EndovascularEmergency endovascular Stent graft and coil placement for internal carotid artery injury during transsphenoidal surgery
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.
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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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Cited by (27)
Carotid Artery Injury After Endonasal Surgery
2011, Otolaryngologic Clinics of North AmericaCitation Excerpt :Heparin therapy is recommended before endovascular intervention and before the BTO.27,39,44 De Souza uses oral ticlopidine for 4 weeks following stent placement,38 Park and colleagues and Leung and colleagues recommended aspirin and clopidogrel therapy for upto 3 months.27,39 It is important to remember that not all ICA injuries manifest during the intra-operative period.
Carotid artery injury in endoscopic endonasal surgery: Risk factors, prevention, and management
2022, World Journal of Otorhinolaryngology - Head and Neck SurgeryIdentifying Best Practices for Managing Internal Carotid Artery Injury During Endoscopic Endonasal Surgery by Consensus of Expert Opinion
2021, American Journal of Rhinology and AllergyUnique Indications for Covered Stent Grafts in Neuroradiology Departments of Level 1 Trauma Centers
2020, Journal of Neurological Surgery, Part A: Central European Neurosurgery
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YS Park and JY Jung contributed equally on this work.