Hemorrhagic Vascular Complications of Endoscopic Transsphenoidal Surgery

Abstract

Two hundred and fifty consecutive patients operated on by an endoscopic endonasal transsphenoidal approach were retrospectively analyzed in order to evaluate hemorrhagic vascular complications occurring during or after the surgical procedure and their appropriate management. Vascular complications of endoscopic transsphenoidal surgery are identical to those of a microsurgical transsphenoidal approach. Damage to the sphenopalatine artery and to the internal carotid artery (ICA), which are the most frequent vascular troubles, may require technical tricks because of some aspects connected to the approach itself and of the physical properties of the endoscope. Furthermore, the progress in interventional neuroradiology in the last decades offers new solutions in respect to the past, where the use of the surgical microscope was already a tremendous progress. The anatomic substrate of each complication is discussed, along with the peculiar surgical details related to it.

Complications - transsphenoidal surgery - vascular complications - endoscopic transsphenoidal surgery - pituitary surgery - endoscopy

References

• 1 Cappabianca P, Alfieri A, de Divitiis E. Endoscopic endonasal transsphenoidal approach to the sella: towards functional endoscopic pituitary surgery (FEPS).  Minim Invasive Neurosurg. 1998;  41 66-73
• 2 Cappabianca P, Alfieri A, de Divitiis E, Tschabitscher M. Atlas of endoscopic anatomy for endonasal intracranial surgery. Wien, New York: Springer Verlag 2001: 134
• 3 Cappabianca P, Cavallo L M, Colao A, Del Basso De Caro M, Esposito F, Cirillo S, Lombardi G, de Divitiis E. Endoscopic endonasal transsphenoidal approach: outcome analysis of 100 consecutive procedures.  Minim Invasive Neurosurg. 2002;  45 193-200
• 4 de Divitiis E, Cappabianca P. Endoscopic endonasal transsphenoidal surgery. In: Pickard JD (eds.). Advances and Technical Standards in Neurosurgery. Wien, New York, Springer Verlag Vol. 27 2002: 137-177
• 5 de Divitiis E, Cappabianca P, Cavallo L M. Endoscopic transsphenoidal approach: adaptability of the procedure to different sellar lesions.  Neurosurgery. 2002;  51 699-707
• 6 de Divitiis E, Cappabianca P, Laws Jr E R. Microscopic and endoscopic transsphenoidal surgery.  Neurosurgery. 2002;  51 1527-1530
• 7 de Divitiis E, Cappabianca P. (eds) .Endoscopic endonasal transsphenoidal surgery. Wien, New York: Springer Verlag 2003: 198
• 8 Jho H D, Carrau R L, Ko Y. Endoscopic pituitary surgery. In: Wilkins RH, Rengachary SS (eds.). Neurosurgical Operative Atlas. Park Ridge (Ill): American Association of Neurological Surgeons, Vol. 5 1996: 1-12
• 9 Jho H D, Carrau R L. Endoscopic endonasal transsphenoidal surgery: experience with 50 patients.  J Neurosurg. 1997;  87 44-51
• 10 Jho H D. Endoscopic surgery of pituitary adenomas. In: Krisht AF, Tindall GT (eds.). Comprehensive management of pituitary disorders. Hagerstown: Lippincott Williams & Wilkins 1999: 389-403
• 11 Jho H D. Endoscopic transsphenoidal surgery. In: Schmidek HH (eds.). Schmidek and Sweet Operative Neurosurgical Techniques. Indications, Methods and Results. Philadelphia: W.B. Saunders Company 2000: 385-397
• 12 Cappabianca P, Cavallo L M, Colao A M, de Divitiis E. Surgical complications associated with endoscopic endonasal transsphenoidal approach for pituitary adenomas.  J Neurosurg. 2002;  97 293-298
• 13 Black P McL, Zervas N T, Candia G L. Incidence and management of complications of transsphenoidal operation for pituitary adenomas.  Neurosurgery. 1987;  20 920-924
• 14 Ciric I, Ragin A, Baumgartner C, Pierce D. Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience.  Neurosurgery. 1997;  40 225-237
• 15 Laws Jr E R, Kern E B. Complications of trans-sphenoidal surgery.  Clin Neurosurg. 1976;  23 401-416
• 16 Laws Jr E R, Kern E B. Complications of trans-sphenoidal surgery. In: Laws ER Jr, Randall RV, Kern EB (eds.). Management of adenomas and related lesions. New York: Appleton-Century-Crofts 1982: 329-346
