernous fistula (CCF) treated with a silk flow diverter stent placed within the injured internal carotid artery and coils placed within the cavernous sinus. Flow diverters may offer a simple and potentially safe vessel-sparing option in this rare complication of transsphenoidal surgery. The management options are discussed and the relevant literature is reviewed.

Management of carotid artery injury in endonasal surgery

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.

Retained transcranial knife blade with transection of the internal carotid artery treated by staged endovascular and surgical therapy: technical case report

BACKGROUND AND IMPORTANCE

We describe the use of proximal and distal endovascular coil embolization of the internal carotid artery followed by operative removal of a retained foreign object transecting the petrocavernous portion of the internal carotid artery.

CLINICAL PRESENTATION

A 20-year-old man sustained a stab wound to the left temporal skull and presented with a retained knife blade. He reported a headache at presentation, but remained neurologically intact with a Glasgow Coma Scale of 15. Computed tomography imaging and subsequent angiography confirmed complete transection of the petrocavernous segment of the left internal carotid artery with effective tamponade by the knife blade in situ and satisfactory collateral flow across the Circle of Willis. Coil embolization of the left internal carotid artery was performed. Retrograde embolization of the petrocavernous internal carotid segment distal to the injury was performed via vertebral and posterior communicating artery access. Antegrade embolization of the internal carotid artery proximal to the injury was completed and the patient was transferred to the operating room for craniectomy and foreign body extraction. Postoperative computed tomography angiography revealed no parenchymal hemorrhage, mass effect, or midline shift, and successful embolization of the internal carotid artery. At 6-week follow-up, the patient remained neurologically intact with no infectious or vascular complications.

CONCLUSION

Staged endovascular and surgical therapy provides complete assessment and effective control of damaged vessels when retained intracranial foreign bodies are present. Given the high risk of vascular injury with retained transcranial foreign bodies, this strategy should be considered a safe approach for these challenging cases.

Jostent covered stent placement for emergency reconstruction of a ruptured internal carotid artery during or after transsphenoidal surgery

OBJECT

Internal carotid artery (ICA) rupture during transsphenoidal surgery (TSS) is an extremely difficult complication to treat. This study aimed to evaluate the immediate and long-term outcomes of covered stent placement for emergency reconstruction of ruptured ICAs during or after TSS.

METHODS

Seven patients underwent covered stent placement for emergency reconstruction of a ruptured ICA during or after TSS. The safety and effectiveness of covered stent placement for emergency reconstruction of ruptured ICAs were retrospectively analyzed.

RESULTS

Pretreatment angiography showed active bleeding in 6 patients (5 intraoperative and 1 postoperative) and a pseudoaneurysm in 1 patient. Of the 6 patients with active bleeding, 5 were treated with a successive operation to control active bleeding. The other patient was treated just after cardiopulmonary resuscitation due to massive nasal bleeding 20 days after revision of TSS. All active bleeding was controlled immediately after covered stent insertion in these 6 patients. One patient showed a gap between the covered stent and ICA wall without active bleeding 30 minutes after glycoprotein IIb/IIIa inhibitor administration due to in-stent thrombosis. The gap was occluded with coil embolization after completion of the temporarily suspended TSS. The seventh patient, whose ICA tear was treated with surgical suture, underwent covered stent placement for a pseudoaneurysm detected on postoperative Day 2. During a mean follow-up period of 46 months (range 12-85 months), all patients had excellent outcomes (modified Rankin Scale score of 0). All the stented ICAs were patent on vascular imaging follow-up at a mean of 34 months (range 12-85 months).

CONCLUSIONS

Covered stents appear to be a safe and effective option for emergency reconstruction of ruptured ICAs during or after TSS.

Cerebrovascular complications and utilization of endovascular techniques following transsphenoidal resection of pituitary adenomas: a study of the Nationwide Inpatient Sample 2001-2010

PURPOSE

Cerebrovascular complications following transsphenoidal resection of pituitary tumors are rare and often evaluated and treated with endovascular techniques. We determined the utilization rate and outcomes of endovascular procedures in transsphenoidal pituitary resection patients using an administrative database.

METHODS

Using the Nationwide Inpatient Sample 2001-2010, patients receiving transsphenoidal resection of benign pituitary tumors were identified. The rate of cerebrovascular complications and utilization of endovascular repair procedures and cerebral angiography were compared between high (≥ 75 procedures/year) and low volume (<75 procedures/year) centers. Chi squared tests were used to compare categorical variables.

RESULTS

70,878 were patients included in this study. ICH/SAH occurred in 0.9 % of patients (652/70,878) and stroke occurred in 0.5 % of patients (327/70,878). Patients treated at high volume centers had significantly lower rates of stroke (0.5 % vs. 1.0 %, P = 0.04), and ICH/SAH (0.5 vs. 1.0 %, P = 0.05) when compared to patients treated at low-volume centers. Overall, 531 patients (0.7 %) received post-operative angiography and 83 patients (0.1 %) received endovascular repair procedures. High volume center patients underwent angiography in 0.4 % of cases compared to 0.9 % for low volume center patients (P = 0.02). There was no significant difference in endovascular repair procedure rates at high and low volume centers (0.1 vs. 0.2 %, P = 0.37).

CONCLUSIONS

Cerebrovascular surgical complications requiring cerebral angiography and endovascular repair are rare among transsphenoidal pituitary resection patients. These occur with higher frequency at low volume centers and are associated with high mortality rates.

