Delayed Endovascular Coil Extrusion after Embolization for Internal Carotid Artery Injury during Endoscopic Sinus Surgery

Objectives: To review the incidence and management of internal carotid artery injury during endoscopic sinus surgery and to describe a delayed complication of endovascular coil extrusion.

Study Design: Case report and literature review.

Methods: A case of endoscopic sinus surgery complicated by internal carotid artery injury in the sphenoid sinus with subsequent pseudoaneurysm formation is presented. The management of such internal carotid artery injuries is discussed. Treatment of a secondary complication of endovascular coil extrusion from the pseudoaneurysm is then presented.

Results: A 44 year-old male experienced massive epistaxis following endoscopic sinus surgery at an outside facility. A cerebral angiogram demonstrated an internal carotid artery pseudoaneurysm filling the sphenoid sinus. Endovascular coiling to occlude the pseudoaneurysm was attempted twice without resolution of intermittent, life-threatening bleeding. The internal carotid artery was therefore occluded with balloon-assisted coil embolization followed by administration of Onyx liquid embolic agent. The patient had no further bleeding, and suffered only small cerebral infarcts from the vessel sacrifice due to the presence of adequate collateral blood flow. Two months after embolization, routine endoscopic exploration showed that several coils had extruded through the pseudoaneurysm sac into the sphenoid sinus and nasal cavity. Onyx material was also filling the interior of the sphenoid sinus with significant inflammatory reaction. The extruded coils and Onyx material were subsequently removed endoscopically from the sphenoid sinus. Complete extraction was not feasible given that some of the coils were located within the internal carotid artery. These coils were trimmed at the site of the carotid defect. Angiography was performed intermittently during the endoscopic procedure and the neurointerventional service was prepared to re-occlude the internal carotid artery if necessary. The internal carotid artery remained occluded, without evidence of contrast extravasation at the site of previous pseudoaneurysm. No bleeding was encountered during the surgery, and the patient tolerated the procedure well. His endoscopic examination has shown a progressive decrease in the degree of nasal crusting and inflammation of the sphenoid sinus at the site of the carotid defect.

Conclusions: Internal carotid artery injury during endoscopic sinus surgery is a rare occurrence. Delayed complications of internal carotid artery embolization, such as extrusion of endovascular coiling, can develop and patients should be monitored for this possibility.