Acute endovascular repair of iatrogenic right internal carotid arterial laceration
A previously healthy 58-year-old man was admitted to an ear, nose, and throat (ENT) specialist due to a right-side serous otitis media and hearing loss. Initially he was treated medically but with no significant improvement of his condition. He was referred for a magnetic resonance imaging (MRI) examination, which showed a right-side contrast-enhancing meningeal skull base expansion with tumor growth into the prepontine cistern, sphenoidal sinus, and along the right ICA (Fig. ).\nA transsphenoidal biopsy from the tumor concluded with a meningo-epithelial meningioma (WHO grade I), and he was scheduled for two-step surgery, starting with the tumor component medial of the ICA. He was admitted to the neurosurgery department in good physical condition, and with a normal neurological and hormonal status. Surgery was performed through a transnasal transsphenoidal approach from the right side. The tumor was fibrotic and during resection a profuse arterial hemorrhage occurred. Hemostasis was achieved temporarily by surgical packing and the patient was admitted to angiography.\nThrough a right-side femoral access, a 6 French (F) sheath (Boston Scientific, Sunnyvale, CA, USA) was placed and a 5 F right coronary catheter (Boston Scientific, Sunnyvale, CA, USA) was used for selective angiography. The angiogram showed some extravasation of the contrast medium, shaped as a small irregular pseudoaneurysm at the distal part of the C3 segment of the right ICA (Fig. ). The extravasation was limited due to the temporary hemostasis. The angiogram also revealed a small proximal segment of the anterior cerebral artery (A1) and a large posterior communicating artery (PCOM) on the right side. Due to tortuous anatomy, a 0.014-inch floppy guidewire was replaced by a 0.0035-inch hydrophilic wire (Boston Scientific, Sunnyvale, CA, USA). With some manipulation a stentgraft (4.5/16 mm Jostent Graftmaster; Abbott Laboratories, Abbott Park, IL, USA) was placed and deployed with balloon dilatation, and the bleeding was immediately occluded (Fig. ). There were no thromboembolic complications and the puncture site was closed successfully. Because of the perioperative bleeding, administration of intra-arterial Heparin (5000 IE) was delayed until the stentgraft was in place. The patient recovered uneventfully and a computed tomography (CT) scan the following day showed an open stentgraft and no bleeding was seen (Fig. a). The CT also confirmed the small A1 (Fig. b) and the large PCOM on the right side, as well as a hypoplastic proximal segment of the right posterior cerebral artery (P1). He continued on Plavix 75 mg daily for a period of 6 months; during this period no events related to the covered stent occurred.