Emergency placement of a Flow Diverter Stent for an Iatrogenic Internal Carotid Artery Injury During Endoscopic Pituitary Surgery

Giorgianni, Andrea; Pozzi, Fabio; Pellegrino, Carlo; Padovan, Stefania; Karligkiotis, Apostolos; Castelnuovo, Paolo; Locatelli, Davide

doi:10.1016/j.wneu.2018.10.234

Cited by 17 publications

(20 citation statements)

References 10 publications

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“…It also provides a scaffold for endothelialization and reconstruction of the vessel wall. Previous studies have shown that pseudoaneurysms treated with flow-diverting stents have high complete occlusion rates and low complication rates ( 6 , 7 , 18 , 19 , 26 , 30 , 53 – 55 , 67 , 69 , 79 ). However, the main limitation of flow-diverting stents is delayed aneurysm obliteration due to a lack of immediate thrombosis.…”

Section: Managementmentioning

confidence: 99%

Intracranial Pseudoaneurysms: Evaluation and Management

Zheng

Lu²,

Shen

et al. 2020

Front. Neurol.

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Intracranial pseudoaneurysms account for about 1% of intracranial aneurysms with a high mortality. The natural history of intracranial pseudoaneurysm is not well-understood, and its management remains controversial. This review provides an overview of the etiology, pathophysiology, clinical presentation, imaging, and management of intracranial pseudoaneurysms. Especially, this article emphasizes the factors that should be considered for the most appropriate management strategy based on the risks and benefits of each treatment option.

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Section: Managementmentioning

confidence: 99%

Intracranial Pseudoaneurysms: Evaluation and Management

Zheng

Lu²,

Shen

et al. 2020

Front. Neurol.

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“…This technique has not been yet described in the literature and the outcomes obtained in our two preliminary cases are encouraging, supporting the usefulness of this combined procedure. It must be noted that FDS placement has some disadvantages, including the need of post-procedural double antiplatelet therapy, which should be maintained for a few months, and the long time necessary for a complete repair of the vessel [2,18].…”

Section: Discussionmentioning

confidence: 99%

“…At present, there are few cases described in the literature of a cavernous ICA acute injury successfully managed with an FDS release. Some cases of iatrogenic cavernous ICA PSA treated in the late post-operative period with FDS are reported in the literature [ 1 , 3 , 12 , 18 ]. Giorgianni et al report two cases describing the emergency positioning of FDS for cavernous ICA acute injury, respectively, in a traumatic [ 3 ] and iatrogenic cavernous ICA tear [ 18 ].…”

Section: Discussionmentioning

confidence: 99%

Emergency endovascular treatment of cavernous internal carotid artery acute bleeding with flow diverter stent: a single-center experience

Giorgianni¹,

Agosti

Terrana³

et al. 2020

Acta Neurochir

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Background and objective To describe our single-center experience in the treatment of cavernous internal carotid artery (ICA) acute bleeding with flow diverter stent (FDS), as a single endovascular procedure or combined with an endoscopic endonasal approach. Methods We analyze a case series of 5 patients with cavernous ICA acute bleeding, i.e., 3 iatrogenic, 1 post-traumatic, and 1 erosive neoplastic. After an immediate nasal packing to temporarily bleeding control, patients underwent digital subtraction angiography (DSA) to identify the site of the ICA injury. A concomitant balloon occlusion test (BOT) was performed, to exclude post-occlusive ischemic neurological damage. An FDS was placed with parallel intravenous infusion of abciximab in 3 cases and tirofiban in 2 cases. In two patients, an innovative "sandwich technique" combining the endovascular reconstruction with an extracranial intrasphenoidal cavernous ICA resurfacing with autologous flaps or grafts by endoscopic endonasal approach was performed. Results No patient had periprocedural ischemic-hemorrhagic complications. All patients had a regular clinical evolution, without general complications or new onset of focal neurological deficits. No further bleeding occurred in 3 patients, while 2 cases experienced a mild rebleeding in a period ranging from 5 to 15 days after the endovascular procedure. In these two cases, we proceeded with an endoscopic endonasal procedure to resurface the exposed ICA wall in the sphenoid sinus. Conclusions Although the treatment of choice for cavernous ICA acute bleeding remains the occlusion of the injured vessel, in cases of poor hemodynamic compensation at the BTO, the endovascular FDS emergency placement can be effective. A combined endoscopic endonasal technique to support the extracranial side of the vessel using autologous flaps or grafts can be performed to prevent the risk of rebleeding.

