Delayed intranasal coil extrusion after internal carotid artery pseudoaneurysm embolization

Abstract

<jats:p> Internal carotid artery (ICA) injury is a rare but potentially life-threatening complication of skull base and neck surgery. Although usually manifested by massive intraoperative haemorrhage, impairment of the ICA might go unnoticed and result in formation of a pseudoaneurysm, causing delayed bleeding. Often additional complications are observed such as thrombosis, spasm, embolism or carotico-cavernous fistula formation. The risk of carotid artery injury in aggressive endonasal skull base surgical interventions ranges from 1% to 9%. Digital subtracted angiography remains the gold standard for evaluation of patients with iatrogenic carotid artery injury as it allows for endovascular treatment at the time of the procedure. Endovascular embolization is currently the preferred method for treating ICA pseudoaneurysms and a successful alternative to the surgical approach. Even though endovascular approaches are considered the safer option, delayed complications have been registered, such as endovascular coil extrusion and migration, which increases the risk of further episodes of bleeding. We present our experience with late coil extrusion in a patient who was previously treated with flow diverter stent and coiling for iatrogenic ICA pseudoaneurysm. </jats:p>

Cavernous Internal Carotid Artery Aneurysm: Giant Posttraumatic Carotid Cavernous Pseudoaneurysm, Presenting with Epistaxis; Treated in Two-Stage Strategy with Complete Occlusion and Delayed Coil Extrusion Through the Nostril

“…The resulting pseudoaneurysms or "false aneurysms" by definition consist of a hematoma surrounded by a fibrous layer, rather than a "true" arterial wall (Wang et al 2018). Due to the influence of continuous, pulsatile arterial forces, these expand to a more spherical shape (Sirakov et al 2019). They are extremely prone to rupture and may cause life-threatening epistaxis resulting from the disruption through the sphenoid sinus (Chaboki et al 2004).…”

Coil Extrusion into the Naso- and Oropharynx Ten Years after Internal Carotid Artery Pseudoaneurysm Embolization: A Case Report

“…Injury to the internal carotid artery (ICA) during endoscopic endonasal approach (EEA) surgery is probably the most feared and catastrophic complication that could happen during an EEA, and control of the surgical field is very challenging [1, 2, 3, 4, 5]. Moreover, even if the intraoperative bleeding is controlled, ICA injury may result in the formation of a pseudoaneurysm that can cause delayed bleeding [1, 5].…”

“…Injury to the internal carotid artery (ICA) during endoscopic endonasal approach (EEA) surgery is probably the most feared and catastrophic complication that could happen during an EEA, and control of the surgical field is very challenging [1, 2, 3, 4, 5]. Moreover, even if the intraoperative bleeding is controlled, ICA injury may result in the formation of a pseudoaneurysm that can cause delayed bleeding [1, 5]. For this reason, in case of ICA injury during the EEA, after an immediate intraoperative control of the site of bleeding through the packing of the ICA tear with the help of topical hemostatic agents, and once the circulation is stabilized, the patient should undergo ICA angiography to disclose and definitively treat the ICA injury [1, 5, 6, 7, 8].…”

“…Moreover, even if the intraoperative bleeding is controlled, ICA injury may result in the formation of a pseudoaneurysm that can cause delayed bleeding [1, 5]. For this reason, in case of ICA injury during the EEA, after an immediate intraoperative control of the site of bleeding through the packing of the ICA tear with the help of topical hemostatic agents, and once the circulation is stabilized, the patient should undergo ICA angiography to disclose and definitively treat the ICA injury [1, 5, 6, 7, 8].…”

“…However, endovascular procedures are associated with a wide spectrum of complications, including endovascular coil extrusion and migration, especially in the first 3–12 months after embolization, which could increase the risk of further episodes of bleeding [5, 6, 7, 8].…”