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Peter Nakaji - One of the best experts on this subject based on the ideXlab platform.
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urgent cerebral revascularization bypass surgery for iatrogenic skull base internal Carotid Artery Injury
Neurosurgery, 2014Co-Authors: Leonardo Rangelcastilla, Cameron G Mcdougall, Robert F. Spetzler, Peter NakajiAbstract:Abstract When feasible, the management of iatrogenic internal Carotid Artery (ICA) Injury during skull base surgery is mainly endovascular. To propose a cerebral revascularization procedure as a rescue option when endovascular treatment is not feasible. We retrospectively reviewed all extracranial-intracranial (EC-IC) bypass procedures performed between July 2007 and January 2014. From 235 procedures, we identified 8 consecutive patients with iatrogenic ICA Injury managed with an EC-IC bypass. Injury to the ICA occurred during an endoscopic transsphenoidal surgery (n=3), endoscopic transfacial-transmaxillary surgery (n=1), myringotomy (n=1), cavernous sinus meningioma resection (n=1), posterior communicating Artery aneurysm clipping (n=1), and cavernous ICA aneurysm coiling (n=1). Endovascular management was considered first-line treatment but was not successful. All patients received a high-flow EC-IC bypass. At a mean clinical/radiographic follow-up of 19 months (range, 3-36 months), all patients had a modified Rankin Scale score of 0 or 1. All bypasses remained patent. Iatrogenic Injury of the skull base ICA is uncommon but can lead to lethal consequences. Many injuries can be treated with endovascular techniques. However, certain cases may still require a cerebral revascularization procedure.
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urgent cerebral revascularization bypass surgery for iatrogenic skull base internal Carotid Artery Injury
Neurosurgery, 2014Co-Authors: Leonardo Rangelcastilla, Cameron G Mcdougall, Robert F. Spetzler, Peter NakajiAbstract:BACKGROUND When feasible, the management of iatrogenic internal Carotid Artery (ICA) Injury during skull base surgery is mainly endovascular. OBJECTIVE To propose a cerebral revascularization procedure as a rescue option when endovascular treatment is not feasible. METHODS We retrospectively reviewed all extracranial-intracranial (EC-IC) bypass procedures performed between July 2007 and January 2014. RESULTS From 235 procedures, we identified 8 consecutive patients with iatrogenic ICA Injury managed with an EC-IC bypass. Injury to the ICA occurred during an endoscopic transsphenoidal surgery (n=3), endoscopic transfacial-transmaxillary surgery (n=1), myringotomy (n=1), cavernous sinus meningioma resection (n=1), posterior communicating Artery aneurysm clipping (n=1), and cavernous ICA aneurysm coiling (n=1). Endovascular management was considered first-line treatment but was not successful. All patients received a high-flow EC-IC bypass. At a mean clinical/radiographic follow-up of 19 months (range, 3-36 months), all patients had a modified Rankin Scale score of 0 or 1. All bypasses remained patent. CONCLUSION Iatrogenic Injury of the skull base ICA is uncommon but can lead to lethal consequences. Many injuries can be treated with endovascular techniques. However, certain cases may still require a cerebral revascularization procedure.
Leonardo Rangelcastilla - One of the best experts on this subject based on the ideXlab platform.
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urgent cerebral revascularization bypass surgery for iatrogenic skull base internal Carotid Artery Injury
Neurosurgery, 2014Co-Authors: Leonardo Rangelcastilla, Cameron G Mcdougall, Robert F. Spetzler, Peter NakajiAbstract:Abstract When feasible, the management of iatrogenic internal Carotid Artery (ICA) Injury during skull base surgery is mainly endovascular. To propose a cerebral revascularization procedure as a rescue option when endovascular treatment is not feasible. We retrospectively reviewed all extracranial-intracranial (EC-IC) bypass procedures performed between July 2007 and January 2014. From 235 procedures, we identified 8 consecutive patients with iatrogenic ICA Injury managed with an EC-IC bypass. Injury to the ICA occurred during an endoscopic transsphenoidal surgery (n=3), endoscopic transfacial-transmaxillary surgery (n=1), myringotomy (n=1), cavernous sinus meningioma resection (n=1), posterior communicating Artery aneurysm clipping (n=1), and cavernous ICA aneurysm coiling (n=1). Endovascular management was considered first-line treatment but was not successful. All patients received a high-flow EC-IC bypass. At a mean clinical/radiographic follow-up of 19 months (range, 3-36 months), all patients had a modified Rankin Scale score of 0 or 1. All bypasses remained patent. Iatrogenic Injury of the skull base ICA is uncommon but can lead to lethal consequences. Many injuries can be treated with endovascular techniques. However, certain cases may still require a cerebral revascularization procedure.
