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CC BY-NC-ND 4.0 · J Neurol Surg Rep 2021; 82(04): e53-e62
DOI: 10.1055/s-0041-1740511
Original Article

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

Gokmen Kahilogullari 
1   Department of Neurosurgery, Ankara University, Ankara, Turkey
,
Burak Bahadır 
1   Department of Neurosurgery, Ankara University, Ankara, Turkey
,
Melih Bozkurt 
1   Department of Neurosurgery, Ankara University, Ankara, Turkey
,
Seray Akcalar 
2   Department of Radiology, Ankara University, Ankara, Turkey
,
Sinan Balci 
3   Department of Radiology, Hacettepe University, Ankara, Turkey
,
Anil Arat 
3   Department of Radiology, Hacettepe University, Ankara, Turkey
› Author Affiliations Funding None.
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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.

Keywords

endonasal endoscopic surgery - endovascular treatment - ICA-cavernous segment - pituitary adenoma - trapping - urgent transcranial surgery

Supplementary Material



Publication History

Received: 14 May 2021

Accepted: 20 September 2021

Article published online:
14 December 2021

© 2021. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Schwartz TH, Fraser JF, Brown S, Tabaee A, Kacker A, Anand VK. Endoscopic cranial base surgery: classification of operative approaches. Neurosurgery 2008; 62 (05) 991-1002 , discussion 1002–1005
    CrossrefPubMedGoogle Scholar
  • 2 Ciric I, Ragin A, Baumgartner C, Pierce D. Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery 1997; 40 (02) 225-236 , discussion 236–237
    CrossrefPubMedGoogle Scholar
  • 3 Berker M, Aghayev K, Saatci I, Palaoğlu S, Onerci M. Overview of vascular complications of pituitary surgery with special emphasis on unexpected abnormality. Pituitary 2010; 13 (02) 160-167
    CrossrefPubMedGoogle Scholar
  • 4 Solares CA, Ong YK, Carrau RL. et al. Prevention and management of vascular injuries in endoscopic surgery of the sinonasal tract and skull base. Otolaryngol Clin North Am 2010; 43 (04) 817-825
    CrossrefPubMedGoogle Scholar
  • 5 Weidenbecher M, Huk WJ, Iro H. Internal carotid artery injury during functional endoscopic sinus surgery and its management. Eur Arch Otorhinolaryngol 2005; 262 (08) 640-645
    CrossrefPubMedGoogle Scholar
  • 6 Babgi M, Alsaleh S, Babgi Y, Baeesa S, Ajlan A. Intracranial intradural vascular injury during endoscopic endonasal transsphenoidal surgery: a case report and literature review. J Neurol Surg Rep 2020; 81 (03) e52-e58
    Article in Thieme ConnectPubMedGoogle Scholar
  • 7 Kahilogullari G, Meco C, Beton S. et al. Endoscopic transnasal skull base surgery in pediatric patients. J Neurol Surg B Skull Base 2020; 81 (05) 515-525
    Article in Thieme ConnectPubMedGoogle Scholar
  • 8 Kocer N, Kizilkilic O, Albayram S, Adaletli I, Kantarci F, Islak C. Treatment of iatrogenic internal carotid artery laceration and carotid cavernous fistula with endovascular stent-graft placement. AJNR Am J Neuroradiol 2002; 23 (03) 442-446
    PubMedGoogle Scholar
  • 9 Safaee M, Young JS, El-Sayed IH, Theodosopoulos PV. Management of noncatastrophic internal carotid artery injury in endoscopic skull base surgery. Cureus 2019; 11 (08) e5537
    PubMedGoogle Scholar
  • 10 Pham M, Kale A, Marquez Y. et al. Management of carotid artery injury during endoscopic endonasal skull base surgery. J Neurol Surg B Skull Base 2014; 75: 309-313
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Cappabianca P, Briganti F, Cavallo LM, de Divitiis E. Pseudoaneurysm of the intracavernous carotid artery following endoscopic endonasal transsphenoidal surgery, treated by endovascular approach. Acta Neurochir (Wien) 2001; 143 (01) 95-96
    CrossrefPubMedGoogle Scholar
