The Management of Endoscopic Endonasal ICA Injury with Proximal and Distal Control—Surgical Anatomy and “Liver Cadaver” Model Simulation

Objective: The ideal management of intraoperative ICA injury aims at achieving hemostasis while preserving normal blood flow, in which safe proximal and distal controls are mandatory. There is still lack of study analyzing the endoscopic anatomy of ICA with emphasize the ideal blocks site, clip choose for proximal and distal controls.

Methods: Six latex injected cadaveric specimens were used for endoscopic dissection. The surgical anatomy of ideal block site/region for proximal and distal controls, clip selection and direction of the clip placement were investigated. Two embalmed, un-injected cadaveric heads were prepared for simulating ICA injury like operative scenarios. The management methods of clip repair, muscle wrapping in the premise of both proximal and distal controls were verified.

Results: Three optimal block sites were identified ([Fig. 1]): paraclival site, the subclinoid site, and the supraclinoid site.

The paraclival site was from foramen lacerum to the petrous process of sphenoid bone with a mean length of 13.6 mm (SD ±1.8; [Table 1]).

Block site	Boundary	Mean length(mm) ± SD	Related structures	Relationship with CS	Clip selection	Tip orientation of clip
Paraclival site	Foramen lacerum to the petrous process of sphenoid bone (PPspb)	13.6 ± 1.8	Lingular process; PPspb; sympathetic trunk	Extra-CS	Curved	Upward
Subclinoid site	Anterior genu of ICA to the proximal dura ring	6.8 ± 1.2	ACP; CCL; CN3	Intra-CS	Straight	Backward
Supraclinoid site	Distal dura ring to the superior hypophyseal artery (SHA)	8.1 ± 0.8	ACP; CN-2; optha A; SHA	Extra-CS	Right-angled	Laterally

A curved clip with tip oriented upward is ideal for controlling the ICA in the paraclival region. The subclinoid site was from the anterior genu of ICA to the proximal dura ring with a mean length of 6.8 mm (SD ± 1.2). For ICA control in the subclinoid site, a straight clip with a backward-facing tip is suitable. The supraclinoid site is from distal dura ring to the first origin site of superior hypophyseal artery with a mean length of 8.1 mm (SD ± 0.8). Using a right-angle clip with the tip positioned laterally is appropriate for vascular control at the supraclinoid site. Both proximal and distal controls for clinoid, parasellar, and paraclival segments of ICA were achieved using the abovementioned three block sites in combination ([Fig. 2]).

An injury located at the ascending vertical segment ICA was created in the simulation model. The injury site was successfully managed with direct clip sealing and muscle wrapping in the premise of both proximal and distal control.

Conclusion: Paraclival, subclinoid, and supraclinod sites were the three optimal sites for ICA control in endoscopic endonasal approaches. A detailed understanding of the surgical anatomy of the ICA and its surrounding structures will provide a great help for clip selection and its placement. It is technically feasible to manage intraoperative ICA injury in the premise of proximal and distal controls in endonasal procedures.

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Artikel online veröffentlicht:
07. Februar 2025