Elsevier

Surgical Neurology

Volume 72, Issue 6, December 2009, Pages 741-746
Surgical Neurology

Endovascular
Emergency endovascular Stent graft and coil placement for internal carotid artery injury during transsphenoidal surgery

https://doi.org/10.1016/j.surneu.2009.05.003Get rights and content

Abstract

Background

An internal carotid artery (ICA) injury is an uncommon but potentially fatal complication of transsphenoidal surgery.

Case Description

We report a 61-year-old male patient with a right cavernous ICA injury sustained during transsphenoidal surgery and who underwent endovascular Stent graft placement. The ICA trapping was not indicated because of the absence of the left A1 on preoperative magnetic resonance angiography. During Stent graft placement, the ICA wall could not be completely fit with a stent due to its stiff nature and the carotid curve. The gap between the stent and the ICA wall was filled using a coiling procedure on the first postoperative day.

Conclusions

Endovascular Stent graft placement for posttranssphenoidal carotid artery injury is a useful technical adjunct to the management strategy and has the potential to minimize the risk of having to sacrifice the ICA. In cases of incomplete reconstruction of the Stent graft placement due to its stiff nature and the carotid curve, an additional coiling procedure could be helpful to obliterate the gap between the stent and the ICA wall. To avoid carotid injury during transsphenoidal surgery, careful preoperative evaluation of vascular structures and meticulous surgical technique are necessary.

Introduction

Internal carotid artery (ICA) injury is an uncommon but potentially fatal complication of transsphenoidal surgery [3], [15]. The presentation of this potentially fatal complication includes severe perioperative or postoperative bleeding, a false aneurysm of the ICA, and a CCF [16]. Immediate diagnosis and treatment of these symptoms is essential because any delay may result in the patient's death.

Traditionally, surgical or endovascular occlusion of the ICA has been used to treat ICA injuries. However, surgical ligation is associated with an unacceptable incidence of major complications [2]. Because of these disadvantages, the endovascular balloon occlusion has become the preferred treatment of ICA injuries. Before endovascular occlusion, a test balloon occlusion should be performed. If the patient does not tolerate the test, additional bypass procedures or reconstructive endovascular procedures should be performed.

In this report, we treated a cavernous ICA injury sustained during transsphenoidal surgery with a Stent graft placement to close the lacerated wall and preserve blood flow through the ICA. In addition, an adjuvant coiling of the incomplete apposition area of the Stent graft was performed to reduce the risk of thrombus formation and leakage from the lacerated ICA.

Section snippets

Case report

A 61-year-old man was admitted to our institution with a complaint of visual disturbance and general weakness for 3 months. A visual field examination performed at admission revealed a bitemporal hemianopsia, and a combined pituitary function test disclosed panhypopituitarism. Magnetic resonance imaging revealed a suprasellar mass with internal necrosis (Fig. 1). Magnetic resonance angiography revealed the absence of the left A1. During transsphenoidal surgery, the sellar floor bone was

Discussion

Vascular injury is a major contributor to the mortality still associated with the transsphenoidal procedure. A cavernous ICA injury is uncommon during transsphenoidal surgery and may result in a carotid-cavernous fistula or pseudoaneurysm, with a reported incidence of 0.2% to 1.2% [3], [16]. Certain factors associated with the size, shape, and location of a pituitary tumor predispose the patient to surgical arterial injury. Injury to the ICA during transsphenoidal resection of pituitary tumors

Conclusions

Injury of the ICA during transsphenoidal surgery is a very rare complication, but when it happens, it can be fatal. To avoid this severe complication, a preoperative MR angiography or intraoperative Doppler is mandatory. These tests provide information about potential variations in the vascular structure. Sphenoid mucosal dissection should be performed carefully when there is sellar floor erosion due to tumor invasion or anatomical variations.

In the event of massive bleeding due to an injury of

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1

YS Park and JY Jung contributed equally on this work.

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