Management of Major

Vas c u l a r I n j u r y D u r i n g
E n d o s c o p i c En d o n a s a l S k u l l
B a se Surg er y
Paul A. Gardner, MDa,*, Carl H. Snyderman, MD, MBAa,b,
Juan C. Fernandez-Miranda, MDa, Brian T. Jankowitz, MDa

KEYWORDS
 Endoscopic skull base surgery  Internal carotid artery  Pseudoaneurysm
 Vascular injury

KEY LEARNING POINTS

At the end of this article, the reader will:

 Understand how major vasculature can be evaluated preoperatively.
 Understand how ischemia can be evaluated intraoperatively.
 Know which tumor types are at greatest risk for internal carotid artery (ICA) injury during
endoscopic endonasal skull base surgery (ESBS).
 Know what techniques can be used to preserve a vessel injury during ESBS.
 Be able to determine if bleeding from the ICA or circle of Willis can be controlled during
ESBS.
 Know how and when arteries can be evaluated following injury.
 Be able to identify the endovascular adjuncts that are currently available following
vascular injury.

INTRODUCTION

The endoscopic endonasal approach to the ventral skull base has gained popularity
over the past decade. Through collaboration between otolaryngologists and neurosur-
geons, these approaches have provided increasingly expanded access to the skull
base, in modules that extend from the crista galli to the odontoid process and laterally

Disclosure Statement: The authors have no conflict of interest to disclose.

a
Department of Neurological Surgery, University of Pittsburgh School of Medicine, 200 Loth-
rop Street, PUH B-400, Pittsburgh, PA 15213, USA; b Department of Otolaryngology, University
of Pittsburgh School of Medicine, 200 Lothrop Street, EEI 500, Pittsburgh, PA 15213, USA
* Corresponding author.
E-mail address: gardpa@upmc.edu

Otolaryngol Clin N Am 49 (2016) 819–828

http://dx.doi.org/10.1016/j.otc.2016.03.003 oto.theclinics.com
0030-6665/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
820 Gardner et al

to the cavernous sinus, middle fossa, and orbit. Great advances have been made in
instrumentation and reconstruction to allow the progression of these approaches.
During any surgery involving the skull base, surgeons must have anatomic knowl-
edge of the internal carotid artery (ICA) with respect to the operative field and have
strategies for dealing with inadvertent injury to this and other major vessels of the cir-
cle of Willis. There remains significant concern about the ability to manage such in-
juries when working with an endoscope through limited openings such as “keyhole”
craniotomies or through the paranasal sinuses.

INJURY AVOIDANCE

 The best strategy for dealing with major vessels is to avoid injury.
 Understand the anatomic landmarks and course of the arteries and recognize
how an individual tumor may have affected the anatomic location of the vessel.
 For the ICA, there are well-established landmarks to its various segments from
an endonasal perspective.

Segment of internal carotid artery and anatomic landmark

Segment of ICA Anatomic Landmark
Paraclinoid Medial opticocarotid recess1
Anterior genu Medial pterygoid plate/wedge2
Horizontal petrous Vidian nerve2
Ascending/parapharyngeal Eustachian tube3

All tumors of the skull base have the potential to

 Encapsulate
 Invade
 Displace the ICA

Cavernous and petroclival meningiomas can encircle the cavernous or petrous ICA
and basilar artery, with narrowing of the vessel or invasion of the adventitia (Fig. 1).
Pituitary adenomas can invade the cavernous sinus and encircle the ICA, but do not
tend to invade the adventitia. Chondroid tumors, such as chordomas and chondrosar-
comas, can significantly displace the ICA or basilar artery. Rarely, they can weaken or
invade the adventitia (Fig. 2). Chondroid tumors were the most common tumor type
injured during endonasal skull base surgery (ESBS) in the authors’ series of more
than 2000 patients.4 Juvenile nasal angiofibromas (JNAs) frequently derive blood sup-
ply from the cavernous ICA via branches such as the vidian artery (Fig. 3) but are rarely
adherent to the ICA. Nasopharyngeal and other paranasal sinus carcinomas can
 Endoscopic Endonasal Skull Base Surgery 821

invade soft tissue or bone up to or surrounding the ICA. Rarely, this can lead to rupture
of the vessel, especially following radiation therapy.

