Carotid artery-sparing repair of a cavernous carotid artery pseudoaneurysm

Carotid artery (CA) injury after transsphenoidal and endoscopic sinus surgery is a well-recognized but fortunately rare complication.1 It is associated with significant morbidity and mortality rates5 and is more common in cases of repeated surgery, cavernous sinus invasion, prior radiotherapy, and anatomical anomalies of the sphenoid and cavernous sinuses.4 It usually results in CA stenosis, occlusion, or pseudoaneurysm formation followed by serious complications, such as stroke and caroticocavernous fistulas.5 Direct surgical repair is difficult, and treatment may require parent vessel sacrifice and possibly vascular bypass.5 We describe the successful treatment of a cavernous? CA pseudoaneurysm with a novel CA-sparing approach. This 62-year-old woman with recurrent esthesioneuroblastoma underwent endoscopic tumor resection. A CA injury occurred intraoperatively. Hemostasis was rapidly achieved by packing the bleeding site with cottonoid and packing strip gauze within the sphenoid sinus. Postoperative angiography performed immediately after surgery revealed a 2-mm pseudoaneurysm at the anterior genu of the left cavernous internal CA (ICA) with minimal stenosis (Fig. 1 left). Eight days after the initial arterial injury, repeat angiography demonstrated persistence of the aneurysm. To repair the arterial defect and preserve the CA, an endovascular stent was placed across the puncture site to restore its normal caliber and to provide a buttressing surface for surgical repair by graft apposition (Fig. 1 right). Subsequently, with the aid of the operating microscope, a small piece of autologous fascia lata graft was placed directly over the arterial puncture site via a transnasal?transsphenoidal approach and bound using BioGlue (CryoLife, Inc., Kennesaw, GA), a two-component (bovine serum albumin and glutaraldehyde) surgical adhesive that is used as an adjunct to open surgical repair of large vessels, such as the aorta, femoral artery, and CA.2 The fascia lata graft was placed over the puncture site to patch the hole in the arterial wall directly because the pseudoaneurysm remained and was unchanged after stent placement alone, presumably because of the interstices of the stent.