Emergency endovascular treatment of cavernous internal carotid artery acute bleeding with flow diverter stent: a single-
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ORIGINAL ARTICLE - VASCULAR NEUROSURGERY - OTHER
Emergency endovascular treatment of cavernous internal carotid artery acute bleeding with flow diverter stent: a single-center experience Andrea Giorgianni 1 & Edoardo Agosti 2 & Alberto Terrana 1 & Fabio Pozzi 2 & Giorgio Sileo 3 & Luca Nativo 1 & Sergio Balbi 2 & Alessandro Motta 4 & Paolo Castelnuovo 3,5 & Davide Locatelli 2,5 & Mario Turri-Zanoni 4,5 Received: 28 May 2020 / Accepted: 30 July 2020 # The Author(s) 2020
Abstract Background and objective To describe our single-center experience in the treatment of cavernous internal carotid artery (ICA) acute bleeding with flow diverter stent (FDS), as a single endovascular procedure or combined with an endoscopic endonasal approach. Methods We analyze a case series of 5 patients with cavernous ICA acute bleeding, i.e., 3 iatrogenic, 1 post-traumatic, and 1 erosive neoplastic. After an immediate nasal packing to temporarily bleeding control, patients underwent digital subtraction angiography (DSA) to identify the site of the ICA injury. A concomitant balloon occlusion test (BOT) was performed, to exclude post-occlusive ischemic neurological damage. An FDS was placed with parallel intravenous infusion of abciximab in 3 cases and tirofiban in 2 cases. In two patients, an innovative “sandwich technique” combining the endovascular reconstruction with an extracranial intrasphenoidal cavernous ICA resurfacing with autologous flaps or grafts by endoscopic endonasal approach was performed. Results No patient had periprocedural ischemic-hemorrhagic complications. All patients had a regular clinical evolution, without general complications or new onset of focal neurological deficits. No further bleeding occurred in 3 patients, while 2 cases experienced a mild rebleeding in a period ranging from 5 to 15 days after the endovascular procedure. In these two cases, we proceeded with an endoscopic endonasal procedure to resurface the exposed ICA wall in the sphenoid sinus. Conclusions Although the treatment of choice for cavernous ICA acute bleeding remains the occlusion of the injured vessel, in cases of poor hemodynamic compensation at the BTO, the endovascular FDS emergency placement can be effective. A combined endoscopic endonasal technique to support the extracranial side of the vessel using autologous flaps or grafts can be performed to prevent the risk of rebleeding. Keywords Cavernous carotid artery . Acute vascular injury . Flow diverter stent . Skull base surgery . Endoscopic endonasal . Hadad flap This article is part of the Topical Collection on Vascular Neurosurgery Other * Edoardo Agosti [email protected] 1
Department of Neuroradiology, ASST Sette Laghi, Varese, Italy
2
Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Via Guicciardini, 9, 21100 Varese, Italy
3
Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
4
Department of Anesthesiology e Resuscitation, ASST Sette Laghi, Varese, Italy
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