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urgent cerebral revascularization bypass surgery for iatrogenic skull base internal Carotid Artery Injury
Neurosurgery, 2014Co-Authors: Leonardo Rangelcastilla, Cameron G Mcdougall, Robert F. Spetzler, Peter NakajiAbstract:BACKGROUND When feasible, the management of iatrogenic internal Carotid Artery (ICA) Injury during skull base surgery is mainly endovascular. OBJECTIVE To propose a cerebral revascularization procedure as a rescue option when endovascular treatment is not feasible. METHODS We retrospectively reviewed all extracranial-intracranial (EC-IC) bypass procedures performed between July 2007 and January 2014. RESULTS From 235 procedures, we identified 8 consecutive patients with iatrogenic ICA Injury managed with an EC-IC bypass. Injury to the ICA occurred during an endoscopic transsphenoidal surgery (n=3), endoscopic transfacial-transmaxillary surgery (n=1), myringotomy (n=1), cavernous sinus meningioma resection (n=1), posterior communicating Artery aneurysm clipping (n=1), and cavernous ICA aneurysm coiling (n=1). Endovascular management was considered first-line treatment but was not successful. All patients received a high-flow EC-IC bypass. At a mean clinical/radiographic follow-up of 19 months (range, 3-36 months), all patients had a modified Rankin Scale score of 0 or 1. All bypasses remained patent. CONCLUSION Iatrogenic Injury of the skull base ICA is uncommon but can lead to lethal consequences. Many injuries can be treated with endovascular techniques. However, certain cases may still require a cerebral revascularization procedure.
Bozena Wrobel - One of the best experts on this subject based on the ideXlab platform.
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Costs and training results of an objectively validated cadaveric perfusion‐based internal Carotid Artery Injury simulation during endoscopic skull base surgery
International Forum of Allergy & Rhinology, 2019Co-Authors: Daniel A. Donoho, Cali E. Johnson, Kevin Hur, Ian A. Buchanan, Vance L. Fredrickson, Michael Minneti, Gabriel Zada, Bozena WrobelAbstract:Background Internal Carotid Artery Injury (ICAI) is a rare, life-threatening complication of endoscopic endonasal approaches (EEAs). High-fidelity simulation methods exist, but optimization of the training cohort, training paradigm, and costs of simulation training remain unknown. Methods Using our previously validated, high-fidelity, perfused-cadaver model, participants attempted to manage a simulated ICAI. After a brief instructional video and coaching, the simulation was repeated. Training success was defined as successful ICAI control on the second attempt after failure on the initial attempt. Marginal costs were measured. Results Seventy-two surgeons participated in the standardized simulation, which lasted ≤15 minutes. The marginal cost of simulation was $275.00 per surgeon. A total of 44.4% (n = 32) succeeded on the first attempt before training (previously proficient); 44.4% (n = 32) failed the first attempt, but succeeded after training (training successes); and 11.1% (n = 8) failed both attempts. The cost per training success was $618.75. Forty-two surgeons had never treated an ICAI, with 24 becoming training successes (57.1% overall, 82.8% when excluding previously proficient surgeons). Twenty-nine had experienced a real or simulated ICAI, with 8 (27.6% overall, 72.7% excluding previously proficient surgeons) becoming training successes. The cost per training success was lowest in the ICAI-naive group ($481.25) and highest among surgeons with simulated and real ICAI experience ($1650). Conclusions Surgeons can be trained to manage ICAI in a single, brief, low-cost session. Although all groups improved, training an ICAI-naive or resident cohort may maximize training results. A perfused-cadaver model is a reproducible, realistic, and low-cost method for training surgeons to manage life-threatening ICAI during an EEA.
