Carotid Artery Injury After Endonasal Surgery
Section snippets
Patients at risk
Prevention of the catastrophic bleeding scenario is better than treatment. It is important to recognize the patient that maybe at risk of an ICA injury. The anatomic relationship between the ICA and the sphenoid sinus makes it particularly vulnerable. Fujii and colleagues55 demonstrated that the bony wall overlying the ICA is not sufficient to protect the artery, at less than 0.5 mm thick. Additionally, in 4 to 22% of cases the lateral sphenoid wall is dehiscent over the carotid with only dura
Controlling the Surgical Field
Intra-operative ICA rupture creates an immediately challenging surgical field, with a high pressure/high flow bleeding scenario, which may rapidly result in exsanguination of the patient. Massive bleeding leads to a loss of orientation and an obscured surgical field often resulted in the surgeon blindly attempting nasal packing to control the hemorrhage. Additional suction is important to regain orientation of the surgical field. The advantages of the ‘2 surgeon’ skull base team allows for
Endovascular techniques
Endovascular techniques aimed at closing a vascular wall defect can either occlude the parent vessel or maintain vascular flow. When performing endovascular techniques it is important to remember that carotid artery injury most frequently occurs only a few millimeters below the origin of the ophthalmic artery.3 Both the deployment of a endovascular balloon and coil can be associated with subsequent distal migration and slippage.27 The main difficulty is deployment in a high-flow vessel where
Delayed cavernous ICA injury
It is important to remember that not all ICA injuries manifest during the intra-operative period. The occurrence of vasospasm in the ICA following transphenoidal surgery has been described as early as a few hours following surgery and upto 1 month following,4 and can be recognized as altered consciouness or stroke formation. Laws4 also notes 2 cases of carotid artery thrombosis following transphenoidal surgery. Delayed formation of a pseudoaneurysm following uneventful transphenoidal surgery is
Complications of cavernous ICA rupture
Following an ICA rupture it is important that all patients receive a post-operative angiogram. If this is normal then all patients should receive a repeat angiogram after the packing has been removed. Iatrogenic ICA injury can create a communicating channel between the sphenoid and/or the cavernous sinus and the sidewall of ICA. This situation may present as an acute hemorrhage, pseudoaneurysm or a CCF. A CCF can most easily be recognized clinically by the presence of proptosis with
Outcomes
Rupture of the cavernous ICA represents a significant insult to the hemodynamic stability of the patient and is not surprising associated with a significant morbidity and subsequent mortality. If is difficult to draw any significant conclusions from a comprehensive literature review as these are case reports only. Many cases of intraoperative ICA rupture may not be published, especially as death and neurologic injury are a common endpoint. Reviewing the 111 cases of ICA rupture, there are a
Summary
Internal carotid artery injury is the most feared and dramatic complication of endonasal skull base surgical approaches with massive bleeding that may result in exanguination of the patient. While ICA injury during endoscopic sinus surgery is a rare event, its frequency during endonasal skull base surgery is much more significant. Prevention is better than cure and surgeons need to be familiar with patients who maybe at risk. Formulating and executing a plan of action during a crisis is
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Disclosures and Conflicts of interest: Dr Wormald receives royalties from Medtronic ENT for instruments designed and is a consultant for Neilmed Pharmaceuticals. Dr Valentine has nothing to disclose.