Endonasal Surgery Carotid Artery Injury Timeout Checklist: Implementation and Case Example

Objective: Carotid artery injury is a rare, but major complication of endonasal operations. The morbidity and mortality of such a complication can be mitigated by preparedness and a clear plan set in place to address the hemorrhage [BG1] expeditiously. This study examines the implementation of such a carotid injury timeout checklist and demonstrates its effectiveness in a patient with possible arterial injury.

Methods: A carotid injury timeout checklist was implemented for high risk endonasal procedures. The case selection was left to the surgeon, with guidelines including prior surgery, prior radiation, invasive tumors, and certain pathologies such as meningioma or chordoma. Factors affecting implementation were analyzed including tumor characteristics and patient history.

Index Case: An 80 year-old-man with a 4.4-cm right pterygopalatine fossa metastatic adenocarcinoma causing optic nerve compression and right-sided vision loss. This tumor appeared to be hypervascular and was preoperatively embolized via the middle meningeal and internal maxillary arteries. A carotid injury timeout was performed and subsequently, the patient underwent an extended endonasal transsphenoidal and transpterygoid resection of this tumor, during which there was significant arterial bleeding from the pterygopalatine fossa, which resulted in approximately 2 L of blood loss. The bleeding was controlled with muslin gauze, thrombin mixed Surgifoam, collagen sponge and Merocel sponge. The patient was then transferred to the interventional neuroradiology suite, where a hypertrophied right vidian artery was identified as the bleeding source and embolized. The patient was successfully resuscitated with blood transfusions and recovered well from this injury without neurological deficit.

Results: A total of 103 endonasal operations were performed over a 12-month period since the carotid artery injury timeout checklist was implemented. Twenty (20.4%) had carotid artery injury timeout performed. Tumor characteristics that were associated with performing this timeout included Knosp grade (for pituitary adenomas, p = 0.002), carotid artery encasement (p < 0.001), extended approach (p < 0.001), tumor size (p = 0.05) and diagnosis (p < 0.001). Reoperation and prior radiation were not factors for this selection. The single carotid artery branch (Vidian artery) injury that was sustained was easily and successfully managed, aided by preparation established via this protocol.

Conclusion: A carotid artery injury timeout can and should be successfully implemented for extended endonasal operations for pituitary and parasellar tumors demonstrating high risk including, but not limited to, carotid injury encasement, large tumor size and non-adenomatous diagnoses ([Fig. 1]).

Fig. 1 Carotid artery injury timeout.

 

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Artikel online veröffentlicht:
15. Februar 2022