Use of Foley Catheter in Control of Internal Carotid Hemorrhage during Endoscopic Endonasal Surgery

Internal carotid artery (ICA) injuries during endoscopic endonasal surgery (EES) are rare life-threatening events. We describe a technique to manage ICA injuries based on the use of Foley catheters. A 26-year-old female underwent endoscopic transnasal trans-sphenoidal removal of pituitary adenoma. Cerebrospinal fluid leak occurred 4 days postoperatively. During repair procedure, accidental injury of ICA occurred. Emergency nasal packing through positioning of four Foley urologic catheters was successfully performed to stop bleeding. The patient did not report neurologic deficits. In author’s opinion, Foley catheters are suitable to obtain immediate bleeding control since they are rapidly available and easily usable.


INTRODUCTION
Endoscopic endonasal surgery (EES) is a mini-invasive procedure, first introduced in the management of paranasal sinus disease. It became progressively popular in surgical management of anterior skull base disease and pituitary adenoma. Complications of EES have been widely described: cerebrospinal fluid leak, orbital hematoma, damage to nasolacrimal duct, optic nerve damage, diplopia, and hemorrhage. 1 Injury of internal carotid artery (ICA) is the most severe and frightening complication which can result in stroke, cranial nerve palsy and death. Revision surgery, radiation, previous bromocriptine treatment and acromegaly, causing fibrosis and alteration of anatomical landmarks, are risk factors for ICA injuries. The massive bleeding is hard to manage in EES because it is a one-hand technique in most cases, and the bleeding reduces visibility in the surgical field by dirtying the tip. 2 Approaches for immediate management of ICA injuries are nasal packing, endoscopic clipping, bipolar coagulation and intraoperative angiography. [3][4][5] The aim of this report was to describe a technique to first line emergency treatment of ICA injuries during EES by using Foley urologic catheters.

CASE REPORT
A 26-year-old female from North Africa presented at the Neurosurgical Department with a history of headache and visual loss. During an access to the Emergency Department, she underwent a brain CT scan that documented a large mass involving sellar and parasellar region with marked erosion of sphenoid sinus walls (Fig. 1A).
A brain MR confirmed the diagnosis, and documented a massive encasement of carotid arteries, cerebral posterior and basilar arteries (Fig. 1B). At 1C). At 4 days postoperatively, the patient showed an intermittent cerebrospinal fluid (CSF) leak with watery rhinorrhea, and persistent pneumocephalus. Hence, a CSF leak repair with fat obliteration of the sphenoid sinus and closure with nasoseptal flap was planned.
During surgery, granulation tissue and inflammatory material was found at the surgical site, consistent with the recent operation. A preliminary exploration and landmark identification from the right nasal fossa were performed, and during demucosization of the previously uncovered lamina papyracea, a marked bleeding was verified. The bleeding was provoked by elevation of granulation tissue by a suction cannula, in the region between lateral wall of sphenoid sinus and lamina papyracea. Surgical field was immediately obscured by blood that could not be suctioned by any kind of aspiration cannula. The suction tube without any aspiration cannula was then used, directly inside the right nasal fossa, but also in this case, the surgical field was not cleared. At this point, any kind of packaging (cottonoids, Merocel, coagulation) was deemed impossible, due to the presence of the aspiration tube and the insufficient view of the surgical field. In this extremely urgent conditions, it was then decided to use a balloon packaging by 14 Fr Foleys urologic catheters, using the technique herein described

Operative technique description: Foley catheter packaging for endonasal carotid bleeding
After removing the aspiration tube from nasal cavity, the first two Foleys are rapidly placed to close the posterior nasal fossa at the level of the choanae (Fig. 2A). To perform this, is can be very useful to overcome the nasal fossa, and feeling the caudal bending of the catheter. Then the catheter is filled with 10-15 cc of water (Fig. 2B), and then pulled back to occlude the ipsilateral choana (Fig. 2C). The same procedure is performed for the contralateral part. At this point, nasal fossae are separated completely from other cavities (i.e. the nasopharynx). The catheter already positioned helps and guides the further ones to be placed in the sphenoethmoidal region, since the most inferior part of the nasal fossa is occupied by  (Figs 2D, 2E), having the true hemostatic purpose. The fourth Foley is placed on the contralateral side to avoid displacement of the previous one. The final result is shown in Fig. 3.
At the end of the procedure, the bleeding stopped immediately. The patients underwent at first angiography that failed to identify the origin of bleeding, most probably because of the packaging in place. An angio-CT scan was performed two days later and a pseudoaneurysm, created by surgical trauma, was identified (Fig. 4A). The position of the Foley compared to the lesion was also verified (Fig. 4B). A stenting was then performed with success, although an occlusion of the carotid was verified 48 hours after the procedure. The patient had a good contralateral supply through the anterior communicating artery, so she did not show any brain ischemia. On the third day after the event, a repair of the fistula was performed as planned in advance, by obliterating the sphenoid sinus with adipose tissue and then covering the repair with mucoperichondrial graft obtained from nasal septum. The patient did not report any neurologic deficit after the procedures and was discharged 20 days after the event, with indications to endocrinology and radiologic follow-up for her residual.