• 17 Laws E R. Vascular complications of transsphenoidal surgery.  Pituitary. 1999;  2 163-170
• 18 Cappabianca P, Briganti F, Cavallo L M, de Divitiis E. Pseudoaneurysm of the intracavernous carotid artery following endoscopic endonasal transsphenoidal surgery, treated by endovascular approach.  Acta Neurochir. 2001;  143 95-96
• 19 Ciric I, Rosenblatt S, Zhao J C. Transsphenoidal microsurgery.  Neurosurgery. 2002;  51 161-169
• 20 Cockroft K M, Carew J F, Trost D, Fraser R A. Delayed epistaxis resulting from external carotid artery injury requiring embolization: a rare complication of transsphenoidal surgery: case report.  Neurosurgery. 2000;  47 236-239
• 21 Raymond J, Hardy J, Czepko R, Roy D. Arterial injuries in transsphenoidal surgery for pituitary adenoma; the role of angiography and endovascular treatment.  Am J Neuroradiol. 1997;  18 655-665
• 22 Skinner D W, Richards S H. Acromegaly: the mucosal changes within the nose and the paranasal sinuses.  J Laryngol Otol. 1988;  102 1107-1110
• 23 Renn W H, Rhoton Jr A L. Microsurgical anatomy of the sellar region.  J Neurosurg. 1975;  43 288-298
• 24 Fukushima T, Maroon J C. Repair of carotid artery perforations during transsphenoidal surgery.  Surg Neurol. 1998;  50 174-177
• 25 Tindall G T, Barrow D L. Disorders of the pituitary. St. Louis: CV Mosby 1986: 498
• 26 Wilson C B, Dempsey L C. Transsphenoidal microsurgical removal of 250 pituitary adenomas.  J Neurosurg. 1978;  48 13-22
• 27 Simpson Jr R K, Harper R L, Bryan R N. Emergency balloon occlusion for massive epistaxis due to traumatic carotid-cavernous aneurysm. Case report.  J Neurosurg. 1998;  68 142-144
• 28 Dolenc V V, Lipovsek M, Slokan S. Traumatic aneurysm and carotid-cavernous fistula following transsphenoidal approach to a pituitary adenoma: treatment by transcranial operation.  Br J Neurosurg. 1999;  13 185-188
• 29 Ahuja A, Guterman L R, Hopkins L N. Carotid cavernous fistula and false aneurysm of the cavernous carotid artery: complications of transsphenoidal surgery.  Neurosurgery. 1992;  31 774-779
• 30 Bavinzski G, Killer M, Knosp E, Ferraz-Leite H, Gruber A, Richling B. False aneurysm of the intracavernous carotid artery: report of 7 cases.  Acta Neurochirurg. 1997;  139 37-43
• 31 Chen D, Concus A P, Halbach V V, Cheung S W. Epistaxis originating from traumatic pseudoaneurysm of the internal carotid artery: diagnosis and endovascular therapy.  Laryngoscope. 1998;  108 326-331
• 32 Kay Y, Hamada J, Nishi T, Ushio Y. Successful treatment with bypass and interventional surgery for a ruptured pseudo carotid artery aneurysm after transsphenoidal surgery: a case report.  No Shinkei Geka. 2001;  29 241-245
• 33 Marks M P, Chee H, Liddell R P, Steinberg G K, Panahian N, Lane B. A mechanically detachable coil for the treatment of aneurysm and occlusion of blood vessels.  Am J Neuroradiol. 1994;  15 821-827
• 34 Park A H, Stankiewicz J A, Chow J, Azar-Kia B. A protocol for management of a catastrophic complication of functional endoscopic sinus surgery: internal carotid artery injury.  Am J Rhinol. 1998;  12 153-158
• 35 Kadyrov N A, Friedman J A, Nichols D A, Cohen-Gadol A A, Link M, Piepgras D G. Endovascular treatment of an internal carotid artery pseudoaneurysm following transsphenoidal surgery. Case report.  J Neurosurg. 2002;  96 624-627
• 36 Lempert T E, Halbach V V, Higashida R T, Dowd C F, Urwin R W, Balousek P A, Hieshima G B. Endovascular treatment of pseudoaneurysm with electrolytically detachable coils.  Am J Neuroradiol. 1998;  19 907-911
• 37 Mericle R A, Lanzino G, Wakhloo A K, Guterman L R, Hopkins L N. Stenting and secondary coiling of intracranial internal carotid artery aneurysm: technical case report.  Neurosurgery. 1998;  43 1229-1234
• 38 Linskey M E, Sekhar L N, Horton J A, Hirsch Jr W L, Yonas H. Aneurysms of the intracavernous carotid artery: a multidisciplinary approach to treatment.  J Neurosurg. 1991;  75 525-534
• 39 Ellegala D B, Maartens N F, Laws E R. Use of Floseal hemostatic sealant in transsphenoidal pituitary surgery: technical note.  Neurosurgery. 2002;  51 513-516