Management of Carotid Artery Injury in Endonasal Surgery

Abstract

Introduction Carotid artery injury (CAI) is the most feared and potentially catastrophic intraoperative complication an endoscopic skull base surgeon may face. With the advancement of transnasal endoscopic surgery and the willingness to tackle more diverse pathology, evidence-based management of this life-threatening complication is paramount for patient safety and surgeon confidence. Objectives We review the current English literature surrounding the management of CAI during endoscopic transnasal surgery. Data Synthesis The searched databases included PubMed, MEDLINE, Cochrane database, LILACS, and BIREME. Keywords included “sinus surgery,” “carotid injury,” “endoscopic skull base surgery,” “hemostasis,” “transsphenoidal” and “pseudoaneurysm.” Conclusions Review of the literature found the incidence of CAI in endonasal skull base surgery to be as high as 9% in some surgeries. Furthermore, current treatment recommendations can result in damage to critical neurovascular structures. Management decisions must be made in the preoperative, operative, and postoperative setting to ensure adequate treatment of CAI and the prevention of its complications such as pseudoaneurysm. Emphasis should be placed on surgical competency, teamwork, and technical expertise through education and training.

ICAR: endoscopic skull‐base surgery

“…Identification of the injury site may be a challenge given the constricted surgical space and the need to keep the endoscope clean to maintain adequate visualization. Multiple retrospective studies have recommended a 2‐surgeon approach because it may be beneficial to introduce an additional suction into the field, diverting blood from the endoscope and maintaining visualization . The most commonly reported ICA segment injured is the C4 (parasellar) segment; however, the C2 (petrous), C3 (paraclival), and C5 (paraclinoidal) segments have also been reported .…”

“…Packing materials reported for initial hemostatic control include gauze, oxidized cellulose ([Surgicel™ (Ethicon, Inc.; Somerville, NJ)], cottonoids/cotton strips, Surgifoam™ (Ethicon, Inc.; Somerville, NJ), and Merocel (Medtronic Inc., Minneapolis, MN) nasal packs with balloon tamponade . The most frequently reported packing material is gauze . These initial methods are usually geared toward providing temporary hemostasis while enabling subsequent implementation of more permanent hemostatic measures.…”

“…also recommended the use of bilateral common carotid compression during initial hemostasis. Other authors have reported achievement of direct intraoperative permanent hemostasis using bipolar cautery, endoscopic aneurysm clip placement, or packing with muscle fascia graft . Bipolar cautery and endoscopic aneurysm clip placement have both been used for either sealing the injury defect or for intraoperative sacrifice of the ICA .…”

Endoscopic Management of Cavernous Carotid Surgical Complications: Evaluation of a Simulated Perfusion Model

“…This is an important component due to the high-pressure and high-flow dynamics of carotid artery injuries. 28 Adequate working space was obtained with this approach for placement of the endoscope, as well as surgical instrumentation through the bilateral nasal passages (Figure 1B). Learners ( n = 10; 1 learner per 1 instructor in each simulation time) were able to perform the stepwise approach to obtain vascular control and ultimately place the muscle graft over the carotid injury and apply counterpressure for vascular control (Figure 1C and D).…”

“…A supervising instructor facilitated the training experience and provided relevant guidance for important anatomic landmarks when appropriate. A 4-handed approach was used similarly to that outlined by Wormald et al 28 The instructor held and directed the endoscope as an intrinsic control between trials. This allowed learners to familiarize themselves with instrumentation.…”