Abdulaziz AlQahtani1, Nyall R London2,3,4, Paolo Castelnuovo5, Davide Locatelli6, Aldo Stamm7, Aaron A Cohen-Gadol8, Hussam Elbosraty9, Roy Casiano10, Jacques Morcos11, Ernesto Pasquini12, Georgio Frank13, Diego Mazzatenta13, Garni Barkhoudarian14, Chester Griffiths14, Daniel Kelly14, Christos Georgalas15, Narayanan Janakiram16, Piero Nicolai17, Daniel M Prevedello2,18, Ricardo L Carrau2,18. 1. Department of Otorhinolaryngology-Head & Neck Surgery, King Fahad Medical City, Riyadh, Saudi Arabia. 2. Department of Otolaryngology-Head & Neck Surgery, The Ohio State University Wexner Medical Center, Columbus. 3. Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland. 4. National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, Maryland. 5. Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy. 6. Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy. 7. Centro de Otorrinolaringologia e Fonoaudiologia, Complexo Hospitalar Edmundo Vasconcelos, São Paulo, Brasil. 8. Indiana University, Department of Neurosurgery and Goodman Campbell Brain and Spine, Indianapolis, Indiana. 9. Department of Otorhinolaryngology, Faculty of Medicine, Cairo University, Cairo, Egypt. 10. Department of Otolaryngology-Head & Neck Surgery, University of Miami, Miller School of Medicine, Miami, Florida. 11. Department of Neurosurgery, University of Miami, Miami, Florida. 12. ENT Department, Ospedale Bellaria, Bologna, Italy. 13. Center of Pituitary and Endoscopic Skull Base Surgery, Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy. 14. Pacific Brain Tumor Center and Pituitary Disorders Program, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, California. 15. Medical School, University of Nicosia, Nicosia, Cyprus. 16. Department of Otorhinolaryngology, Royal Pearl Hospital, Tiruchirapally, Tamil Nadu, India. 17. Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy. 18. Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus.
Abstract
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.
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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