Early and late complications of endoscopic hemostatic techniques following different carotid artery injury characteristics

BACKGROUND

The most dreaded hemorrhagic complication in endoscopic endonasal surgery is injury to the internal carotid artery (ICA). Although a number of treatment protocols are currently used, none have been formally investigated. This study aims to compare the efficacy of the muscle patch, bipolar diathermy, and aneurysm clip on hemostasis, pseudoaneurysm formation, and long-term vessel patency for different injury types in a sheep model of carotid bleeding.

METHODS

Twenty-seven sheep underwent ICA dissection/isolation followed by the artery placement within a modified "sinus model otorhino neuro trainer" (SIMONT) model. Standardized linear, punch, and stellate injuries were made. Randomization of sheep to receive 1 of 3 hemostatic techniques was performed (muscle, bipolar, clip). Specific outcome measures included attainment of primary hemostasis, time to hemostasis, blood loss, pseudoaneurysm formation, and carotid patency on follow-up magnetic resonance imaging (MRI).

RESULTS

Bipolar achieved primary hemostasis in 7 of 9 cases and 2 cases of secondary hemorrhage. It had no associated pseudoaneurysm formation. Carotid patency was variable on follow-up MRI. Muscle patch achieved 100% primary hemostasis with 2 cases of secondary hemorrhage. There were 2 cases of pseudoaneurysm and 100% patency rate on follow-up MRI. Aneurysm clip achieved 100% primary hemostasis with 1 case of secondary hemorrhage. No pseudoaneurysm formation and a 50% rate of carotid insufficiency on MRI.

CONCLUSION

This study shows that the crushed muscle patch and aneurysm clip can be viable options in the management of ICA injury with short-term and long-term benefits. Complications associated with these techniques were comparable if not reduced when compared to the published literature.

Emergency reconstructive endovascular management of intraoperative complications involving the internal carotid artery from trans-sphenoidal surgery

PURPOSE

To report our experience with intraoperative complications involving the internal carotid artery (ICA) during trans-sphenoidal surgery and their outcome with reconstructive endovascular management.

METHODS

A retrospective review was conducted of patients with an ICA injury related to trans-sphenoidal surgery from 2000 to 2012. Demographic data, clinical charts, indications for treatment, radiographic images, lesion characteristics, operative notes, endovascular procedure notes and post-procedure hospital course were reviewed.

RESULTS

Three men and one woman of mean age of 52 years (range 33-74) were identified. The lesions included two macroadenomas, one meningioma and one chondrosarcoma. Risk factors for ICA rupture included two patients with carotid dehiscence, one with sphenoid septal attachment to the ICA, two with revision surgery, one with prior radiation to the tumor, one with bromocriptine treatment and two with acromegaly. In three patients, covered stent placement achieved hemostasis at the site of injury within the ICA. One patient developed delayed bleeding 6 h after covered stent placement and underwent successful endovascular occlusion of the ICA but died 6 days after the injury. The fourth patient had an intraoperative ICA stroke requiring suction thrombectomy, thrombolysis, stent placement and evacuation of an epidural hematoma. At 1-year follow-up, two patients had a modified Rankin score (mRS) and National Institute of Health Stroke Scale (NIHSS) score of 0; in the patient who had a stroke the mRS score was 1 and the NIHSS score 2.

CONCLUSIONS

Endovascular management with arterial reconstruction is helpful in the treatment of ICA injuries during trans-sphenoidal surgery.

Endoscopic endonasal approach for the treatment of a large clival giant cell tumor complicated by an intraoperative internal carotid artery rupture

Giant cell tumors (GCTs) are primary bone neoplasms that rarely involve the skull base. These lesions are usually locally aggressive and require complete removal, including the surrounding apparently healthy bone, to provide the best chance of cure. GCTs, as well as other lesions located in the clivus, can nowadays be treated by a minimally invasive fully endoscopic extended endonasal approach. This approach ensures a more direct route to the craniovertebral junction than other possible approaches (transfacial, extended lateral, and posterolateral approaches). The case reported is a clival GCT operated on by an extended endonasal approach that provides another contribution on how to address one of the most feared complications attributed to this approach: a massive bleed due to an internal carotid artery injury.

Spontaneous healing of iatrogenic direct carotid cavernous fistula

Direct carotid-cavernous fistula (CCF) by selective navigation using a microcatheter or microwire is a rare complication, and its timing of treatment has not been elucidated. We report two cases of direct CCFs resulting from injury to the cavernous posterior segment of the internal carotid artery during selective navigation. We did not plan to perform emergent endovascular treatment for these direct CCFs because no symptoms related to direct CCFs developed. Follow-up angiography revealed spontaneous healing of both direct CCFs. Close observation rather than emergent treatment may represent another option for direct CCF by selective navigation during the endovascular procedure.

Carotid artery injury after endonasal surgery

Carotid artery injury during endonasal surgery is the most feared and catastrophic complication. Internal carotid artery injury is more frequent during skull base surgery, and risk factors include acromegaly, previous revision surgery, and prior radiotherapy and bromocriptine therapy. Nasal packing is frequently used to gain hemostasis, often resulting in vascular occlusion. Recent research recommends the crushed muscle patch treatment as an effect hemostat that maintains vascular patency. Endovascular techniques are recommended for vascular control and complication management. Coil or balloon embolization is preferred in patients with adequate collateral cerebral blood flow, and stent-graft placement or bypass surgery is indicated in those who do not.