title: Combined use of covered stent and flow diversion to seal iatrogenic carotid injury with vessel preservation during transsphenoidal endoscopic resection of clival tumor.
abstract: BACKGROUND
  Transsphenoidal tumor resection can lead to internal carotid artery (ICA) injury. Vascular disruption is often treated with emergent vessel deconstruction, incurring complications in a subset of patients with poor collateral circulation and resulting in minor and major ischemic strokes.
  
  
  METHODS
  We attempted a novel approach combining a covered stent graft (Jostent) and two flow diverter stents [Pipeline embolization devices (PEDs)] to treat active extravasation from a disrupted right ICA that was the result of a transsphenoidal surgery complication. This disruption occurred during clival tumor surgery and required immediate sphenoidal sinus packing. Emergent angiography revealed continued petrous carotid artery extravasation, warranting emergent vessel repair or deconstruction for treatment. To preserve the vessel, we utilized a covered Jostent. Due to tortuosity and lack of optimal wall apposition, there was reduced, yet persistent extravasation from an endoleak after Jostent deployment that failed to resolve despite multiple angioplasties. Therefore, we used PEDs to divert the flow.
  
  
  RESULTS
  Flow diversion relieved the extravasation. The patient remained neurologically intact post-procedure.
  
  
  CONCLUSIONS
  This case demonstrates successful combined use of a covered stent and flow diverters to treat acute vascular injury resulting from transsphenoidal surgery. However, concerns remain, including the requirement of dual antiplatelet agents increasing postoperative bleeding risks, stent-related thromboembolic events, and delayed in-stent restenosis rates.
authors.affiliation: Department of Neurosurgery, University at Buffalo, State University of New York, USA ; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
authors.forename: Hakeem J
authors.initials: HJ
authors.lastname: Shakir
authors.affiliation: Department of Neurosurgery, University at Buffalo, State University of New York, USA ; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
authors.forename: Alex D
authors.initials: AD
authors.lastname: Garson
authors.affiliation: Department of Neurosurgery, University at Buffalo, State University of New York, USA ; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
authors.forename: Grant C
authors.initials: GC
authors.lastname: Sorkin
authors.affiliation: Department of Neurosurgery, University at Buffalo, State University of New York, USA ; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
authors.forename: Maxim
authors.initials: M
authors.lastname: Mokin
authors.affiliation: Department of Neurosurgery, University at Buffalo, State University of New York, USA ; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
authors.forename: Jorge L
authors.initials: JL
authors.lastname: Eller
authors.affiliation: Department of Neurosurgery, University at Buffalo, State University of New York, USA ; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
authors.forename: Travis M
authors.initials: TM
authors.lastname: Dumont
authors.affiliation: Department of Head and Neck and Plastic and Reconstructive Surgery, Roswell Park Cancer Institute, Buffalo, NY, USA.
authors.forename: Saurin R
authors.initials: SR
authors.lastname: Popat
authors.affiliation: Department of Neurosurgery, University at Buffalo, State University of New York, USA ; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
authors.forename: Jody
authors.initials: J
authors.lastname: Leonardo
authors.affiliation: Department of Neurosurgery, University at Buffalo, State University of New York, USA ; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA ; Department of Radiology, University at Buffalo, State University of New York, USA ; Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, USA.
authors.forename: Adnan H
authors.initials: AH
authors.lastname: Siddiqui
keywords: Carotid artery stenting; Jostent; Pipeline embolization device; clival tumor; transsphenoidal resection