鼻内镜手术(EES)期间颈内动脉(ICA)损伤是灾难性的并发症。随着医疗仪器和材料的进步,有必要修改以前的治疗方式和原则.
对2012年1月至2017年12月在作者机构接受EES的3658例患者进行了回顾性分析。最终,纳入20例EES后ICA损伤患者(0.55%)进行分析。数据收集包括人口统计数据,术前诊断,损伤设置,修复方法,以及即时和随访血管造影和临床结果。
在20名患者中,11人立即接受了血管内治疗,9人仅接受了包装治疗。在接受血管内治疗的11名患者中,6例通过覆膜支架治疗,5例通过亲代动脉闭塞(PAO)治疗。在2016年1月Willis覆盖的支架移植物可用后,受伤的ICA的保存率从20.0%(5个中的1个)增加到83.3%(6个中的5个)。在研究的20名患者中,19例恢复良好,1例患者-患有假性动脉瘤,接受PAO用可拆卸的球囊治疗-在病房中取出鼻腔止血剂后出现鼻出血,那天晚些时候她就去世了.作者推测,可拆卸的球囊已经转移到ICA的远端,尽管患者无法接受再次血管造影,因为她很快遭受休克,无法转移到导管室。引入混合手术室(OR)后,1例首次血管造影显示无ICA损伤的患者被发现患有假性动脉瘤.当他在鼻腔中取出止血剂后5天后在混合OR中被带到重复血管造影时,他接受了血管内治疗。在接受PAO治疗的4名幸存患者中,不需要颈外动脉-ICA搭桥术.作者提出了一种针对EES期间遭受的ICA损伤的改良血管内治疗方案,该方案利用了覆膜支架移植物和混合OR的优势。
本研究中用于EES期间ICA损伤的血管内治疗方案有助于这种罕见并发症的治疗。Willis支架置入提高了EES期间损伤ICA的保存率。在混合OR中或通过移动C形臂处理这种并发症以获得清晰的术中血管造影将是非常有利的。
Internal carotid artery (ICA) injuries during endoscopic endonasal surgery (EES) are catastrophic complications. Alongside the advancements in medical instrumentation and material, there is a need to modify previous treatment modalities and principles.
A retrospective review of 3658 patients who underwent EES performed at the authors\' institution between January 2012 and December 2017 was conducted. Ultimately, 20 patients (0.55%) with ICA injury following EES were enrolled for analysis. Data collection included demographic data, preoperative diagnosis, injury setting, repair method, and immediate and follow-up angiographic and clinical outcomes.
Among the 20 patients, 11 received immediate endovascular therapy and 9 were treated only with packing. Of the 11 patients who received endovascular treatment, 6 were treated by covered stent and 5 by parent artery occlusion (PAO). The preservation rate of injured ICA increased from 20.0% (1 of 5) to 83.3% (5 of 6) after the Willis covered stent graft became available in January 2016. Of the 20 patients in the study, 19 recovered well and 1 patient-who had a pseudoaneurysm and was treated by PAO with a detachable balloon-suffered epistaxis after the hemostat in her nasal cavity was removed in ward, and she died later that day. The authors speculated that the detachable balloon had shifted to the distal part of ICA, although the patient could not undergo a repeat angiogram because she quickly suffered shock and could not be transferred to the catheter room. After the introduction of a hybrid operating room (OR), one patient whose first angiogram showed no ICA injury was found to have a pseudoaneurysm. He received endovascular treatment when he was brought for a repeat angiogram 5 days later in the hybrid OR after removing the hemostat in his nasal cavity. Of the 4 surviving patients treated with PAO, no external carotid artery-ICA bypass was required. The authors propose a modified endovascular treatment protocol for ICA injuries suffered during EES that exploits the advantage of the covered stent graft and the hybrid OR.
The endovascular treatment protocol used in this study for ICA injuries during EES was helpful in the management of this rare complication. Willis stent placement improved the preservation rate of injured ICA during EES. It would be highly advantageous to manage this complication in a hybrid OR or by a mobile C-arm to get a clear intraoperative angiogram.