Managing Internal Carotid Artery Injury during Endoscopic Transsphenoidal Surgery

Introduction: Endoscopic endonasal, transsphenoidal exposure is the standard approach for pituitary tumor resection. Considered safe and effective, risks for serious life-threatening complications remain. Due to proximity of the siphon of the internal carotid artery (ICA) to the pituitary fossa, injury to the ICA leads to high morbidity and mortality. Although injury to the ICA is one of the most feared complications of transsphenoidal surgery, there is limited published literature on management, relying mostly on anecdotal case reports.

Case Description: A 59-year-old male with symptoms of blurry vision, occasional diplopia and decreased libido was found to have a 2.5 × 1.5 cm pituitary mass impinging on the visual apparatus. Endocrinologic consultation confirmed the lesion to be non-secretory while ophthalmologic evaluation showed bitemporal visual field deficits. After risk-benefit discussions, it was decided to proceed with image-guided endoscopic transsphenoidal resection of the sellar mass. During the final phases of resection, extension of the durotomy on the right side led to excessive arterial bleeding. Concerted efforts made by the surgical and anesthesia teams successfully achieved swift hemostasis, utilizing endoscopic dual suction, manual carotid compression, and nonabsorbable patties. Patties were then replaced with rectus abdominis muscle graft augmented with oxidized cellulose (Surgicel). Immediate angiographic evaluation of the suspected ICA injury showed carotid cavernous fistula, which was managed with a flow diverting stent, placed in the cavernous segment of the ICA and coil embolization of the cavernous sinus. Once angiogram confirmed no further contrast extravasation, the patient was taken to the intensive care unit, intubated and sedated. On the second postoperative day, repeat angiogram was performed before removing the nonabsorbable patties and performing final sellar closure. Upon extubation, the patient had a stable neurological exam, with no new deficits, and was discharged one week later.

Discussion: This novel case demonstrates the intraoperative and postoperative management of a patient with ICA injury during endonasal, transsphenoidal pituitary mass resection. ICA injury during endoscopic transsphenoidal surgery is a rare complication, with incidence ranging from 0.2 to 2%. Historically, endoscopic carotid injury is associated with serious morbidity but recent advances in endovascular interventions have improved outcomes. Multiple factors can augment the risk of surgical ICA injury, including anomalous anatomy or history of previous surgery or radiotherapy. A two surgeon approach to controlling the ICA bleed includes resuscitation, large bore suction, and abdominal muscle graft for hemostasis. Surgical competency, teamwork, and technical expertise have been cited as positive prognostic factors in ICA injury management. Training on animal models further strengthens surgical training for better preparedness and stress coping. Once reasonable hemostasis has been achieved, immediate angiographic evaluation is vital. While vessel sacrifice has previously been used for ICA injury management, it has been proposed that using covered or flow diverting stents results in better outcomes.

This patient's excellent outcome despite an often morbid or fatal complication highlights the necessity of an interdisciplinary neurovascular and skull base team response that incorporates meticulous anatomic knowledge, surgical preparation, and early mobilization to angiography.

 

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No conflict of interest has been declared by the author(s).

Publication History

Article published online:
15 February 2022