Endoscopic Repair of Iatrogenic Carotid Artery Injury Using a Lateral Tongue Muscle Patch

Objective: Iatrogenic injury to the internal carotid artery (ICA) is one of the most catastrophic complications of endoscopic sinus and skull base surgery. Previous research has shown that packing with a crushed muscle graft at the injury site can be an effective management technique to control bleeding, and may prevent the need for ICA sacrifice. Here we describe a new and a readily available repair donor site, an autologous lateral tongue muscle patch.

Methods: Two representative cases of a successful repair of ICA injuries using lateral tongue muscle patch. The graft measured approximately 2 cm × 3 cm and was taken from the lateral intrinsic muscle of the tongue. The first case involved repair of a delayed cavernous ICA pseudoaneurysm following functional endoscopic sinus surgery. The second case involved ICA injury during an expanded endonasal approach for a craniopharyngioma. We describe the harvest of the graft, its advantages, and the details of operative repair.

Results: The lateral tongue provides a large and readily accessible source of muscle within the surgical field that can be quickly harvested during an endoscopic procedure. Advantages include the speed of harvest, donor site being readily accessible in the surgical field, and its low morbidity. An expanding 3-mm ICA parasellar pseudoaneurysm in an unfavorable location for embolization and stenting was treated solely with muscle patch and nasal packing. Postoperative angiograms and serial CTAs showed complete resolution of the pseudoaneurysm, and the patient continues to do well, even now 1 year after repair. In the second case, a cavernous ICA injury was sustained during craniopharyngioma resection. Durable and rapid hemostasis was achieved with a muscle patch harvested from the tongue and the procedure was aborted. Nasal packing and a pedicled nasoseptal flap were used to reinforce the repair. A postoperative angiogram did not show any active extravasation or evidence of an ICA pseudoaneurysm.

Conclusion: Lateral tongue muscle graft appears to be an effective and an efficient method to manage ICA injuries during endoscopic endonasal surgery. It should be added to the repertoire of possible donor sites while dealing with catastrophic bleeding and has the advantage of being in the surgical field and easily harvested with minimal morbidity.

Publication History

Article published online:
15 February 2022