Combined Pipeline Embolization Device with Endoscopic Endonasal Fascia Lata/Muscle Graft Repair as a Salvage Technique for Treatment of Iatrogenic Carotid Artery Injury and Pseudoaneurysm

Introduction: The incidence of internal carotid artery (ICA) injury associated with endoscopic endonasal approaches to the pituitary is 0.2–2%. While parent vessel sacrifice has historically been the choice of treatment, vessel-preserving endovascular techniques have been reported. We describe the use of a combined pipeline embolization device (PED) with endoscopic endonasal repair using a fascia lata/muscle graft to treat an iatrogenic ICA pseudoaneurysm.

Case Presentation: A 77-year-old woman with a nonsecreting pituitary macroadenoma treated at an another institution was transferred to our hospital due to intraoperative ICA injury during ultrasonic bone removal. She was emergently packed with pledgets and three Foley catheters. Once resuscitated and hemodynamically stabilized, she was transferred from the OR to our institution. Upon arrival, she underwent an angiogram showing a 1.4 × 2 mm right medial cavernous segment pseudoaneurysm. She subsequently underwent a balloon test occlusion (BTO) with left arm weakness after 9 minutes of occlusion. Due to the failed BTO, she was started on aspirin 325 mg and prasugrel 5 mg daily in anticipation for flow diversion. She underwent endovascular flow diversion on day of admission (DOA) 5. Three telescoping PED were deployed using a standard triaxial catheter. Repeat angiography on DOA12 showed good stent-vessel wall apposition but continued residual filling of the pseudoaneurysm (2.9 mm). The patient developed fevers and increased white counts despite broad spectrum antibiotics and packing/Foley removal was planned given concern this was the source of her fevers. Due to residual filling, repair of her ICA was necessary. A fascia lata/muscle graft was harvested at the beginning of the case. Superficial packing was removed and the sphenoidotomy was expanded for increased access. Brisk arterial bleeding was noted from the region of the anterior genu of the carotid while attempting to dissect the final pledgets. Hemostasis was obtained by gentle pressure on a pledget over the rupture site. This was removed and the graft was placed over the pseudoaneurysm/wall of the ICA with excellent hemostasis. The site was packed with Gelfoam wrapped in Surgicel. Two nasopores were positioned into the sphenoid sinus and a gloved merocel was placed in each nostril. Angiography on DOA19 showed complete obliteration. Aspirin dose was decreased to 81 mg. She was weaned off the ventilator and transferred to the floor being discharged to rehab soon after. Follow-up angiography at 6 months and 2.5 years confirmed complete obliteration of the pseudoaneurysm with no in-stent stenosis or thrombosis.

Discussion: Pseudoaneurysms lack true walls and have increased risk of rupture during manipulation. Flow diversion offers endoluminal treatment without accessing the aneurysm. The major limitation is the delay in obtaining complete occlusion. Close follow-up for continued filling of the pseudoaneurysm is necessary and additional treatment may be needed. As the false wall of the pseudoaneurysm remodels, fascia lata/muscle grafting can help reinforce the false wall, rather than opting for vessel sacrifice. Further investigation into the utility of directed endoscopic endonasal repair of traumatic pseudoaneurysms after PED is necessary, especially given the need of post-PED anticoagulation and the rate of permanent neurological deficit after ICA sacrifice.

No conflict of interest has been declared by the author(s).