Simulating Internal Carotid Artery Injury during Transsphenoidal Transclival Endoscopic Surgery in a Perfused Cadaver Model

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

• References

• 1 Gardner PA, Tormenti MJ, Pant H, Fernandez-Miranda JC, Snyderman CH, Horowitz MB. Carotid artery injury during endoscopic endonasal skull base surgery: incidence and outcomes. Neurosurgery 2013; 73 (2, Suppl Operative) ons261-ons269 , discussion ons269–ons270
• 2 Valentine R, Wormald PJ. Carotid artery injury after endonasal surgery. Otolaryngol Clin North Am 2011; 44 (05) 1059-1079
• 3 Shakir HJ, Garson AD, Sorkin GC. , et al. Combined use of covered stent and flow diversion to seal iatrogenic carotid injury with vessel preservation during transsphenoidal endoscopic resection of clival tumor. Surg Neurol Int 2014; 5: 81
• 4 Kocer N, Kizilkilic O, Albayram S, Adaletli I, Kantarci F, Islak C. Treatment of iatrogenic internal carotid artery laceration and carotid cavernous fistula with endovascular stent-graft placement. AJNR Am J Neuroradiol 2002; 23 (03) 442-446
• 5 Silva D, Attia M, Kandasamy J, Alimi M, Anand VK, Schwartz TH. Endoscopic endonasal transsphenoidal “above and below” approach to the retroinfundibular area and interpeduncular cistern--cadaveric study and case illustrations. World Neurosurg 2014; 81 (02) 374-384
• 6 Pham M, Kale A, Marquez Y. , et al. A perfusion-based human cadaveric model for management of carotid artery injury during endoscopic endonasal skull base surgery. J Neurol Surg B Skull Base 2014; 75 (05) 309-313
• 7 van Doormaal TP, van der Zwan A, Aboud E. , et al. The sutureless excimer laser assisted non-occlusive anastomosis (SELANA); a feasibility study in a pressurized cadaver model. Acta Neurochir (Wien) 2010; 152 (09) 1603-1608 , discussion 1608–1609
• 8 Koutourousiou M, Gardner PA, Tormenti MJ. , et al. Endoscopic endonasal approach for resection of cranial base chordomas: outcomes and learning curve. Neurosurgery 2012; 71 (03) 614-624 , discussion 624–625
• 9 Solares CA, Ong YK, Carrau RL. , et al. Prevention and management of vascular injuries in endoscopic surgery of the sinonasal tract and skull base. Otolaryngol Clin North Am 2010; 43 (04) 817-825
• 10 Dusick JR, Esposito F, Malkasian D, Kelly DF. Avoidance of carotid artery injuries in transsphenoidal surgery with the Doppler probe and micro-hook blades. Neurosurgery 2007; 60 (04) (Suppl. 02) 322-328 , discussion 328–329
• 11 Valentine R, Wormald PJ. Controlling the surgical field during a large endoscopic vascular injury. Laryngoscope 2011; 121 (03) 562-566
• 12 Couldwell WT, Weiss MH, Rabb C, Liu JK, Apfelbaum RI, Fukushima T. Variations on the standard transsphenoidal approach to the sellar region, with emphasis on the extended approaches and parasellar approaches: surgical experience in 105 cases. Neurosurgery 2004; 55 (03) 539-547 , discussion 547–550
• 13 Hillen B, Hoogstraten HW, Post L. A mathematical model of the flow in the circle of Willis. J Biomech 1986; 19 (03) 187-194
• 14 Lavine SD, Masri LS, Levy ML, Giannotta SL. Temporary occlusion of the middle cerebral artery in intracranial aneurysm surgery: time limitation and advantage of brain protection. J Neurosurg 1997; 87 (06) 817-824
• 15 Paluzzi A, Fernandez-Miranda JC, Tonya Stefko S, Challinor S, Snyderman CH, Gardner PA. Endoscopic endonasal approach for pituitary adenomas: a series of 555 patients. Pituitary 2014; 17 (04) 307-319
• 16 Van Rompaey J, Bowers G, Radhakrishnan J, Panizza B, Solares CA. Endoscopic repair of an injured internal carotid artery utilizing femoral endovascular closure devices. Laryngoscope 2014; 124 (06) 1318-1324