Department of Otorhinolaryngology-Head & Neck Surgery, King Fahad Medical City, Riyadh, Saudi Arabia.
Department of Otolaryngology-Head & Neck Surgery, The Ohio State University Wexner Medical Center, Columbus.
JAMA Otolaryngol Head Neck Surg. 2020 Apr 1;146(4):364-372. doi: 10.1001/jamaoto.2019.4864.
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.
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.
Root cause analysis of demographic, human, patient, process, technique, instrument, and environmental factors as well as mortality and morbidity data.
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.
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.
内镜经鼻颅底手术中对内颈动脉（ICA）的损伤通常不是孤立发生的，而是多种因素共同作用的结果。
评估与 ICA 损伤相关的因素，以降低其发生率。
设计、地点和参与者：本质量改进研究采用多中心根本原因分析，对 1993 年 1 月 1 日至 2018 年 12 月 31 日在四大洲（北美、南美、欧洲和亚洲）的 11 个三级护理中心进行的内镜经鼻颅底手术中发生的 ICA 损伤患者进行分析。建立鱼骨图模型以促进根本原因分析。纳入分析的患者接受了扩大的内镜经鼻入路手术，这些手术存在 ICA 损伤的实质性潜在风险。各中心的外科医生完成了一份问卷，以评估与损伤相关的人为、患者、过程、技术、器械和环境因素。
对人口统计学、人为、患者、过程、技术、器械和环境因素以及死亡率和发病率数据进行根本原因分析。
在 7160 例扩大的内镜经鼻入路手术中发生了 28 例 ICA 损伤（发生率为 0.4%）。患者的平均年龄为 49 岁，女性与男性的比例为 1.8:1（18 名女性对 10 名男性）。解剖（23 [82%]）、病理（15 [54%]）和外科切除（26 [93%]）因素是最常报告的因素。有 4 例（14%）报告术者的身心状况不佳。有 6 例（21%）报告影像学不理想。术者的经验水平与 ICA 损伤无关。ICA 损伤与使用动力或锐利器械有关的有 20 例（71%），与使用新器械或技术有关的有 7 例（25%）。有 2 例（7%）患者在手术室死亡，3 例（11%）患者存活但存在神经功能缺损。总体而言，与患者相关的因素是 28 例（96%）中最常报告的危险因素。与 ICA 损伤相关的因素促成了一系列预防建议。
本研究发现人为因素与术中 ICA 损伤有关；然而，它们通常伴有其他缺陷。这些发现表明，确定危险因素对于预防此类损伤至关重要。术前计划和尽量减少 ICA 损伤的可能性似乎也很重要。
