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Original Investigation
February 27, 2020

Assessment of Factors Associated With Internal Carotid Injury in Expanded Endoscopic Endonasal Skull Base Surgery

Author Affiliations
  • 1Department of Otorhinolaryngology–Head & Neck Surgery, King Fahad Medical City, Riyadh, Saudi Arabia
  • 2Department of Otolaryngology–Head & Neck Surgery, The Ohio State University Wexner Medical Center, Columbus
  • 3Department of Otolaryngology–Head & Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
  • 4National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, Maryland
  • 5Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
  • 6Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
  • 7Centro de Otorrinolaringologia e Fonoaudiologia, Complexo Hospitalar Edmundo Vasconcelos, São Paulo, Brasil
  • 8Indiana University, Department of Neurosurgery and Goodman Campbell Brain and Spine, Indianapolis, Indiana
  • 9Department of Otorhinolaryngology, Faculty of Medicine, Cairo University, Cairo, Egypt
  • 10Department of Otolaryngology–Head & Neck Surgery, University of Miami, Miller School of Medicine, Miami, Florida
  • 11Department of Neurosurgery, University of Miami, Miami, Florida
  • 12ENT Department, Ospedale Bellaria, Bologna, Italy
  • 13Center of Pituitary and Endoscopic Skull Base Surgery, Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
  • 14Pacific Brain Tumor Center and Pituitary Disorders Program, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
  • 15Department of Otorhinolaryngology–Head & Neck Surgery, Hygeia Hospital, Athens, Greece
  • 16Department of Otorhinolaryngology, Royal Pearl Hospital, Tiruchirapally, Tamil Nadu, India
  • 17Unit of Otorhinolaryngology–Head and Neck Surgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
  • 18Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus
JAMA Otolaryngol Head Neck Surg. 2020;146(4):364-372. doi:10.1001/jamaoto.2019.4864
Key Points

Question  What are the factors associated with internal carotid artery injury in endoscopic endonasal skull base surgery?

Findings  In this multicenter quality improvement study that analyzed 28 cases of internal carotid artery injury sustained during endoscopic endonasal skull base surgery, the incidence of injury was 0.4%. All cases were associated with 1 or more of the identified risk factors; however, patient-related factors were reported most frequently (in 96% of cases).

Meaning  Results of this study suggest that internal carotid artery injury during endoscopic endonasal skull base surgery is rare and has multifactorial origins.


Importance  Injury to the internal carotid artery (ICA) during endoscopic endonasal skull base surgery does not typically occur as an isolated circumstance but often is the result of multiple factors.

Objective  To assess the factors associated with ICA injury in an effort to reduce its occurrence.

Design, Setting, and Participants  This quality improvement study used a multicenter root cause analysis of ICA injuries sustained during endoscopic endonasal skull base surgery performed at 11 tertiary care centers across 4 continents (North America, South America, Europe, and Asia) from January 1, 1993, to December 31, 2018. A fishbone model was built to facilitate the root cause analysis. Patients who underwent an expanded endoscopic endonasal approach that carried a substantial potential risk of an ICA injury were included in the analysis. A questionnaire was completed by surgeons at the centers to assess relevant human, patient, process, technique, instrument, and environmental factors associated with the injury.

Main Outcomes and Measures  Root cause analysis of demographic, human, patient, process, technique, instrument, and environmental factors as well as mortality and morbidity data.

Results  Twenty-eight cases of ICA injury occurred during 7160 expanded endoscopic endonasal approach procedures (incidence of 0.4%). The mean age of the patients was 49 years, with a female to male predominance ratio of 1.8:1 (18 women to 10 men). Anatomical (23 [82%]), pathological (15 [54%]), and surgical resection (26 [93%]) factors were most frequently reported. The surgeon’s mental or physical well-being was reported as inadequate in 4 cases (14%). Suboptimal imaging was reported in 6 cases (21%). The surgeon’s experience level was not associated with ICA injury. The ICA injury was associated with use of powered or sharp instruments in 20 cases (71%), and use of new instruments or technology in 7 cases (25%). Two patients (7%) died in the operating room, and 3 (11%) were alive with neurological deficits. Overall, patient-related factors were the most frequently reported risk factors (in 27 of 28 cases [96%]). Factors associated with ICA injury catalyzed a list of preventive recommendations.

Conclusions and Relevance  This study found that human factors were associated with intraoperative ICA injuries; however, they were usually accompanied by other deficiencies. These findings suggest that identifying risk factors is crucial for preventing such injuries. Preoperative planning and minimizing the potential for ICA injury also appear to be essential.

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