  • 12 Cappabianca P, Cavallo LM, Colao A, de Divitiis E. Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg 2002; 97 (02) 293-298
    CrossrefPubMedGoogle Scholar
  • 13 Liu HS, Di X. Endoscopic endonasal surgery for biopsy of cavernous sinus lesions. Minim Invasive Neurosurg 2009; 52 (02) 69-73
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 Zada G, Cavallo LM, Esposito F. et al. Transsphenoidal surgery in patients with acromegaly: operative strategies for overcoming technically challenging anatomical variations. Neurosurg Focus 2010; 29 (04) E8
    CrossrefPubMedGoogle Scholar
  • 15 Gondim JA, Almeida JPC, Albuquerque LA. et al. Endoscopic endonasal approach for pituitary adenoma: surgical complications in 301 patients. Pituitary 2011; 14 (02) 174-183
    CrossrefPubMedGoogle Scholar
  • 16 Berker M, Hazer DB, Yücel T. et al. Complications of endoscopic surgery of the pituitary adenomas: analysis of 570 patients and review of the literature. Pituitary 2012; 15 (03) 288-300
    CrossrefPubMedGoogle Scholar
  • 17 Gardner PA, Tormenti MJ, Pant H, Fernandez-Miranda JC, Snyderman CH, Horowitz MB. Carotid artery injury during endoscopic endonasal skull base surgery: incidence and outcomes. Neurosurgery 2013;73(2, Suppl Operative):ons261ȃons269, discussion ons269–ons270
    PubMedGoogle Scholar
  • 18 Iacoangeli M, Di Rienzo A, Re M. et al. Endoscopic endonasal approach for the treatment of a large clival giant cell tumor complicated by an intraoperative internal carotid artery rupture. Cancer Manag Res 2013; 5: 21-24
    CrossrefPubMedGoogle Scholar
  • 19 Kalinin PL, Sharipov OI, Shkarubo AN. et al. [Damage to the cavernous segment of internal carotid artery in transsphenoidal endoscopic removal of pituitary adenomas (report of 4 cases)]. Vopr Neirokhir 2013; 77 (06) 28-37 , discussion 38
    PubMedGoogle Scholar
  • 20 Rangel-Castilla L, McDougall CG, Spetzler RF, Nakaji P. Urgent cerebral revascularization bypass surgery for iatrogenic skull base internal carotid artery injury. Neurosurgery 2014; 10 (Suppl. 04) 640-647 , discussion 647–648
    PubMedGoogle Scholar
  • 21 Padhye V, Valentine R, Sacks R. et al. Coping with catastrophe: the value of endoscopic vascular injury training. Int Forum Allergy Rhinol 2015; 5 (03) 247-252
    CrossrefPubMedGoogle Scholar
  • 22 Magro E, Graillon T, Lassave J. et al. Complications related to the endoscopic endonasal transsphenoidal approach for nonfunctioning pituitary macroadenomas in 300 consecutive patients. World Neurosurg 2016; 89: 442-453
    CrossrefPubMedGoogle Scholar
  • 23 Romero ADCB, Lal Gangadharan J, Bander ED, Gobin YP, Anand VK, Schwartz TH. Managing arterial injury in endoscopic skull base surgery: case series and review of the literature. Oper Neurosurg (Hagerstown) 2017; 13 (01) 138-149
    CrossrefPubMedGoogle Scholar
  • 24 Dedmon M, Meier J, Chambers K. et al. Delayed endovascular coil extrusation following internal carotid artery embolization. J Neurol Surg Rep 2014; 75 (02) e255-e258
    Article in Thieme ConnectPubMedGoogle Scholar
  • 25 Duek I, Sviri GE, Amit M, Gil Z. Endoscopic endonasal repair of internal carotid artery injury during endoscopic endonasal surgery. J Neurol Surg Rep 2017; 78 (04) e125-e128
    Article in Thieme ConnectPubMedGoogle Scholar
  • 26 Snyderman CH, Pant H, Carrau RL, Prevedello D, Gardner P, Kassam AB. What are the limits of endoscopic sinus surgery?: the expanded endonasal approach to the skull base. Keio J Med 2009; 58 (03) 152-160
    CrossrefPubMedGoogle Scholar
  • 27 Dehdashti AR, Ganna A, Witterick I, Gentili F. Expanded endoscopic endonasal approach for anterior cranial base and suprasellar lesions: indications and limitations. Neurosurgery 2009; 64 (04) 677-687 , discussion 687–689
