Endovascular Management of Vascular Injury during Transsphenoidal Surgery

Abstract

Vascular injury is an unusual and serious complication of transsphenoidal surgery. We aimed to define the role of angiography and endovascular treatment in patients with vascular injuries occurring during transsphenoidal surgery. During the last ten-year period, we retrospectively evaluated nine patients with vascular injury after transsphenoidal surgery. Eight patients were symptomatic due to vascular injury, while one had only suspicion of vascular injury during surgery. Four patients presented with epistaxis, two with subarachnoid hemorrhage, one with exophthalmos, and one with hemiparesia. Emergency angiography revealed a pseudoaneurysm in four patients, contrast extravasation in two, vessel dissection in one, vessel wall irregularity in one, and arteriovenous fistula in one. All patients but one were treated successfully with parent artery occlusion, with one covered stent implantation, one stent-assisted coiling method, while one patient was managed conservatively. One patient died due to complications related to the primary insult without rebleeding. Vascular injuries suspected intra or postoperatively must be investigated rapidly after transsphenoidal surgery. Endovascular treatment with parent artery occlusion is feasible with acceptable morbidity and mortality rates in the treatment of vascular injuries occurring in transsphenoidal surgery.

Figure 1

Case 1. Preoperative postcontrast coronal T1-weighted MR image showing a pituitary tumor that had suprasellar extension (A). Post operative CT image shows diffuse subarachnoid haemorrhage in all basal cisterns (B). 3D rotational angiography showed a ruptured small aneurysm of the left P1 (C). Control angiography showed complete occlusion of the aneurysm (D) with total preservation of the posterior communicating artery and left posterior cerebral artery (E).

Figure 2

Case 4. Postoperative axial T2-weighted MR image showing anexophthalmos of the left eye (A). Reconstructed MIP of the subtracted images from CTA (B). Left carotid angiogram shows a direct CCF mainly draining to the superior ophtalmic vein (C). Postprocedural left CCA angiogram obtained after deployment of stent-graft reveals cessation of contrast material extravasation and closure of the CCF (D).

Figure 3

Case 6. Post-operative active bleeding following transnasal surgery (A). Oblique CCA angiography showed the active extravasation of contrast from the right cavernous ICA(B). Right common carotid angiography after coil embolization of the internal carotid artery (C). Left internal carotid (D) and vertebral angiography (E) during occlusion shows adequate anterior and posterior communicating artery collateral filling. Permanent carotid occlusion was performed with no further episode of bleeding.