- Department of Neurosurgery, University at Buffalo, State University of New York, USA
- Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA
- Department of Head and Neck and Plastic and Reconstructive Surgery, Roswell Park Cancer Institute, Buffalo, NY, USA
- Department of Radiology, University at Buffalo, State University of New York, USA
- Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, USA
Adnan H. Siddiqui
Department of Neurosurgery, University at Buffalo, State University of New York, USA
Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA
Department of Radiology, University at Buffalo, State University of New York, USA
Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, USA
DOI:10.4103/2152-7806.133638Copyright: © 2014 Shakir HJ. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Shakir HJ, Garson AD, Sorkin GC, Mokin M, Eller JL, Dumont TM, Popat SR, Leonardo J, Siddiqui AH. Combined use of covered stent and flow diversion to seal iatrogenic carotid injury with vessel preservation during transsphenoidal endoscopic resection of clival tumor. Surg Neurol Int 31-May-2014;5:81
How to cite this URL: Shakir HJ, Garson AD, Sorkin GC, Mokin M, Eller JL, Dumont TM, Popat SR, Leonardo J, Siddiqui AH. Combined use of covered stent and flow diversion to seal iatrogenic carotid injury with vessel preservation during transsphenoidal endoscopic resection of clival tumor. Surg Neurol Int 31-May-2014;5:81. Available from: http://sni.wpengine.com/surgicalint_articles/combined-use-of-covered-stent-and-flow-diversion-to-seal-iatrogenic-carotid-injury-with-vessel-preservation-during-transsphenoidal-endoscopic-resection-of-clival-tumor/
Background:Transsphenoidal tumor resection can lead to internal carotid artery (ICA) injury. Vascular disruption is often treated with emergent vessel deconstruction, incurring complications in a subset of patients with poor collateral circulation and resulting in minor and major ischemic strokes.
Methods:We attempted a novel approach combining a covered stent graft (Jostent) and two flow diverter stents [Pipeline embolization devices (PEDs)] to treat active extravasation from a disrupted right ICA that was the result of a transsphenoidal surgery complication. This disruption occurred during clival tumor surgery and required immediate sphenoidal sinus packing. Emergent angiography revealed continued petrous carotid artery extravasation, warranting emergent vessel repair or deconstruction for treatment. To preserve the vessel, we utilized a covered Jostent. Due to tortuosity and lack of optimal wall apposition, there was reduced, yet persistent extravasation from an endoleak after Jostent deployment that failed to resolve despite multiple angioplasties. Therefore, we used PEDs to divert the flow.
Results:Flow diversion relieved the extravasation. The patient remained neurologically intact post-procedure.
Conclusions:This case demonstrates successful combined use of a covered stent and flow diverters to treat acute vascular injury resulting from transsphenoidal surgery. However, concerns remain, including the requirement of dual antiplatelet agents increasing postoperative bleeding risks, stent-related thromboembolic events, and delayed in-stent restenosis rates.
Keywords: Carotid artery stenting, clival tumor, Jostent, Pipeline embolization device, transsphenoidal resection
Carotid injury is a complication of transsphenoidal approaches to the sella and clivus. The narrow operative field required for this approach limits effective intraoperative management of vascular injury.[
A 61-year-old woman initially presented with a clival tumor. During transsphenoidal resection of the tumor, ICA injury was identified, prompting emergent diagnostic angiography after sinus packing and administration of vasoconstrictors failed to control the bleeding. Angiography revealed active extravasation from the petrous carotid artery, despite sinus packing [Figures
Digital subtraction angiogram. Anteroposterior (left) and lateral (right) projections of right common carotid artery injection. An area of extravasation is appreciated in the anterior and medial cavernous segment (arrow). The extravasation is not visualized on the AP view due to artifact caused by nasal packing
Digital subtraction angiogram. Magnified views of lateral projections of right common carotid artery injection. An area of extravasation is appreciated in the anterior cavernous segment (arrows). The four images are from early (left) to late (right) arterial phase of the injection, displaying the time course of the extravasation
A 6-French long sheath Neuron Max catheter (Penumbra, Alameda, CA, USA) was transfemorally placed in the distal cervical ICA. After administering a loading dose of prasugrel (60 mg) and aspirin (650 mg), the disrupted carotid artery segment was crossed using an SL-10 microcatheter (Boston Scientific, Natick, MA, USA) and a 0.0014-inch Synchro-2 microwire (Boston Scientific). While the Synchro-2 microwire was exchanged for a 0.0014-inch balance middleweight microwire (Abbott Vascular, Abbott Park, IL, USA) and the SL-10 microcatheter removed, a 4 × 12 mm Jostent was brought into position and deployed [
At the 1-month follow-up evaluation, the patient remained neurologically intact and reported no interval neurologic sequelae. A computed tomographic angiogram obtained at that time revealed wide stent patency, with no flow restriction.
Stenting via the Jostent has been reported for anecdotal cases of intracranial aneurysm and traumatic carotid cavernous fistula.[
Dr. Dumont, Dr. Eller, Mr. Garson, Dr. Leonardo, Dr. Popat, Dr. Shakir, and Dr. Sorkin report no financial relationships. Dr. Mokin has received an educational grant from Toshiba. Dr. Siddiqui has received research grants from the National Institutes of Health (co-investigator: NINDS 1R01NS064592-01A1, Hemodynamic induction of pathologic remodeling leading to intracranial aneurysms and co-investigator NINDS 5 Ro1 EB002873-07, Micro-Radiographic Image for Neurovascular Interventions), and the University at Buffalo (Research Development Award); holds financial interests in Hotspur, Intratech Medical, StimSox, Valor Medical, Blockade Medical, and Lazarus Effect; serves as a consultant to Blockade Medical, Codman & Shurtleff, Inc., Concentric Medical, ev3/Covidien Vascular Therapies, GuidePoint Global Consulting, Lazarus Effect, MicroVention, Penumbra, Inc., Stryker Neurovascular and Pulsar Vascular; belongs to the speakers’ bureaus of Codman & Shurtleff, Inc. and Genentech; serves on National Steering Committees for the following company-sponsored trials: 3D Separator (Penumbra, Inc.), FRED (MicroVention) and SWIFT PRIME (Covidien); serves on advisory boards for Codman & Shurtleff and Covidien Neurovascular; and has received honoraria from Abbott Vascular and Codman & Shurtleff, Inc. for training other neurointerventionists in carotid stenting and for training physicians in endovascular stenting for aneurysms. Dr. Siddiqui receives no consulting salary arrangements. All consulting is per project and/or per hour.
The authors thank Paul H. Dressel BFA for preparation of the illustrations and Debra J Zimmer for editorial assistance.
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