    CrossrefPubMedGoogle Scholar
  • 28 Zanation AM, Carrau RL, Snyderman CH. et al. Nasoseptal flap reconstruction of high flow intraoperative cerebral spinal fluid leaks during endoscopic skull base surgery. Am J Rhinol Allergy 2009; 23 (05) 518-521
    CrossrefPubMedGoogle Scholar
  • 29 Cavallo LM, Briganti F, Cappabianca P. et al. Hemorrhagic vascular complications of endoscopic transsphenoidal surgery. Minim Invasive Neurosurg 2004; 47 (03) 145-150
    Article in Thieme ConnectPubMedGoogle Scholar
  • 30 Valentine R, Wormald PJ. Carotid artery injury after endonasal surgery. Otolaryngol Clin North Am 2011; 44 (05) 1059-1079
    CrossrefPubMedGoogle Scholar
  • 31 Laws Jr ER. Vascular complications of transsphenoidal surgery. Pituitary 1999; 2 (02) 163-170
    CrossrefPubMedGoogle Scholar
  • 32 Alahmadi H, Dehdashti AR, Gentili F. Endoscopic endonasal surgery in recurrent and residual pituitary adenomas after microscopic resection. World Neurosurg 2012; 77 (3-4): 540-547
    CrossrefPubMedGoogle Scholar
  • 33 Pasquini E, Zoli M, Frank G. Endoscopic endonasal surgery: new perspectives in recurrent and residual pituitary adenomas. World Neurosurg 2012; 77 (3-4): 457-458
    CrossrefPubMedGoogle Scholar
  • 34 Halvorsen H, Ramm-Pettersen J, Josefsen R. et al. Surgical complications after transsphenoidal microscopic and endoscopic surgery for pituitary adenoma: a consecutive series of 506 procedures. Acta Neurochir (Wien) 2014; 156 (03) 441-449
    CrossrefPubMedGoogle Scholar
  • 35 Frank G, Pasquini E, Farneti G. et al. The endoscopic versus the traditional approach in pituitary surgery. Neuroendocrinology 2006; 83 (3-4): 240-248
    CrossrefPubMedGoogle Scholar
  • 36 Ammirati M, Wei L, Ciric I. Short-term outcome of endoscopic versus microscopic pituitary adenoma surgery: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2013; 84 (08) 843-849
    CrossrefPubMedGoogle Scholar
  • 37 Fang X, Di G, Zhou G. et al. The anatomy of the parapharyngeal segment of the internal carotid artery for endoscopic endonasal approach. Neurosurg Rev 2019; ••• DOI: 10.1007/s10143-019-01176-3.
    CrossrefPubMedGoogle Scholar
  • 38 Dal Secchi MM, Dolci RLL, Teixeira R, Lazarini PR. An analysis of anatomic variations of the sphenoid sinüs and its relationship to the internal carotid artery. Int Arch Otorhinolaryngol 2018; 22 (02) 161-166
    Article in Thieme ConnectPubMedGoogle Scholar
  • 39 Truong HQ, Najera E, Zanabria-Ortiz R. et al. Surgical anatomy of the superior hypophyseal artery and its relevance for endoscopic endonasal surgery. J Neurosurg 2018; 131 (01) 154-162
    CrossrefPubMedGoogle Scholar
  • 40 Skandalakis GP, Koutsarnakis C, Pantazis N. et al. The carotico-clinoid bar: a systematic review and meta-analysis of its prevalence and potential implications in cerebrovascular and skull base surgery. World Neurosurg 2019; 124: 267-276
    CrossrefPubMedGoogle Scholar
  • 41 Rowan NR, Turner MT, Valappil B. et al. Injury of the carotid artery during endoscopic endonasal surgery: surveys of skull base surgeons. J Neurol Surg B Skull Base 2018; 79 (03) 302-308
    Article in Thieme ConnectPubMedGoogle Scholar
  • 42 AlQahtani A, London Jr NR, Castelnuovo P. et al. Assessment of factors associated with internal carotid injury in expanded endoscopic endonasal skull base surgery. JAMA Otolaryngol Head Neck Surg 2020; 146 (04) 364-372
    CrossrefPubMedGoogle Scholar
  • 43 Dziedzic T, Koczyk K, Gotlib T, Kunert P, Maj E, Marchel A. Sphenoid sinus septations and their interconnections with parasphenoidal internal carotid artery protuberance: radioanatomical study with literature review. Wideochir Inne Tech Malo Inwazyjne 2020; 15 (01) 227-233
    PubMedGoogle Scholar
