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Review
. 2019 Apr;39(2):130-136.
doi: 10.14639/0392-100X-1312. Epub 2019 Jan 31.

Internal carotid artery injury during endonasal sinus surgery: our experience and review of the literature

S G Lum  1 , B S Gendeh  1 , S Husain  1 , H S Gendeh  1 , M R Ismail  2 , C J Toh  3 , A Izaham  4 , H J Tan  5
Affiliations
Review

Internal carotid artery injury during endonasal sinus surgery: our experience and review of the literature

S G Lum et al. Acta Otorhinolaryngol Ital. 2019 Apr.

Abstract

Rottura dell’arteria carotide interna durante la chirurgia nasale endoscopica: nostra esperienza e review della letteratura.

Riassunto: La rottura iatrogena dell’arteria carotide interna è una complicanza catastrofica, sebbene non frequente, della chirurgia endoscopica nasale. In questo lavoro presentiamo la nostra esperienza nella gestione di questa emergenza. Un uomo di 52 anni è stato sottoposto ad intervento di chiusura di fistola rinoliquorale, e durante l’intervento si è verificata una copiosa emorragia durante l’apertura, mediante pinza sfenoidale di Hajek, della parete anteriore del seno sfenoidale. L’immediato tamponamento del seno sfenoidale ha controllato l’emorragia. Mediante l’esecuzione di un’angiografia urgente, è stato individuato un punto di rottura della carotide interna sinistra a livello del segmento paraclivale. Quindi inizialmente è stato posizionato uno stent, ma si è trombizzato; successivamente è stata utilizzata una spirale endovascolare. Il paziente è andato incontro ad ischemia cerebrale con emiparesi post-procedura, che si è risolta del tutto nel giro di 6 settimane. Il tamponamento nasale seguito da un’angiografia in urgenza e il posizionamento di uno stent endovascolare possono rappresentare il trattamento definitivo meno invasivo. Se lo stent non dovesse avere successo, l’occlusione mediante balloon endovascolare o l’embolizzazione mediante spirale dovrebbero essere i trattamenti di scelta quando la rivascolarizzazione dai distretti controlaterali è garantita. Il successo del trattamento si basa soprattutto sull’immediatezza della gestione da parte di un team multidisciplinare.

Keywords: Angiography; Endoscopy sphenoid sinus; Endovascular procedures; Internal carotid artery injuries.

Plain language summary

Iatrogenic internal carotid artery injury is a catastrophic but uncommon complication of endonasal sinus surgery. We present our experience in managing this emergency situation. A 52-year-old man underwent revision endoscopic repair of recurrent cerebrospinal fluid leak that was complicated with profuse haemorrhage during removal of the anterior wall of sphenoid sinus using a Hajek sphenoid punch forceps. Immediate packing of the sphenoid sinus controlled the haemorrhage. Urgent angiography revealed injury at the paraclival segment of the left internal carotid artery. An endovascular stent was initially placed but thrombosed; it was subsequently converted to coil embolisation. The patient had watershed cerebral infarct with hemiparesis post procedure but made full recovery within 6 weeks. Immediate nasal packing followed by urgent angiography and endovascular stent placement is the least invasive definitive treatment. If stenting is unsuccessful, endovascular balloon occlusion or coil embolisation is the next preferred treatment, if there is adequate cross-cerebral circulation. The success of treatment relies on its immediate management by a multidisciplinary team.

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Figures

Fig. 1.
Fig. 1.
Coronal CT image showing a bony defect at the lateral recess of right sphenoid sinus with soft tissue density in the right sphenoid sinus.
Fig. 2.
Fig. 2.
a) 3D rotational angiogram reveals irregular outline at the posterior border of the left ICA (black arrow), with active extravasation of contrast media, and flow limitation to middle cerebral artery (MCA); b) micro-catheter crossing the injured portion of ICA before stenting; c) complete obliteration of the left ICA distal to the ophthalmic artery post endovascular stenting due to stent thrombosis; d) balloon occlusion test (BOT) of left ICA reveals satisfactory cross flow from right ICA to the left cerebral hemisphere, via anterior communicating artery and left posterior communicating artery; e) coil mesh in the injured portion of left ICA with complete obliteration of distal ICA. No extravasation of contrast media; f) reconstitution of left ophthalmic artery from facial artery collateral.
Fig. 3.
Fig. 3.
Algorithm for emergency management of ICA injury during ESS.
See this image and copyright information in PMC

References

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