Carotid Injury during Endoscopic Endonasal Surgery: Incidence and Outcomes in 2015 Cases

Introduction: Injury to the internal carotid artery (ICA) during endoscopic endonasal skull base surgery (ESBS) is a feared complication that is not well studied or reported. The purpose of this study was to evaluate the incidence, identify potential risk factors, and present management strategies and outcomes of ICA injury during ESBS at our institution.

Methods: We performed a retrospective review of all endoscopic endonasal operations performed at our institution between 1998 and 2010 to examine potential factors predisposing to ICA injury, including pathological diagnosis, anatomical variations, site of injury, surgical technique, and stage of the operation when injury occurred. We also documented the perioperative management and outcomes following ICA injury.

Results: There were seven ICA injuries encountered in 2015 ESBSs, giving an incidence of 0.3%. Most injuries (5/7) involved the left ICA, and the most common diagnosis was chondroid neoplasm (chordoma, chondrosarcoma; 3/7). There were only 2/660 injuries during pituitary adenoma resection (0.3%). The paraclival ICA segment was the most commonly injured site (5/7). In 4/7, injured ICAs were sacrificed, either intra- or postoperatively. No patient suffered a stroke or neurologic deficit as a result of ICA injury. There were no intraoperative mortalities, one patient died postoperatively due to cardiac ischemia. One of the three preserved ICAs developed a pseudoaneurysm, which was treated endovascularly.

Conclusions: ICA injury during ESBS is an infrequent and manageable complication. Preservation of the vessel remains difficult. Chondroid tumors represent a higher risk and should be resected by surgical teams with significant prior experience.