  • 44 Erdogan U, Turhal G, Kaya I. et al. Cavernous sinus and parasellar region: An endoscopic endonasal anatomic cadaver dissection. J Craniofac Surg 2018; 29 (07) e667-e670
    CrossrefPubMedGoogle Scholar
  • 45 Feng Y, Zhao JW, Liu M. et al. Internal carotid artery in the operative plane of endoscopic endonasal transsphenoidal surgery. J Craniofac Surg 2012; 23 (03) 909-912
    CrossrefPubMedGoogle Scholar
  • 46 Zhang Y, Tian Y, Song J, Li Y, Li W. Internal carotid artery in endoscopic endonasal transsphenoidal surgery. J Craniofac Surg 2012; 23 (06) 1866-1869
    CrossrefPubMedGoogle Scholar
  • 47 Perry A, Graffeo CS, Meyer J. et al. Beyond the learning curve: comparison of microscopic and endoscopic incidences of internal carotid artery injury in a series of highly experienced operators. World Neurosurg 2019; 131: e128-e135
    CrossrefPubMedGoogle Scholar
  • 48 Valentine R, Wormald PJ. Controlling the surgical field during a large endoscopic vascular injury. Laryngoscope 2011; 121 (03) 562-566
    CrossrefPubMedGoogle Scholar
  • 49 Koitschev A, Simon C, Löwenheim H, Naegele T, Ernemann U. Management and outcome after internal carotid artery laceration during surgery of the paranasal sinuses. Acta Otolaryngol 2006; 126 (07) 730-738
    CrossrefPubMedGoogle Scholar
  • 50 Fastenberg JH, Garzon-Muvdi T, Hsue V. et al. 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 (09) 1023-1029
    CrossrefPubMedGoogle Scholar
  • 51 Zhang HK, Ma N, Sun XC, Wang DH. Endoscopic repair of the injured internal carotid artery utilizing oxidized regenerated cellulose and a free fascia lata graft. J Craniofac Surg 2016; 27 (04) 1021-1024
    CrossrefPubMedGoogle Scholar
  • 52 Chin OY, Ghosh R, Fang CH, Baredes S, Liu JK, Eloy JA. Internal carotid artery injury in endoscopic endonasal surgery: a systematic review. Laryngoscope 2016; 126 (03) 582-590
    CrossrefPubMedGoogle Scholar
  • 53 Valentine R, Wormald PJ. A vascular catastrophe during endonasal surgery: an endoscopic sheep model. Skull Base 2011; 21 (02) 109-114
    Article in Thieme ConnectPubMedGoogle Scholar
  • 54 Maza G, VanKoevering KK, Yanez-Siller JC. et al. Surgical simulation of a catastrophic internal carotid artery injury: a laser-sintered model. Int Forum Allergy Rhinol 2019; 9 (01) 53-59
    CrossrefPubMedGoogle Scholar
  • 55 Muto J, Carrau RL, Oyama K, Otto BA, Prevedello DM. Training model for control of an internal carotid artery injury during transsphenoidal surgery. Laryngoscope 2017; 127 (01) 38-43
    CrossrefPubMedGoogle Scholar
  • 56 Pacca P, Jhawar SS, Seclen DV. et al. ‘Live Cadaver’ model for internal carotid artery injury simulation in endoscopic endonasal skull base surgery. Oper Neurosurg (Hagerstown) 2017; 13 (06) 732-738
    CrossrefPubMedGoogle Scholar
  • 57 Shen J, Hur K, Zhang Z. et al. Objective validation of perfusion-based human cadaveric simulation training model for management of internal carotid artery injury in endoscopic endonasal sinus and skull base surgery. Oper Neurosurg (Hagerstown) 2018; 15 (02) 231-238
    CrossrefPubMedGoogle Scholar
  • 58 Dusick JR, Esposito F, Malkasian D, Kelly DF. Avoidance of carotid artery injuries in transsphenoidal surgery with the Doppler probe and micro-hook blades. Neurosurgery 2007;60(4, Suppl 2):322–328, discussion 328–329
    PubMedGoogle Scholar
  • 59 Raymond J, Hardy J, Czepko R, Roy D. Arterial injuries in transsphenoidal surgery for pituitary adenoma; the role of angiography and endovascular treatment. AJNR Am J Neuroradiol 1997; 18 (04) 655-665
    PubMedGoogle Scholar
  • 60 Ahuja A, Guterman LR, Hopkins LN. Carotid cavernous fistula and false aneurysm of the cavernous carotid artery: complications of transsphenoidal surgery. Neurosurgery 1992; 31 (04) 774-778 , discussion 778–779