Technologies that can be used intraoperatively to localize the ICA and prevent its
injury include the following:
 Doppler ultrasound
 Navigation or image guidance
 Computed tomographic (CT) angiography, which is best for evaluating major
vasculature

Fig. 1. Axial (A) and coronal (B) postcontrast MRI showing a sphenopetroclival meningioma
with encasement, displacement, and narrowing of the right ICA (arrows). (C) Intraoperative
injury of the right ICA during resection of the petroclival meningioma. This was controlled
with an aneurysm clip without sequelae (D). Doppler is used to confirm flow in the pre-
served ICA after clipping.
822 Gardner et al

Fig. 2. Preoperative T2 MRI and CT angiogram showing involvement of bilateral paraphar-

yngeal ICAs (arrows) and displacement and narrowing of the left petrous ICA (arrowhead)
by a chordoma.

MANAGEMENT STRATEGIES FOR CONTROLLING ARTERIAL INJURY

1. Sacrifice
a. Approximately 80% patients will initially tolerate ICA sacrifice
b. Role of balloon test occlusion (BTO) and neurophysiological monitoring
2. Bypass
a. Prophylactic
b. Emergent
3. Vessel preservation techniques
a. Bipolar electrocautery
b. Aneurysm clips
c. Muscle or other packing
d. Suture

When considering sacrifice, preoperative ICA testing with BTO or intraoperative

neurophysiologic monitoring is helpful. BTO is recommended for recurrent tumors
that may invade the artery wall (ie, meningiomas, chordomas). The addition of perfu-
sion study during the BTO can risk-stratify those patients who clinically tolerate occlu-
sion. Most patients (80%–87%) will initially tolerate ICA sacrifice, based on
intraoperative carotid endarterectomy shunting studies.5,6
Bypass surgery is best used prophylactically when the patient has failed BTO or has
borderline perfusion. Emergent bypass following injury often cannot be performed
quickly enough to avoid infarct.
Vessel preservation techniques are designed to control bleeding while maintaining
flow within the ICA. These strategies include sealing of the edges with bipolar elec-
trocautery, placement of aneurysm clips, direct suture repair, and nonocclusive
packing. Endonasal suturing is generally not feasible for most ICA injuries because
 Endoscopic Endonasal Skull Base Surgery 823

of the inherent limitations posed by the location of vessel, access, and nature of
injury.

Any arterial injury, regardless of approach, should be managed by

 Localizing and controlling the site of bleeding (often with a cottonoid and
suction)
 Gaining proximal and distal control
 Increasing exposure to better identify the injury

Muscle can be harvested from abdominal rectus, sternocleidomastoid, or tempora-

lis muscle. Crushing the muscle graft releases calcium that may promote the initial
fibrin plug and improve arterial wall healing.7

Advantages of team surgery

 Dynamic endoscopy allows close visualization of site of bleeding while

maintaining a view, even if the endoscope is contaminated repeatedly with
blood.
 Maintaining calm during a major, stressful complication.
 Troubleshooting and problem-solving.

Working as a team is essential for controlling a major endonasal vascular injury.

NEUROPHYSIOLOGIC MONITORING AND ITS ROLE DURING VASCULAR INJURY

Somatosensory evoked potentials and electroencephalography monitoring can

provide surrogate information for BTO in the setting of an intraoperative injury.
Surrogate information includes the following:
 A general idea on the distribution of hemispheric ischemia
 A guide for intraoperative and immediate postoperative management.
 Determination about whether the vessel can be sacrificed without stroke-
related morbidity or whether it must be preserved.

The tests can be performed with the vessel controlled or occluded under hypotensive
conditions to evaluate a perfusion deficit. However, active bleeding can lead to a tran-
sient decrement in evoked potentials which does not clearly predict impact of sacri-
fice; therefore, testing for necessity of preservation should be done after bleeding is
controlled.

