Management Protocol for Intraoperative Internal Carotid Artery Injury: A Modified Delphi Method and Multidisciplinary Expert Panel

Background: Intra-operative internal carotid artery (ICA) injury during transnasal endoscopic surgery is a rare, but potentially catastrophic event. Such an injury is life-threatening in the immediate setting, with a reported perioperative mortality rate of 10%. Of patients who survive past the immediate post-operative period, up to 90% live without permanent neurological deficits. This promising prognosis places emphasis on the surgical team to manage the intra-operative hemorrhage safely and effectively—in order to provide patients with the best chance at neurological recovery. Nasal packing, muscle patches, direct vessel closure, and endovascular techniques have all been described as useful strategies for managing a catastrophic ICA bleed. Currently, no formalized evidence-based management protocol exists for intraoperative ICA injury. The objective of this study was to develop a management protocol for intra-operative ICA injury using a modified Delphi method with engagement of a multi-disciplinary expert panel.

Methods: A modified Delphi method including extensive literature review, iterative rounds of stakeholder feedback, and expert panel discussions was used to develop a management protocol for ICA injury during transnasal endoscopic surgery. The 10-person multi-disciplinary panel included otolaryngologists, neurosurgeons, interventional radiologists, anesthesiologists, and operating room nursing staff.

Results: After three rounds of stakeholder engagement with the expert panel, a consensus was reached on important elements to include within the protocol. The protocol was divided in three categories: alert, control, and transfer. “Alert” focuses on communication with anesthesia and nursing staff, in addition to calling for assistance from a second surgeon. “control” focuses on techniques to expose the injury and obtain hemostasis or adequate tamponade. Lastly, “transfer” describes the process of contacting a neurointerventional radiologist and how to safely transfer the patient. A one-page handout of the protocol was developed for placement in operating room suites.

Conclusion: Due to the life-threatening nature of an ICA injury, it is imperative that endoscopic sinus and skull base surgeons are prepared to manage this complication. Using a modified Delphi method with a multidisciplinary expert panel, a protocol for management of intra-operative ICA injury was developed for centers performing transnasal endoscopic surgery.

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Publication History

Article published online:
12 February 2021