DISCUSSION
EES is considered worldwide the gold-standard technique for diseases of nasal cavity, paranasal sinus and anterior skull base, since it offers significant advantages over open approaches including lack of external incisions, direct access to the tumour without frontal lobe retraction, improved visualization using high-definition endoscopes with dynamic endoscopy, less postoperative pain, and reduced length of hospital stay. However, the expansion of the surgical field in EES exposes more of the ICA, increasing the potential risks of its injury and, hence, massive intraoperative bleeding. Moreover, profuse bleeding during EES can cause loss of intraoperative orientation and obscuration of surgical field. 5,6 Management of catastrophic hemorrhage requires the skills of an experienced skull base surgeon familiar with the endoscopic hemostatic techniques and an experienced anesthesiology and radiology team familiar with the medical and surgical management of cerebral ischemia including endovascular stenting and revascularization. Risk factors for ICA injury have been identified by numerous groups and include the following: prior surgery, radiation, prolonged bromocriptine, acromegaly (tortuous arteries), anatomical variations (dehiscent carotid), and invasive tumours. 5 Prevention of ICA injury is the best surgical strategy. The knowledge of the anatomical intracranial course of the ICA and preoperative imaging evaluation are fundamental requirements to minimize the risk of iatrogenic ICA injuries. The most common segment injured is the cavernous segment due to its anatomic intimate relationship with the lateral wall of the sphenoid sinus. The lateral wall of the sphenoid sinus can be thinned because of anatomical conformities or because of the expansion of the pathology. Incautious surgical maneuvers in the sphenoid sinus and anterior skull base can lead to a damage of ICA. 3 Chin et al. 5 recently described all possible surgical interventions in case of ICA rupture, reporting nasal packing (72%) using various material (Surgicel, cottonoid, Merocel), endoscopic clip sacrifice (16%), bipolar cautery (8%).
Immediate cessation of the procedure to perform direct hemostasis should be followed by immediate intraoperative or early post-operative angiography to assess ICA injury. 5 Angiographic findings can show either carotid cavernous fistula or a pseudo-aneurism, stenosis, dissection, and thrombosis of the ICA. In the case reported, angiography failed to identify the site of injury, and angio-CT scan was necessary to identify a pseudo-aneurism which was then treated by stenting. If stenting is unsuccessful, endovascular balloon occlusion or coil embolization should be the next treatment, with high risk of ischemic complications. 5 In the case reported, successful control of bleeding was achieved by placing four Foley catheters through nasal cavity to occupy the entire nasopharynx and sphenoid cavity. The technique is inspired by classic posterior nasal packing used by otolaryngologists to stop bleedings from sphenopalatine artery branches. In those cases, it is nowadays popular to use balloon packing (e.g. Bivona®, Epistax™, etc.), but only one catheter per time is placed in a nasal fossa. Actually, the drawback of those epistaxis catheters is that they have two cuffs (one anterior and larger and one posterior and smaller). The anterior cuff makes the catheter bulkier compared to a standard Foley urologic catheter, and this prevents the placement of two devices in a nasal fossa at the same time. On the contrary, Foley catheter has a single cuff, and the body of the device is thin and pliable. So, it is possible to place up to four Foley catheters in total, the first two occupying the nasopharynx and the second two the sphenoid cavity and they can be cuffed with water until complete hemostasis is reached. Furthermore, positioning of Foley catheters can be obtained even in cases of low visibility caused by massive bleeding, while other techniques, such as endoscopic clip position, require clear visibility of the surgical field which is hard to reach, especially in a one-hand technique. Last but not least, it is widely and rapidly available in every operative room.

CONCLUSIONS
Inadvertent intraoperative injury to ICA during EES represents a life-threatening event. Approaches for the immediate management of ICA injuries are nasal packing, endoscopic clipping, bipolar coagulation and intraoperative angiography. However, these procedures are not always feasible.
Foley catheter can be a safe, low-cost and widely accessible alternative in the immediate bleeding control in case of injury of ICA during EES.

Ethical statement
This research was conducted in accordance with the World Medical Association Declaration of Helsinki (2002) and with the ethical standards of the institutional research committee of the University Hospital of Modena.

ICMJE Statement
All authors meet the ICMJE authorship criteria.