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

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.

Internal carotid artery injury during endoscopic endonasal surgery for skull base pathologies: an institutional incidence, management, and outcome

“…ICA‐cavernous segment injury trapping with a combined cervical and transcranial approach is another treatment. ICA trapping strategy will be a considerable option when there is no available endovascular treatment in the operating center; which is not an uncommon condition in developing countries 19 …”

“…ICA trapping strategy will be a considerable option when there is no available endovascular treatment in the operating center; which is not an uncommon condition in developing countries. 19 Concerning our experience and literature review, we introduce an algorithm for intraoperative and postoperative management of ICA injury during EES (Figs. 6 and 7).…”

How team work makes the dream work: Successful management of internal carotid artery lesion during routine Functional Endoscopic Sinus Surgery (FESS)

“…Multiple factors including vascular anatomy, injury characteristics, and risk of dual antiplatelet therapy should guide best treatment, but as many other areas of the practice of medicine, more research is needed to refine the decision making [7]. Nonetheless, it is clear from our perspective and from the available literature that ideally all endovascular treatment options and an experienced group of providers should be available at institutions performing endonasal surgery [6][7][8].…”

Endoscopic Endonasal Skull Base Surgery Complication Avoidance: A Contemporary Review

“…However, the present review does not describe complication management, a topic with a breadth of discussion beyond the scope of our manuscript. Complication management has been discussed previously in other publications [ 107 , 176 , 177 , 178 , 179 , 180 , 181 , 182 ]. Additionally, the present discussion is limited to the endoscopic endonasal technique but there are several circumstances in which alternative approaches such as the open or microscopic technique may represent more favorable surgical approaches.…”