ENDOVASCULAR EVALUATION AND MANAGEMENT OF MAJOR VASCULAR INJURY

An immediate postoperative digital subtracted angiogram (DSA) should be performed

before waking the patient.
Further vascular evaluation should be performed at least a week after injury
to ensure that no pseudoaneurysm has formed, even if the initial DSA is normal. CT
824 Gardner et al

Fig. 3. (A) Preoperative, postcontrast axial MRI showing encasement of the right ICA by a
JNA. (B) ICA injection following tumor embolization showing significant residual vascularity
from the involved ICA.

angiography can be used for future evaluation, although DSA remains the gold
standard.
Pseudoaneurysm formation is common and follow-up imaging for up to 6 months
postoperatively should include vascular imaging (CT angiography, MR angiography,
DSA).

Reasons for endovascular salvage

 Active extravasation
 Pseudoaneurysm
 ICA stenosis from packing

Endovascular treatment options vary depending on the injury and patient anatomy/
physiology. For patients with active extravasation on a postoperative angiogram, im-
mediate treatment is mandated. Options include pseudoaneurysm treatment with
coils or a liquid embolic, ICA occlusion (if patient has visible collaterals and passes
a balloon test occlusion with neurophysiologic monitoring or awake evaluation with
provocative hypotension), OR flow diverson/covered stenting. Finally, critical stenosis
(>50% or resulting in delayed distal flow) can be treated with observation, balloon an-
gioplasty, or stenting.

INTERNAL CAROTID ARTERY INJURY MANAGEMENT ALGORITHM

The algorithm in Fig. 4 is based on the authors’ experience with ICA injury during
ESBS.4
 Endoscopic Endonasal Skull Base Surgery 825

Fig. 4. ICA injury management algorithm. ECA, external carotid artery; ICA, internal carotid
artery; XRT, radiation therapy. (From Gardner PA, Tormenti MJ, Pant H, et al. Carotid artery
injury during endoscopic endonasal skull base surgery: incidence and outcomes. Neurosur-
gery 2013;73(2 Suppl Operative):ons267; with permission.)
826 Gardner et al

POST-HOC ANALYSIS FOLLOWING INJURY (ROOT CAUSE ANALYSIS)

Root cause analysis (RCA) is a useful way to evaluate the injury to understand why it
happened and try to prevent future similar errors. RCA evaluates a complication
looking at several categories to judge their role.

Examples of categories that can be used to evaluate a vascular injury are as

follows:
 Patient (tortuous ICA, fibrotic tumor, collateral circulation)
 Surgeons (multiple surgeons, goal of surgery, distractions [eg, simultaneous
surgeries])
 Technique (sharp vs blunt dissection, proper use of Doppler or navigation,
proximal control obtained)
 Materials (navigation accuracy, Doppler, availability of vascular clamps, clips,
suture, packing)
 Process (communication with operative staff, availability of equipment)

SUMMARY
 Major vascular injury can be controlled during ESBS.
 A variety of techniques can be used to control a major injury.
 Packing with a crushed muscle graft may be the best first option for most injuries
to control bleeding before postinjury angiogram.
 A team of surgeons (otolaryngology and neurosurgery) is important for identifica-
tion and control of a major vascular injury applying basic principles of vascular
control.
 Immediate and close angiographic follow-up is critical to prevent and manage
subsequent complications of vascular injury.

Post-Test Questions (Correct answers are in italics)

1. Which of the following is not a reliable option for control of vascular injury during
ESBS?
a. Aneurysm clip
b. Suturing
c. Muscle patch
d. Bipolar coagulation
e. All of the above
2. Which of the following can help avoid an ICA injury?
a. Doppler probe
b. Intraoperative navigation
c. Two-surgeon technique
d. Careful study of individual patient anatomy
e. All of the above
3. Which of the following conditions lead to increased tortuosity of the ICA?
a. Cushing disease
b. Esthesioneuroblastoma
c. Juvenile nasal angiofibroma
d. Acromegaly
 Endoscopic Endonasal Skull Base Surgery 827

4. Which of the following are possible sequelae of ICA injury?

a. Stenosis
b. Distal embolus
c. Nasoseptal flap infarct
d. Pseudoaneurysm
e. a, b, and d
5. Which of the following is a critical anatomic relationship for ICA identification?
a. The lateral OCR is pneumatization of the optic strut.
b. The vidian nerve crosses the horizontal petrous ICA.
c. The vidian nerve and maxillary nerve converge on Meckel cave.
d. The sphenopalatine artery can be found behind the crista ethmoidalis.

