Transsphenoidal Surgery: Carotid Artery Injury

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This video describes the techniques for management of intraoperative carotid artery rupture during transsphenoidal surgery. This is a 49 year-old female who presented with progressive visual decline and was diagnosed with this relatively invasive pituitary macroadenoma. Reviewing the scans, you can see that one of the carotid arteries is situated relatively somewhat in the middle of the tumor. The tumor really has invaded all the way through the sphenoid sinus and I expected that the anatomy of the sinus was significantly affected and altered and could also affect my surgical orientation. Again, it's important to recognize the location of the carotid artery, somewhat in the middle of the tumor pre-operatively and avoid any injury to the vessel. This picture well describes the feelings during this case. This was a older case where the tumor was removed via the microscopic transseptal transsphenoidal approach. You can see that all the anatomical orientation markers are not available. There was some evidence of scar tissue in this area that I thought I can cut with a micro scissors. I didn't feel I was that deep into the tumor. I was still dissecting within the floor of the sphenoid sinus. But as you can see, the speculum can guide you toward the contralateral carotid artery. You can see a sharp cut that was inflicted on the artery. I immediately placed a piece of cotton to control the bleeding. Unfortunately, this wasn't effective. Next, I tried to pack the nose using Gelfoam and pieces of Cottonoid. Obviously, most of the bleeding right now is going toward the nasal pharynx. Try to create some tamponade with the cotton. This method didn't appear to be effective either. Unfortunately, the bleeding now is becoming more problematic. Using some Gelfoam to further control the bleeding but again, the blood is unfortunately floating out of the nares. I regained my composure and removed all the packing material and I identified the exact site of the bleeding and placed a Cottonoid right over the site of the bleeding, rather than just packing the whole operative field with cotton and Gelfoam. So I removed all of those one by one because the initial indiscriminate packing was not effective anyways. I left a piece of cotton right at the site of the bleeding over the carotid artery, where I had partially created a hole within the artery. This patient was suffering from significant visual decline, and I felt that since the bleeding is under control and I still have some operative space, I can remove as much of the soft tumor as possible. Obviously, if the bleeding was not readily controllable, I would have stopped immediately and taken patient for an angiogram and correction of the site of the tear. It's important to recognize that aborting the procedure due to injury to the carotid artery is a very reasonable and appropriate response and management strategy. Again, in this case, I felt that a piece of cotton can be placed exactly at the site of the sharp tear, which was very focal. Situation would have been different if it's a carotid avulsion injury or a larger tear within the artery when I will not be able to control the bleeding with a small piece of cotton. So I continued further tumor removal, was able to achieve reasonable tumor decompression, obviously not as much as desired, but using the suction device, holding a piece of cotton over the area of the tear, also using my assistant's help to keep the cotton in place, I was able to sneak around the Cottonoid and remove the soft tumor and see just a piece of the diaphragma sellae. After resection of the tumor, patient was taken to the angiography suite. Small pseudo aneurysm as expected was found. The patient underwent a stenting procedure at the area of the pseudo-aneurysm. A three-month evaluation, you can see there is no further growth of the pseudo-aneurysm. I was able to achieve reasonable subtotal removal of the mass with generous decompression of the optic apparatus. And fortunately, this patient did not suffer from any untoward sequelae and her vision significantly improved after surgery. Thank you.

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