    PubMedGoogle Scholar
  • 61 Wang WH, Lieber S, Lan MY. et al. Nasopharyngeal muscle patch for the management of internal carotid artery injury in endoscopic endonasal surgery. J Neurosurg 2019; 18: 1-6
    PubMedGoogle Scholar
  • 62 Valentine R, Boase S, Jervis-Bardy J, Dones Cabral JD, Robinson S, Wormald PJ. The efficacy of hemostatic techniques in the sheep model of carotid artery injury. Int Forum Allergy Rhinol 2011; 1 (02) 118-122
    CrossrefPubMedGoogle Scholar
  • 63 Padhye V, Valentine R, Paramasivan S. et al. Early and late complications of endoscopic hemostatic techniques following different carotid artery injury characteristics. Int Forum Allergy Rhinol 2014; 4 (08) 651-657
    CrossrefPubMedGoogle Scholar
  • 64 Karadag A, Kinali B, Ugur O, Oran I, Middlebrooks EH, Senoglu M. A case of pseudoaneurysm of the internal carotid artery following endoscopic endonasal pituitary surgery: endovascular treatment with flow-diverting stent implantation. Acta Med (Hradec Kralove) 2017; 60 (02) 89-92
    CrossrefPubMedGoogle Scholar
  • 65 Biswas D, Daudia A, Jones NS, McConachie NS. Profuse epistaxis following sphenoid surgery: a ruptured carotid artery pseudoaneurysm and its management. J Laryngol Otol 2009; 123 (06) 692-694
    CrossrefPubMedGoogle Scholar
  • 66 Cobb MI, Nimjee S, Gonzalez LF, Jang DW, Zomorodi A. Direct repair of iatrogenic internal carotid artery injury during endoscopic endonasal approach surgery with temporary endovascular balloon-assisted occlusion: technical case report. Neurosurgery 2015; 11 (Suppl. 03) E483-E486 , discussion E486–E487
    PubMedGoogle Scholar
  • 67 Zhang Y, Tian Z, Li C. et al. A modified endovascular treatment protocol for iatrogenic internal carotid artery injuries following endoscopic endonasal surgery. J Neurosurg 2019; 132 (02) 343-350
    CrossrefPubMedGoogle Scholar
  • 68 Sylvester PT, Moran CJ, Derdeyn CP. et al. Endovascular management of internal carotid artery injuries secondary to endonasal surgery: case series and review of the literature. J Neurosurg 2016; 125 (05) 1256-1276
    CrossrefPubMedGoogle Scholar
  • 69 Dolenc VV, Lipovsek M, Slokan S. Traumatic aneurysm and carotid-cavernous fistula following transsphenoidal approach to a pituitary adenoma: treatment by transcranial operation. Br J Neurosurg 1999; 13 (02) 185-188
    CrossrefPubMedGoogle Scholar
  • 70 Oskouian RJ, Kelly DF, Laws Jr ERJ. Vascular injury and transsphenoidal surgery. Front Horm Res 2006; 34: 256-278
    CrossrefPubMedGoogle Scholar
  • 71 Orlov K, Arat A, Osiev A. et al. Transvenous treatment of carotid aneurysms through transseptal access. World Neurosurg 2019; S1878-8750 (19)30086-5. Doi: 10.1016/j.wneu.2018.12.207
    PubMedGoogle Scholar
  • 72 Halbach VV, Higashida RT, Hieshima GB, Hardin CW. Direct puncture of the proximally occluded internal carotid artery for treatment of carotid cavernous fistulas. AJNR Am J Neuroradiol 1989; 10 (01) 151-154
    PubMedGoogle Scholar
  • 73 Chang FC, Lirng JF, Luo CB, Teng MM, Guo WY, Chang CY. Carotid blowout treated by direct percutaneous puncture of internal carotid artery with temporary balloon occlusion. Interv Neuroradiol 2005; 11 (04) 349-354
    CrossrefPubMedGoogle Scholar
  • 74 Tsai YH, Weng HH, Chen YL, Wu YM, Wong HF. Treatment of recurrent carotid cavernous fistula by direct puncture of a previously trapped internal carotid artery. J Vasc Interv Radiol 2010; 21 (05) 738-740
    CrossrefPubMedGoogle Scholar
  • 75 Khan A, Chaudhary N, Pandey AS, Gemmete JJ. Direct puncture of the highest cervical segment of the internal carotid artery for treatment of an iatrogenic carotid cavernous fistula in a patient with Ehlers-Danlos syndrome. J Neurointerv Surg 2012; 4 (05) e29
    CrossrefPubMedGoogle Scholar