SUPPLEMENTARY DATA

Supplementary PDF slides related to this article can be found online at http://www.
oto.theclinics.com/.

REFERENCES

1. Fernandez-Miranda JC, Prevedello DM, Madhok R, et al. Sphenoid septations and

their relationship with internal carotid arteries: anatomical and radiological study.
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3. Ozturk K, Snyderman CH, Gardner PA, et al. The anatomical relationship between
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4. Gardner PA, Tormenti MJ, Pant H, et al. Carotid artery injury during endoscopic en-
donasal skull base surgery: incidence and outcomes. Neurosurgery 2013;73(2
Suppl Operative):ons261–9.
5. Modica PA, Tempelhoff R, Rich KM, et al. Computerized electroencephalographic
monitoring and selective shunting: influence on intraoperative administration of
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arterectomy. Neurosurgery 1992;30(6):842–6.
6. Plestis KA, Loubser P, Mizrahi EM, et al. Continuous electroencephalographic
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7. Padhye V, Valentine R, Paramasivan S, et al. Early and late complications of endo-
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SUGGESTED READINGS

AlQahtani A, Castelnuovo P, Nicolai P, et al. Injury of the internal carotid artery during
endoscopic skull base surgery: prevention and management protocol. Otolar-
yngol Clin North Am 2016;49(1):237–52.
The authors describe their approach to the prevention and management of ICA
injuries during ESBS.
828 Gardner et al

Chin OY, Ghosh R, Fang CH, et al. Internal carotid artery injury in endoscopic endo-
nasal surgery: a systematic review. Laryngoscope 2016;126(3):582–90.
This is a systematic review of ICA injuries during endoscopic endonasal
surgery, including sinus surgery and skull base surgery. Twenty-five articles
with 50 cases were included in this review. The most commonly injured ICA
segment was the cavernous (34 cases) segment. Injuries occurred more
commonly on the left (1.3:1). Initial hemostasis was achieved with packing in
35 cases, endoscopic clip sacrifice in 4 cases, bipolar coagulation with the
intent to seal defect in 3 cases, and bipolar coagulation with the intent to sac-
rifice the ICA in 1 case.
Gardner PA, Tormenti MJ, Pant H, et al. Carotid artery injury during endoscopic endo-
nasal skull base surgery: incidence and outcomes. Neurosurgery 2013;73(2
Suppl Operative):ons261–9.
This article describes the authors’ collective experience with ICA injuries during
ESBS. Most injuries involved the left paraclival ICA. Risk factors include a diag-
nosis of chondroid neoplasm. A treatment strategy with algorithm is presented
for the management of small and large vascular injuries.
Padhye V, Valentine R, Paramasivan S, et al. Early and late complications of endo-
scopic hemostatic techniques following different carotid artery injury characteris-
tics. Int Forum Allergy Rhinol 2014;4(8):651–7.
This study compares the efficacy of the muscle patch, bipolar diathermy, and
aneurysm clip on hemostasis, pseudoaneurysm formation, and long-term vessel
patency for different injury types in a sheep model of carotid bleeding. Standard-
ized linear, punch, and stellate injuries were made. Randomization of sheep to
receive 1 of 3 hemostatic techniques was performed (muscle, bipolar, clip).
This study shows that the crushed muscle patch and aneurysm clip can be viable
options in the management of ICA injury with short-term and long-term benefits.
Complications associated with these techniques were comparable if not reduced
when compared with the published literature.