Assessment of Factors Associated With Internal Carotid Injury in Expanded Endoscopic Endonasal Skull Base Surgery

Abstract

to the internal carotid artery (ICA) during endoscopic endonasal skull base surgery does not typically occur as an isolated circumstance but often is the result of multiple factors.OBJECTIVE To assess the factors associated with ICA injury in an effort to reduce its occurrence. DESIGN, SETTING, AND PARTICIPANTSThis quality improvement study used a multicenter root cause analysis of ICA injuries sustained during endoscopic endonasal skull base surgery performed at 11 tertiary care centers across 4 continents (North America, South America, Europe, and Asia) from January 1, 1993, to December 31, 2018. A fishbone model was built to facilitate the root cause analysis. Patients who underwent an expanded endoscopic endonasal approach that carried a substantial potential risk of an ICA injury were included in the analysis. A questionnaire was completed by surgeons at the centers to assess relevant human, patient, process, technique, instrument, and environmental factors associated with the injury. MAIN OUTCOMES AND MEASURESRoot cause analysis of demographic, human, patient, process, technique, instrument, and environmental factors as well as mortality and morbidity data. RESULTS Twenty-eight cases of ICA injury occurred during 7160 expanded endoscopic endonasal approach procedures (incidence of 0.4%). The mean age of the patients was 49 years, with a female to male predominance ratio of 1.8:1 (18 women to 10 men). Anatomical (23 [82%]), pathological (15 [54%]), and surgical resection (26 [93%]) factors were most frequently reported. The surgeon's mental or physical well-being was reported as inadequate in 4 cases (14%). Suboptimal imaging was reported in 6 cases (21%). The surgeon's experience level was not associated with ICA injury. The ICA injury was associated with use of powered or sharp instruments in 20 cases (71%), and use of new instruments or technology in 7 cases (25%). Two patients (7%) died in the operating room, and 3 (11%) were alive with neurological deficits. Overall, patient-related factors were the most frequently reported risk factors (in 27 of 28 cases [96%]). Factors associated with ICA injury catalyzed a list of preventive recommendations. CONCLUSIONS AND RELEVANCEThis study found that human factors were associated with intraoperative ICA injuries; however, they were usually accompanied by other deficiencies. These findings suggest that identifying risk factors is crucial for preventing such injuries. Preoperative planning and minimizing the potential for ICA injury also appear to be essential.

Characterization of outcomes and practices utilized in the management of internal carotid artery injury not requiring definitive endovascular management

“…An international multi‐institutional retrospective study was performed of cases of ICA injury during endoscopic endonasal skull base surgery not treated with embolization, stenting, or ligation. This is a follow up study to the previously reported ICA injury root cause analysis 17 . This study underwent Institutional Review Board review and approval.…”

“…Lack of experience may also contribute to ICA injury and a greater risk has been suggested earlier in the learning curve prior to achieving proficiency 16 . A recent international multi‐institutional root cause analysis of 28 cases of ICA injury found that these cases are typically characterized by more than one risk factor and the study provided a case‐by‐case event description and recommendations 17 …”

When is a multidisciplinary surgical approach required in sinonasal tumours with cranial involvement?

“…While the indications and contraindications to surgery for sinonasal tumours have considerably evolved throughout the last decades, abutment, encasement, and frank invasion of the ICA have been invariably considered as a major criterion of difficult, dangerous, or even impossible resectability. Intraoperative rupture of the ICA has been reported to occur in 28/7160 (0.4%) endoscopic procedures and its consequences ranges from death to non-lethal cerebrovascular events, pseudoaneurysm, carotid-cavernous fistula, and need for vascular occlusion 45,46 . Although one could hypothesize that vessels-encroaching tumours should be referred to radiation oncologists, vascular toxicity actually represents a major concern even in patients undergoing RT that can considerably limit dose delivery in areas neighboring the vessel (Fig.…”

“…Tolerance can be evaluated through a combination of several techniques including clinical assessment, cross flow tim- ing, evoked potentials, and functional imaging. In patients demonstrating adequate cross flow from the contralateral vascular system, the decision on whether or not to perform endovascular ICA occlusion prior to surgery should be based on the estimated risk of intraoperative rupture, which has a known lethality of roughly 7-15% 46,47 , and possible need for vessel removal as part of the resection 48 . However, preoperative endovascular ICA occlusion should not be indicated carelessly, as the long-term effects of the procedure are unknown.…”

“…Injury of the ICA is a rare but potentially catastrophic intraoperative complication of endoscopic skull base surgery. Wang et al reported that an incidence of 0.016% to 1% was estimated based on large endoscopic transnasal surgery series 94 ; AlQahtani et al reported an in-depth analysis of 28 cases of ICA injury out of 7160 endoscopic procedures, with a resulting frequency of 0.4% 46 .…”