Endonasal Arteriovenous Fistula Following Transsphenoidal Resection of Pituitary Adenoma Treated with N-Butyl-2-Cyanoacrylate

Abstract

Vascular lesions of the external carotid artery after transsphenoidal pituitary surgery are rare. Immediate diagnosis must be done and endovascular embolization is the treatment of choice.

We report the case of a 53-year-old woman with visual complaints who underwent transsphenoidal surgery of a pituitary adenoma with good clinical and radiological evolution. Five days after surgery nasal tampons were removed and suddenly the patient started to bleed: nasal packing and air way protection were required. Digital subtraction angiography revealed an endonasal arteriovenous fistula with a feeder from the sphenopalatine artery and drainage to sphenopalatine veins. Embolization with N-butyl-2-cyanoacrylate was performed with total obliteration of the arteriovenous fistula. We suggest that endovascular treatment of external carotid artery lesions after transsphenoidal surgery is the best alternative in cases of active bleeding.

Keywords

pituitary - arteriovenous fistula - N-butyl-2-cyanoacrylate - transsphenoidal Surgery

• References

• 1 Black PM, Zervas NT, Candia GL. Incidence and management of complications of transsphenoidal operation for pituitary adenomas. Neurosurgery 1987; 20 (06) 920-924
• 2 Berker M, Aghayev K, Saatci I, Palaoğlu S, Önerci M. Overview of vascular complications of pituitary surgery with special emphasis on unexpected abnormality. Pituitary 2010; 13 (02) 160-167
• 3 Raymond J, Hardy J, Czepko R, Roy D. Arterial injuries in transsphenoidal surgery for pituitary adenoma; the role of angiography and endovascular treatment. Am J Neuroradiol 1997; 18 (04) 655-665
• 4 Ciric I, Ragin A, Baumgartner C, Pierce D. Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery 1997; 40 (02) 225-236, discussion 236–237
• 5 Agam MS, Zada G. Complications associated with transsphenoidal pituitary surgery: review of the Literature. Neurosurgery 2018; 65 CN suppl 1 69-73
• 6 Çinar C, Bozkaya H, Parildar M, Oran I. Endovascular management of vascular injury during transsphenoidal surgery. Interv Neuroradiol 2013; 19 (01) 102-109
• 7 Cockroft KM, Carew JF, Trost D, Fraser RA. Delayed epistaxis resulting from external carotid artery injury requiring embolization: a rare complication of transsphenoidal surgery: case report. Neurosurgery 2000; 47 (01) 236-239
• 8 Eneling J, Karlsson PM, Rossitti S. Sphenopalatine arteriovenous fistula complicating transsphenoidal pituitary surgery: a rare cause of delayed epistaxis treatable by endovascular embolization. Surg Neurol Int 2016; 7 Suppl 41 S1053-S1056
• 9 Nishioka H, Ohno S, Ikeda Y, Ohashi T, Haraoka J. Delayed massive epistaxis following endonasal transsphenoidal surgery. Acta Neurochir (Wien) 2007; 149 (05) 523-526, discussion 526–527
• 10 Halbach VV, Higashida RT, Hieshima GB, Hardin CW. Arteriovenous fistula of the internal maxillary artery: treatment with transarterial embolization. Radiology 1988; 168 (02) 443-445
• 11 Campbell RG. Sphenopalatine artery pseudoaneurysm after endoscopic sinus surgery: a case report and literature review. Ear Nose Throat J 2012; 91 (02) E4-E11
• 12 Dubel GJ, Ahn SH, Soares GM. Transcatheter embolization in the management of epistaxis. Semin Intervent Radiol 2013; 30 (03) 249-262
• 13 Sylvester PT, Moran CJ, Derdeyn CP. et al. Endovascular management of internal carotid artery injuries secondary to endonasal surgery: case series and review of the literature. J Neurosurg 2016; 125 (05) 1256-1276