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“…The cavernous segments of the ICA are at risk during surgical exploration of the pituitary gland such as when removing the sellar floor, opening the sellar dura, and resecting tumors. 14,[17][18][19][20][21] The reported incidence of ICA injuries during TSS for pituitary tumors ranges between 0.55 and 1.1%. 6,8,22 ICA pseudoaneurysms resulting from iatrogenic injuries during TSS are similar to blood blister-type aneurysms histologically (indicating focal artery laceration), and geographically (occurring at non-branching sites of the ICA), with the possibility for rapid enlargement and rupture with a 30-50% reported mortality rate.…”

Section: Discussionmentioning

confidence: 99%

“…Conversely, regarding the former method, there are multiple case reports detailing successful use of flow-diverting stents in treating intracranial pseudoaneurysms of varying etiologies, although flow-diverting stents for pseudoaneurysms are beyond the original on-label application. 1,2,4,7,8,11,[13][14][15]17,[19][20][21][22]28,30,31 To our knowledge, there are only 11 cases reported of pseudoaneurysms caused after TSS for pituitary tumors, including ours (Table 1). 14,17,[19][20][21][22]31 In the 11 cases, one was lost to follow-up immediately after the Pipeline embolization.…”

Section: Discussionmentioning

confidence: 99%

Pipeline embolization for an iatrogenic intracranial internal carotid artery pseudoaneurysm after transsphenoidal pituitary tumor surgery: Case report and review of the literature

et al. 2019

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Intracranial pseudoaneurysms are uncommon and among the most difficult lesions to treat with surgery or endovascular means without parent artery sacrifice. Here, we report on a patient who underwent successful treatment using a flow-diverting stent for an iatrogenic intracranial internal carotid artery pseudoaneurysm following a vessel injury after endoscopic pituitary tumor resection via the transsphenoidal approach. A 62-year-old man with a Rathke’s cleft cyst presenting with bitemporal hemianopia and progressive decline of left visual acuity underwent endoscopic transsphenoidal pituitary tumor resection. During dura incision, brisk arterial bleeding was encountered from the right internal carotid artery. Immediate packing was performed, and hemostasis was achieved. Three days after the vessel injury, an angiography revealed a pseudoaneurysm (2.9 × 2.1 mm) at the cavernous segment of the right internal carotid artery, which showed enlargement on follow-up magnetic resonance imaging at six days postoperatively. Pipeline embolization was performed nine days after the vessel injury. Angiography performed one month after Pipeline embolization revealed significant stagnation but not complete occlusion of blood flow inside the pseudoaneurysm cavity. Dual antiplatelet therapy was replaced with single antiplatelet therapy. Follow-up angiograms three months after Pipeline embolization confirmed complete obliteration of the pseudoaneurysm and successful endoluminal reconstruction of the damaged vessel. Despite the possibility of short-term bleeding and the need for dual antiplatelet therapy administration for a certain period, the use of flow-diverting stents is a feasible vessel-sparing option in the management of intracranial internal carotid artery pseudoaneurysms resulting from transsphenoidal surgery injuries if intraoperative hemodynamic stability can be achieved with effective packing.

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Emergency placement of a Flow Diverter Stent for an Iatrogenic Internal Carotid Artery Injury During Endoscopic Pituitary Surgery

Cited by 17 publications

References 10 publications

Intracranial Pseudoaneurysms: Evaluation and Management

Intracranial Pseudoaneurysms: Evaluation and Management

Emergency endovascular treatment of cavernous internal carotid artery acute bleeding with flow diverter stent: a single-center experience

Pipeline embolization for an iatrogenic intracranial internal carotid artery pseudoaneurysm after transsphenoidal pituitary tumor surgery: Case report and review of the literature

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