Abstract
Introduction Managing internal carotid artery (ICA) injury during extended endoscopic transsphenoidal
surgery is an extreme challenge. We aimed to find a possible surgical treatment strategy.
Methods We operated seven fresh, perfused cadaver heads with a transsphenoidal endoscopic
approach of the ICA using a three-dimensional-high definition (3D-HD) endoscope. We
made a paraclival ICA leak, which we tried to manage with clips and microsutures.
Results Accurate transsphenoidal clip application on the ICA was impossible with standard
aneurysm clips and applier. It was only feasible with a 9 mm slightly bended clip
that could be opened from the inside and be applied with a dedicated flexible thin
applier. Transsphenoidal suturing of an ICA leak was impossible from the ipsilateral
nostril or with standard microinstruments. Suturing was only feasible from the contralateral
nostril using flexible microinstruments with a thin 90-mm shaft. This was technically
very challenging and involved a steep learning curve.
Conclusion Tamponade with muscle or fat and a quick transfer to the angiography suite for endovascular
control remains the preferable option in case of an ICA leak during endoscopic transsphenoidal
surgery. If tamponade gives insufficient initial control, ICA clipping could be possible
with dedicated instruments, with risk of increasing the defect, stenosis, or occlusion
of the vessel. Transsphenoidal ICA suturing remains extremely difficult, and laboratory
practice seems essential.
Keywords
internal carotid artery injury - transsphenoidal endoscopic Surgery - perfused Cadaver
Model