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costs and training results of an objectively validated cadaveric perfusion based internal Carotid Artery Injury simulation during endoscopic skull base surgery
International Forum of Allergy & Rhinology, 2019Co-Authors: Daniel A. Donoho, Cali E. Johnson, Kevin Hur, Ian A. Buchanan, Vance L. Fredrickson, Michael Minneti, Gabriel Zada, Bozena WrobelAbstract:Background Internal Carotid Artery Injury (ICAI) is a rare, life-threatening complication of endoscopic endonasal approaches (EEAs). High-fidelity simulation methods exist, but optimization of the training cohort, training paradigm, and costs of simulation training remain unknown. Methods Using our previously validated, high-fidelity, perfused-cadaver model, participants attempted to manage a simulated ICAI. After a brief instructional video and coaching, the simulation was repeated. Training success was defined as successful ICAI control on the second attempt after failure on the initial attempt. Marginal costs were measured. Results Seventy-two surgeons participated in the standardized simulation, which lasted ≤15 minutes. The marginal cost of simulation was $275.00 per surgeon. A total of 44.4% (n = 32) succeeded on the first attempt before training (previously proficient); 44.4% (n = 32) failed the first attempt, but succeeded after training (training successes); and 11.1% (n = 8) failed both attempts. The cost per training success was $618.75. Forty-two surgeons had never treated an ICAI, with 24 becoming training successes (57.1% overall, 82.8% when excluding previously proficient surgeons). Twenty-nine had experienced a real or simulated ICAI, with 8 (27.6% overall, 72.7% excluding previously proficient surgeons) becoming training successes. The cost per training success was lowest in the ICAI-naive group ($481.25) and highest among surgeons with simulated and real ICAI experience ($1650). Conclusions Surgeons can be trained to manage ICAI in a single, brief, low-cost session. Although all groups improved, training an ICAI-naive or resident cohort may maximize training results. A perfused-cadaver model is a reproducible, realistic, and low-cost method for training surgeons to manage life-threatening ICAI during an EEA.
Peter John Wormald - One of the best experts on this subject based on the ideXlab platform.
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endoscopic direct vessel closure in Carotid Artery Injury
International Forum of Allergy & Rhinology, 2015Co-Authors: Vikram Padhye, Rowan Valentine, Jae Murphy, Ahmed Bassiouni, Peter John WormaldAbstract:BACKGROUND Internal Carotid Artery (ICA) Injury represents one of the most challenging management scenarios for the endoscopic skull base surgeon. Techniques developed through use of an animal model of Carotid Injury have shown direct vessel closure techniques to be effective in gaining hemostasis and preventing subsequent complications. The aim of this study was to investigate the effectiveness of the novel AnastoClip vessel closure system in ICA Injury. METHODS Nine sheep underwent ICA dissection/isolation followed by the Artery placement within a modified "sinus model otorhino neuro trainer" (SIMONT) model. Standardized linear injuries were made and treated endoscopically with the AnastoClip device. Specific outcome measures included attainment of primary hemostasis, procedure time, blood loss, pseudoaneurysm formation and Carotid patency on follow-up magnetic resonance imaging (MRI). RESULTS Primary hemostasis was achieved in all cases. No instances of secondary bleeding. Procedure times averaged 5 minutes and 25 seconds. Average blood loss was 146 mL. All 9 sheep reached the 3-month end point. Eight showed normal Carotid flow on MRI, with 1 case of pseudoaneurysm. CONCLUSION Direct vessel closure is an effective endoscopic technique in ICA Injury. It allows for visual confirmation of hemostasis and Carotid flow and permits the surgeon to continue with surgery despite the complication. The novel design of the AnastoClip can maintain normal vessel patency as well as accommodate pulsatile flow.
