Carotid artery injury in endoscopic endonasal surgery: Risk factors, prevention, and management

Abstract

Objective Endoscopic approaches for sinus and skull base surgery are increasing in popularity. The objective of this narrative review is to characterize risk factors for internal carotid artery injury in endoscopic endonasal surgery (EES), highlight preventative measures, and illustrate key management principles. Data Sources Comprehensive literature review. Methods Relevant literature was reviewed using PubMed/MEDLINE. Results Carotid artery injury in EES is rare, with most studies reporting an incidence below 0.1%. Anatomic aberrancies, wide dissection margins, as well as specific provider and hospital factors, may increase the risk of injury. Multidisciplinary teams, comprehensive preoperative imaging, patient risk assessment, and formal training in vascular emergencies may reduce the risk. Management protocols should emphasize proper visualization of the injury site, fluid replacement, rapid packing, angiography, and endovascular techniques to achieve hemostasis. Conclusions While EES is a relatively safe procedure, carotid artery injury is a devastating complication that warrants full consideration in surgical planning. Important preventative measures include identifying patients with notable risk factors and obtaining preoperative imaging. Multidisciplinary teams and management protocols are ultimately necessary to reduce morbidity and mortality.

A Case of Left Carotid Artery Injury

“…Although ICA artery injury is quite rare during TSS, with an incidence of 0.1%, preoperative measures are imperative to reduce the risk of carotid injury as much as possible. 6 Preoperative evaluations prior to TSS generally include a multidisciplinary disease management approach and preoperative imaging such as CT and magnetic resonance imaging, allowing the surgical team to gauge the risk of a carotid injury. A multidisciplinary team including surgeons and physicians from an array of specialties is recommended when treating pituitary adenomas for preoperative planning, planning treatment decision-making, and discussing all possible options.…”

“…Since carotid artery injury occurs at such a low incidence during endoscopic TSS, very few studies or meta-analyses provide enough statistical information to draw significant conclusions. A study published by Sharma et al 6 found that anatomic aberrations and wide dissection margins shown by preoperative imaging can increase the risk of carotid artery injury. However, 1 multicenter study on internal carotid artery injury showed that 82% of instances of carotid injury during transsphenoidal procedures involved patients who had anatomic aberrations of the internal carotid artery.…”

Internal Carotid Injury during Skull Base Surgery—Case Report and a Review of the Literature

“…During a resection, twisting and pushing movements can cause a bone fragment to injure the ICA wall. Therefore, the use of a diamond drill or cutting instruments is recommended [ 6 , 19 , 21 ].…”

“…Initial treatments aim to manage bleeding promptly, before the injury is treated with definitive long-term methods. At the moment of an ICA injury, the most fundamental requirements are cooperation among surgeons, the surgeons’ experience with “four-handed” endoscopic surgery, and cooperation with the anesthesiologist [ 1 , 3 , 6 , 21 ].…”

Tranexamic acid in endoscopic sinus and skull base surgery: A systematic review and meta‐analysis

“…Endoscopic surgery has revolutionized the surgical management of sinonasal and skull base pathologies. [1][2][3] The success of endoscopic sinus surgery (ESS), however, is heavily dependent on optimal visualization and surgical exposure in order to identify relevant anatomy and safely proceed with dissection. Excess intraoperative blood loss interferes with visualization in ESS and may be attributed to a variety of both surgical and anesthesia factors.…”