Managing Arterial Injury in Endoscopic Skull Base Surgery. Case Series and Review of the Literature

Introduction: The most feared complications following endoscopic endonasal skull base surgery are arterial vascular injuries, particularly of the internal carotid artery (ICA). The ideal method for controlling arterial bleeding during this kind of procedure is debated in the literature and a variety of techniques have been advocated.

Methods: We performed a retrospective review of a prospectively acquired database of consecutive endonasal endoscopic surgeries at our institution from 12/2003 to 6/2015 and identified all cases of arterial injury. Management strategy and outcome were analyzed and compared with a comprehensive review of the literature.

Results: Of 800 cases, there were four arterial injuries (0.5%) of which only one involved the ICA for a risk of 0.125%. The other three involved the ophthalmic artery, anterior communicating artery and A1 segment of the anterior cerebral artery. In all cases, definitive treatment involved occlusion of the artery either through endovascular means (3 cases) or direct surgical ligation (1 case). Neurological examinations were unchanged after arterial repair with only one small asymptomatic stroke. Literature review identified 7336 patients, of which there were 25 arterial injuries, of which 19 were of the ICA. Hence the total rate of arterial injury was 0.34% and the rate of ICA injury was 0.26%. Arterial sacrifice was the only reliable method for managing arterial injury. Stenting devices offer a potential alternative but too little data are present to evaluate this mode of therapy.

Conclusions: Arterial injury is an uncommon event during after endoscopic endonasal surgery. Attempts at arterial repair are rarely successful and vessel sacrifice is the most reliable technique at this point in time.