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Management of Carotid Artery Injury in Endonasal Surgery
International Archives of Otorhinolaryngology, 2014Co-Authors: Vikram Padhye, Rowan Valentine, Peter John WormaldAbstract:Introduction: Carotid Artery Injury (CAI) is the most feared and potentially catastrophic intraoperative complication an endoscopic skull base surgeon may face. With the advancement of transnasal endoscopic surgery and the willingness to tackle more diverse pathology, evidence-based management of this life-threatening complication is paramount for patient safety and surgeon confidence. Objectives: We review the current English literature surrounding the management of CAI during endoscopic transnasal surgery. Data Synthesis: The searched databases included PubMed, MEDLINE, Cochrane database, LILACS, and BIREME. Keywords included "sinus surgery," "Carotid Injury," "endoscopic skull base surgery," "hemostasis," "transsphenoidal" and "pseudoaneurysm." Conclusions: Review of the literature found the incidence of CAI in endonasal skull base surgery to be as high as 9% in some surgeries. Furthermore, current treatment recommendations can result in damage to critical neurovascular structures. Management decisions must be made in the preoperative, operative, and postoperative setting to ensure adequate treatment of CAI and the prevention of its complications such as pseudoaneurysm. Emphasis should be placed on surgical competency, teamwork, and technical expertise through education and training.Vikram Padhye, Rowan Valentine, Peter-John Wormal
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management of Carotid Artery Injury in endonasal surgery
International Archives of Otorhinolaryngology, 2014Co-Authors: Vikram Padhye, Rowan Valentine, Peter John WormaldAbstract:Introduction Carotid Artery Injury (CAI) is the most feared and potentially catastrophic intraoperative complication an endoscopic skull base surgeon may face. With the advancement of transnasal endoscopic surgery and the willingness to tackle more diverse pathology, evidence-based management of this life-threatening complication is paramount for patient safety and surgeon confidence. Objectives We review the current English literature surrounding the management of CAI during endoscopic transnasal surgery. Data Synthesis The searched databases included PubMed, MEDLINE, Cochrane database, LILACS, and BIREME. Keywords included “sinus surgery,” “Carotid Injury,” “endoscopic skull base surgery,” “hemostasis,” “transsphenoidal” and “pseudoaneurysm.” Conclusions Review of the literature found the incidence of CAI in endonasal skull base surgery to be as high as 9% in some surgeries. Furthermore, current treatment recommendations can result in damage to critical neurovascular structures. Management decisions must be made in the preoperative, operative, and postoperative setting to ensure adequate treatment of CAI and the prevention of its complications such as pseudoaneurysm. Emphasis should be placed on surgical competency, teamwork, and technical expertise through education and training.
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early and late complications of endoscopic hemostatic techniques following different Carotid Artery Injury characteristics
International Forum of Allergy & Rhinology, 2014Co-Authors: Vikram Padhye, Rowan Valentine, Ahmed Bassiouni, Sathish Paramasivan, Camille Jardeleza, Sarah Vreugde, Peter John WormaldAbstract:Background The most dreaded hemorrhagic complication in endoscopic endonasal surgery is Injury to the internal Carotid Artery (ICA). Although a number of treatment protocols are currently used, none have been formally investigated. This study aims to compare the efficacy of the muscle patch, bipolar diathermy, and aneurysm clip on hemostasis, pseudoaneurysm formation, and long-term vessel patency for different Injury types in a sheep model of Carotid bleeding. Methods Twenty-seven sheep underwent ICA dissection/isolation followed by the Artery placement within a modified “sinus model otorhino neuro trainer” (SIMONT) model. Standardized linear, punch, and stellate injuries were made. Randomization of sheep to receive 1 of 3 hemostatic techniques was performed (muscle, bipolar, clip). Specific outcome measures included attainment of primary hemostasis, time to hemostasis, blood loss, pseudoaneurysm formation, and Carotid patency on follow-up magnetic resonance imaging (MRI). Results Bipolar achieved primary hemostasis in 7 of 9 cases and 2 cases of secondary hemorrhage. It had no associated pseudoaneurysm formation. Carotid patency was variable on follow-up MRI. Muscle patch achieved 100% primary hemostasis with 2 cases of secondary hemorrhage. There were 2 cases of pseudoaneurysm and 100% patency rate on follow-up MRI. Aneurysm clip achieved 100% primary hemostasis with 1 case of secondary hemorrhage. No pseudoaneurysm formation and a 50% rate of Carotid insufficiency on MRI. Conclusion This study shows that the crushed muscle patch and aneurysm clip can be viable options in the management of ICA Injury with short-term and long-term benefits. Complications associated with these techniques were comparable if not reduced when compared to the published literature.
