2025 Proffered Presentations
S328: THE MANAGEMENT OF ENDOSCOPIC ENDONASAL ICA INJURY WITH PROXIMAL AND DISTAL CONTROL-SURGICAL ANATOMY AND "LIVER CADAVER" MODEL SIMULATION
Limin Xiao, MD1; Joaquin Chuang, MD2; Ludovico Agostini, MD2; Jonathan Rychen, MD2; Yuanzhi Xu, MD2; Vera Vigo, MD2; 1Jiangxi Cancer Hospital; 2Stanford University
Objective: The ideal management of intraoperative ICA injury aims at achieving hemostasis while preserving normal blood flow, in which safe proximal and distal controls are mandatory. There is still lack of study analyzing the endoscopic anatomy of ICA with emphasize the ideal blocks site, clip choose for proximal and distal controls.
Methods: Six latex injected cadaveric specimens were used for endoscopic dissection. The surgical anatomy of ideal block site/region for proximal and distal controls, clip selection and direction of the clip placement were investigated. Two embalmed, un-injected cadaveric heads were prepared for simulating ICA injury like operative scenarios. The management methods of clip repair, muscle wrapping in the premise of both proximal and distal controls were verified.
Results: Three optimal block sites were identified (Figure.1): paraclival site, the subclinoid site, the supraclinoid site
The paraclival site was from foramen lacerum to the petrous process of sphenoid bone with a mean length of 13.6 mm (SD±1.8) (Table.1).
| Block site | Boundary |
Mean length (mm)±SD |
Related Structures | Relationship with CS | Clip selection | Tip orientation of clip |
| Paraclival site | foramen lacerum to the petrous process of sphenoid bone(PPspb) | 13.6±1.8 |
Lingular process; PPspb; sympathetic trunk |
Extra-CS |
Curved | Upward |
|
Subclinoid site |
anterior genu of ICA to the proximal dura ring | 6.8±1.2 | ACP; CCL; CN3 | Intra-CS | Straight | Backward |
| Supraclinoid site | distal dura ring to the superior hypophyseal artery(SHA) | 8.1±0.8 | ACP; CN-2; optha A; SHA | Extra-CS | Right-angled | Laterally |
A curved clip with tip oriented upward is ideal for controlling the ICA in the paraclival region. The subclinoid site was from the anterior genu of ICA to the proximal dura ring with a mean length of 6.8 mm (SD±1.2). For ICA control in the subclinoid site, a straight clip with a backward-facing tip is suitable. The supraclinoid site is from distal dura ring to the first origin site of superior hypophyseal artery with a mean length of 8.1mm (SD±0.8). Using a right-angle clip with the tip positioned laterally is appropriate for vascular control at the supraclinoid site. Both proximal and distal controls for clinoid, parasellar, and paraclival segments of ICA were achieved using the abovementioned three block sites in combination (Figure.2).
An injury located at the ascending vertical segment ICA were created in the simulation model. The injury site was successfully managed with direct clip sealing and muscle wrapping in the premise of both proximal and distal control.
Conclusion: Paraclival, subclinoid, supraclinod sites were the three optimal sites for ICA control in endoscopic endonasal approaches. A detailed understanding of the surgical anatomy of the ICA and its surrounding structures will provide a great help for clip selection and its placement. It is technically feasible to manage intraoperative ICA injury in the premise of proximal and distal controls in endonasal procedures.