title: Carotid artery injury during endoscopic endonasal skull base surgery: incidence and outcomes.
abstract: BACKGROUND
  Injury to the internal carotid artery (ICA) during endoscopic endonasal skull base surgery is a feared complication that is not well studied or reported.
  
  
  OBJECTIVE
  To evaluate the incidence, to identify potential risk factors, and to present management strategies and outcomes of ICA injury during endonasal skull base surgery at our institution.
  
  
  METHODS
  We performed a retrospective review of all endoscopic endonasal operations performed at our institution between 1998 and 2011 to examine potential factors predisposing to ICA injury. We also documented the perioperative management and outcomes after injury.
  
  
  RESULTS
  There were 7 ICA injuries encountered in 2015 endonasal skull base surgeries, giving an incidence of 0.3%. Most injuries (5 of 7) involved the left ICA, and the most common diagnosis was chondroid neoplasm (chordoma, chondrosarcoma; 3 of 7 [2% of 142 cases]). Two injuries occurred during 660 pituitary adenoma resections (0.3%). The paraclival ICA segment was the most commonly injured site (5 of 7), and transclival and transpterygoid approaches had a higher incidence of injury, although neither factor reached statistical significance. Four of 7 injured ICAs were sacrificed either intraoperatively or postoperatively. No patient suffered a stroke or neurological deficit. There were no intraoperative mortalities; 1 patient died postoperatively of cardiac ischemia. One of the 3 preserved ICAs developed a pseudoaneurysm over a mean follow-up period of 5 months that was treated endovascularly.
  
  
  CONCLUSIONS
  ICA injury during endonasal skull base surgery is an infrequent and manageable complication. Preservation of the vessel remains difficult. Chondroid tumors represent a higher risk and should be resected by surgical teams with significant experience.
authors.affiliation: *Department of Neurological Surgery and §Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania ‡Department of Medicine, University of Adelaide, Adelaide, Australia.
authors.forename: Paul A
authors.initials: PA
authors.lastname: Gardner
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Tormenti
authors.forename: Harshita
authors.initials: H
authors.lastname: Pant
authors.forename: Juan C
authors.initials: JC
authors.lastname: Fernandez-Miranda
authors.forename: Carl H
authors.initials: CH
authors.lastname: Snyderman
authors.forename: Michael B
authors.initials: MB
authors.lastname: Horowitz
mesh_terms: D020212:Carotid Artery Injuries / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000209:etiology; D017023:Coronary Angiography; D019723:Endoscopes / Q000009:adverse effects*; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000209:etiology; D012189:Retrospective Studies; D019291:Skull Base / Q000601:surgery*; D019292:Skull Base Neoplasms / Q000453:epidemiology / Q000601:surgery*; D013101:Sphenoid Sinus / Q000601:surgery*