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Carotid Artery Injury after endonasal surgery
Otolaryngologic Clinics of North America, 2011Co-Authors: Rowan Valentine, Peter John WormaldAbstract:Carotid Artery Injury during endonasal surgery is the most feared and catastrophic complication. Internal Carotid Artery Injury is more frequent during skull base surgery, and risk factors include acromegaly, previous revision surgery, and prior radiotherapy and bromocriptine therapy. Nasal packing is frequently used to gain hemostasis, often resulting in vascular occlusion. Recent research recommends the crushed muscle patch treatment as an effect hemostat that maintains vascular patency. Endovascular techniques are recommended for vascular control and complication management. Coil or balloon embolization is preferred in patients with adequate collateral cerebral blood flow, and stent-graft placement or bypass surgery is indicated in those who do not.
Robert F. Spetzler - One of the best experts on this subject based on the ideXlab platform.
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urgent cerebral revascularization bypass surgery for iatrogenic skull base internal Carotid Artery Injury
Neurosurgery, 2014Co-Authors: Leonardo Rangelcastilla, Cameron G Mcdougall, Robert F. Spetzler, Peter NakajiAbstract:Abstract When feasible, the management of iatrogenic internal Carotid Artery (ICA) Injury during skull base surgery is mainly endovascular. To propose a cerebral revascularization procedure as a rescue option when endovascular treatment is not feasible. We retrospectively reviewed all extracranial-intracranial (EC-IC) bypass procedures performed between July 2007 and January 2014. From 235 procedures, we identified 8 consecutive patients with iatrogenic ICA Injury managed with an EC-IC bypass. Injury to the ICA occurred during an endoscopic transsphenoidal surgery (n=3), endoscopic transfacial-transmaxillary surgery (n=1), myringotomy (n=1), cavernous sinus meningioma resection (n=1), posterior communicating Artery aneurysm clipping (n=1), and cavernous ICA aneurysm coiling (n=1). Endovascular management was considered first-line treatment but was not successful. All patients received a high-flow EC-IC bypass. At a mean clinical/radiographic follow-up of 19 months (range, 3-36 months), all patients had a modified Rankin Scale score of 0 or 1. All bypasses remained patent. Iatrogenic Injury of the skull base ICA is uncommon but can lead to lethal consequences. Many injuries can be treated with endovascular techniques. However, certain cases may still require a cerebral revascularization procedure.
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urgent cerebral revascularization bypass surgery for iatrogenic skull base internal Carotid Artery Injury
Neurosurgery, 2014Co-Authors: Leonardo Rangelcastilla, Cameron G Mcdougall, Robert F. Spetzler, Peter NakajiAbstract:BACKGROUND When feasible, the management of iatrogenic internal Carotid Artery (ICA) Injury during skull base surgery is mainly endovascular. OBJECTIVE To propose a cerebral revascularization procedure as a rescue option when endovascular treatment is not feasible. METHODS We retrospectively reviewed all extracranial-intracranial (EC-IC) bypass procedures performed between July 2007 and January 2014. RESULTS From 235 procedures, we identified 8 consecutive patients with iatrogenic ICA Injury managed with an EC-IC bypass. Injury to the ICA occurred during an endoscopic transsphenoidal surgery (n=3), endoscopic transfacial-transmaxillary surgery (n=1), myringotomy (n=1), cavernous sinus meningioma resection (n=1), posterior communicating Artery aneurysm clipping (n=1), and cavernous ICA aneurysm coiling (n=1). Endovascular management was considered first-line treatment but was not successful. All patients received a high-flow EC-IC bypass. At a mean clinical/radiographic follow-up of 19 months (range, 3-36 months), all patients had a modified Rankin Scale score of 0 or 1. All bypasses remained patent. CONCLUSION Iatrogenic Injury of the skull base ICA is uncommon but can lead to lethal consequences. Many injuries can be treated with endovascular techniques. However, certain cases may still require a cerebral revascularization procedure.