Characterization of Outcomes and Practices Utilized in the Management of Internal Carotid Artery Injury Not Requiring Embolization, Stenting, or Ligation

Introduction: Injury of the internal carotid artery (ICA) during endoscopic endonasal skull base surgery is an uncommon and feared complication. After immediate control of hemostasis, patients are typically taken for neuroendovascular evaluation for potential definitive management. The majority of patients undergo ICA embolization or stenting to treat active extravasation or pseudoaneurysm development. However, management practices when embolization or stenting is not required have not been well described.

Objective: To determine how patients with ICA injury but no embolization, stenting, or ligation do long-term and ascertain the reconstruction methods utilized.

Methods: Twenty nine cases of ICA injury were identified in an international multi-institutional retrospective review. Of these, we identified 6 cases that were not treated with embolization, stenting, or ICA sacrifice. Information was available on 5 cases.

Results: Four injuries occurred to the main ICA while one case was to an ICA branch. A lack of available resources influenced the decision not to perform embolization or stenting in only one case. The average number of postinjury angiography performed per case was 3 (range: 1–5). Angiography was negative for pseudoaneurysm each time in 2 cases and positive in 1 case. In one case a micropseudoaneurysm was detected which resolved on later angiography. The median time for the first follow-up angiography was 14 days (range: 3 days to 2 months).

A muscle patch was used in the immediate repair of all five cases. An intranasal flap (nasoseptal flap) was added to the reconstruction in only one case. Prefabricated nasal tampons were used in all cases. Nasal packing was initially left in for a median of 7 days (range: 5 days to 11 days) prior to removal. No complications with the nasal packing were noted. On packing removal, the initial muscle patch was reinforced with a second muscle graft in one case. One case demonstrated ICA bleeding at the time of packing removal and was re-packed an additional week. Follow-up for each of these cases was at least one year. No cases of subsequent carotid rupture were found and none of these cases ultimately underwent endovascular stenting. Radiation or proton therapy has not been subsequently used in any of these patients.

Conclusion: This international multi-institutional study details the reconstruction, lessons learned, and long-term follow-up for five cases of ICA injury not treated with embolization, stenting, or ligation.

Publication History

Article published online:
12 February 2021