Endovascular management of internal carotid artery injuries secondary to endonasal surgery: case series and review of the literature

Abstract

OBJECTIVE Internal carotid artery (ICA) injury is a rare but severe complication of endonasal surgery. The authors describe their endovascular experience managing ICA injuries after transsphenoidal surgery; they review and summarize the current literature regarding endovascular techniques; and they propose a treatment algorithm based on the available evidence. METHODS A retrospective review of 576 transsphenoidal pituitary adenoma resections was performed. Cases of ICA injury occurring at our institution and transfers from other hospitals were evaluated. Endovascular treatments for ICA injury reported in the literature were also reviewed and summarized. RESULTS Seven cases were identified from the institutional cohort (mean age 46.3 years, mean follow-up 43.4 months [1-107 months]) that received endovascular treatment for ICA injury. Five injuries occurred at our institution (5 [0.9%] of 576), and 2 injuries occurred at outside hospitals. Three patients underwent ICA sacrifice by coil placement, 2 underwent lesion embolization (coil or stent-assisted coil placement), and 2 underwent endoluminal reconstruction (both with flow diversion devices). Review of the literature identified 98 cases of ICA injury treated with endovascular methods. Of the 105 total cases, 46 patients underwent ICA sacrifice, 28 underwent lesion embolization, and 31 underwent endoluminal reconstruction. Sacrifice of the ICA proved a durable solution in all cases; however, the rate of persistent neurological complications was relatively high (10 [21.7%] of 46). Lesion embolization was primarily performed by coil embolization without stenting (16 cases) and stent-assisted coiling (9 cases). Both techniques had a relatively high rate of at least some technical complication (6 [37.5%] of 16 and 5 [55.6%] of 9, respectively) and major technical complications (i.e., injury, new neurological deficit, or ICA sacrifice) (5 [31.3%] of 16 and 2 [22.2%] of 9, respectively). Endoluminal reconstruction was performed by covered stent (24 cases) and flow diverter (5 cases) placement. Covered stents showed a reasonably high rate of technical complications (10 [41.7%] of 24); however, 8 of these problems were resolved, leaving a small percentage with major technical complications (2 [8.3%] of 24). Flow diverter placement was also well tolerated, with only 1 minor technical complication. CONCLUSIONS Endovascular treatments including vessel sacrifice, coil embolization (with or without stent assistance), and endoluminal reconstruction offer a tailored approach to ICA injury management after endonasal surgery. Vessel sacrifice remains the definitive treatment for acute, uncontrolled bleeding; however, vessel preservation techniques should be considered carefully in select patients. Multiple factors including vascular anatomy, injury characteristics, and risk of dual antiplatelet therapy should guide best treatment, but more study is needed (particularly with flow diverters) to refine this decision-making process. Ideally, all endovascular treatment options should...

ICAR: endoscopic skull‐base surgery

“…Whether temporary or permanent repair was attempted endonasally, most reported cases subsequently underwent catheter‐angiography . Angiography was used to determine the degree of injury, adequacy of repair, and determine need for subsequent endovascular or open repair . Although some reported cases showed adequate ICA integrity after endonasal repair, angiography demonstrated a significant rate of ICA pathology .…”

“…Angiography was used to determine the degree of injury, adequacy of repair, and determine need for subsequent endovascular or open repair . Although some reported cases showed adequate ICA integrity after endonasal repair, angiography demonstrated a significant rate of ICA pathology . The most common pathology reported as a consequence of endoscopic ICA injury was pseudoaneurysm formation.…”

“…The most common pathology reported as a consequence of endoscopic ICA injury was pseudoaneurysm formation. Additional vascular abnormalities identified angiographically included carotid cavernous fistula, ICA occlusion, active extravasation, stenosis, dissection, and middle cerebral artery (MCA) thromboembolus requiring thrombectomy or heparinization …”

Use of the Pipeline embolization device in the treatment of iatrogenic intracranial vascular injuries: a bi-institutional experience

“…Similarly, Amenta et al 2 reported a case of an iatrogenic ICA pseudoaneurysm that was successfully treated with telescoping PEDs. Sylvester et al 17 presented 2 cases of transsphenoidal pituitary tumor resection with vessel injury treated with PEDs. In both cases, iatrogenic pseudoaneurysms were treated successfully with PEDs without complications, and the patients had good clinical outcomes.…”

Surgical Iatrogenic Internal Carotid Artery Injury Treated with Pipeline Embolization Device: Case Report and Review of the Literature

“…A Pubmed search for flow diverter placement for treatment of surgical iatrogenic ICA injury revealed eight patients. [4][5][6][7][8][9] Including our case, seven trans-sphenoidal surgeries and two endoscopic sinus surgeries were involved. Angiographic findings include seven pseudo-aneurysms, one extravasation of contrast, and one carotid cavernous fistula (CCF) ( Table 1).…”