A Skull Base Course Participants' Experience with Endoscopic Endonasal Carotid Artery Injuries

Introduction: With the shift from traditional external approaches to the endoscopic endonasal approach for pituitary and skull base pathologies, there is also a shift in the surgical complication profile and its management. Endoscopic skull base surgery may be associated with increased risk of carotid artery injury, a complication that is underreported. Current skull base courses may not adequately prepare surgeons to manage this complication and may actually foster vascular injuries through increased application of endoscopic techniques. The type of training may have an impact on the ability to effectively manage a carotid artery injury. This study sought to review past endoscopic skull base course participants’ experiences with carotid artery injuries and their perspective regarding vascular injury training.

Methods: Online survey of past participants of a well-established endoscopic skull base surgery course.

Results: Ninety-five past participants completed the survey in full. Respondents had attended an average of 2.7 skull base surgery courses. Forty-two percent of respondents perform, on average, less than 4 endoscopic endonasal skull base surgeries per month while the remaining 53% percent performed at least 4–8 surgeries per month. There were a similar proportion of respondents who reported carotid artery injuries before attending our skull base course (68%) as there were participants who reported carotid artery injuries after attending our course (67%). Twenty-five percent of respondents reported a carotid artery injury within the past 12 months. These injuries were parasellar in 68.1% of cases and most frequently reported in association with pituitary adenoma surgery (51%). Injuries occurred most commonly with a rongeur or another dissecting surgical instrument (21% of cases each); most commonly during tumor removal/dissection (53%) and tumor exposure (32%). A variety of techniques were used to manage the injury intraoperatively and postoperatively with sacrifice (occlusion) of the artery in 12 of 47 (25.5%) patients. Of 47 carotid injuries, 5 (11%) developed pseudoaneurysm; most were managed with endovascular coiling. Complications included 5 strokes and 7 deaths (32% of carotid injuries). Most respondents reported that the best way to learn management of carotid injuries was through review of live surgeries (43%) and cadaver simulation (34%).

Conclusions: Despite the underreported nature of carotid artery injuries, the risk of carotid artery injury during endoscopic endonasal skull base surgery is significant. These injuries were most common when manipulating the parasellar carotid artery for the removal of benign pathologies. The morbidity/mortality of a carotid injury is high. Attendance at our course did not increase or decrease the incidence of carotid injury. Surgical courses may not provide adequate training for management of carotid injuries and should be an area of focus for these educational courses to improve surgeon comfort as well as patient outcomes.