Endovascular management of iatrogenic carotid artery injuries during transsphenoidal endoscopic sinus surgery: single-center, case series

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Abstract Background Endoscopic endonasal surgery can result in iatrogenic damage to the internal carotid artery (ICA), which is uncommon but can have dangerous side effects. This may manifest intraoperatively as high-volume arterial bleeding or may present after surgery as delayed hemorrhage or the development of a pseudoaneurysm. Our hospital is a national referral center for endoscopic endonasal surgeries. In this case series, we present our experience with 25 patients referred for endovascular management of iatrogenic carotid injury during transsphenoidal endoscopic sinus surgery. Results A retrospective analysis of the angiographic characteristics, technical data, and clinical outcomes of 25 consecutive patients who experienced iatrogenic injuries to the ICA during transsphenoidal sinus surgery. Patients were treated using endovascular techniques between January 2015 and December 2023. Twelve patients were managed intraoperatively; 8 underwent the endovascular procedure one day following surgery; and five were managed several days after surgery. A total of 21 patients underwent an endovascular therapeutic procedure to control bleeding. In contrast, diagnostic angiography was performed in 4 patients. The angiographic findings revealed contrast extravasation in 10 patients (40%), pseudoaneurysms in 10 patients (40%), carotid occlusion in 3 patients (12%), and vessel wall irregularities in 2 patients (8%). Balloon test occlusion (BTO) was done in 22 patients, with 19 showing good collaterals and treated by vessel sacrifice. A flow diverter stent was used in one patient. One patient was treated using a covered stent. Diagnostic angiography was performed in the remaining four patients, and no endovascular treatment was undertaken. One patient died, while the remaining 20 patients achieved favorable outcomes. Conclusion The most effective treatment for severe, uncontrollable bleeding is carotid occlusion. Nonetheless, for some patients, vascular preservation methods should be carefully evaluated. When performing endoscopic endonasal surgery, medical facilities should have easy access to endovascular therapy options.

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