Preoperative carotid stent reinforcement for recurrent skull base tumors: technical note and early feasibility series

OBJECTIVE: Recurrent skull-base malignancies that circumferentially encase the internal carotid artery (ICA) in irradiated fields carry a major risk of vascular injury during repeat surgery. When balloon test occlusion (BTO) shows inadequate collateral supply, high-flow extracranial-intracranial bypass is often required to enable resection. We evaluated staged, segment-specific endoluminal ICA reinforcement with covered and open-cell stents to permit carotid-preserving re-resection. METHODS: We conducted a prospective single-center study of patients with recurrent skull-base tumors previously treated with surgery and high-dose radiotherapy, scheduled for repeat resection. Patients with 360° ICA encasement and BTO failure, defined by neurological change and/or delayed venous drainage during hypotensive challenge, underwent preoperative stent reinforcement. High-resolution MRI fused with 3D-rotational angiography characterized the tumor-ICA interface and guided segment-specific deployment. Balloon-expandable covered stents reconstructed encased petrous, lacerum, and cavernous segments; open-cell or flow-diverting devices were used selectively in the clinoidal ICA. Dual antiplatelet therapy continued for 3 months before re-resection under aspirin monotherapy. RESULTS: Gross-total, near-total, and subtotal resection was achieved in two, one, and one patient, respectively; in the subtotal case, all ICA-adjacent disease was removed, with staged management planned for residual extracranial extension. One patient (25%) developed delayed postoperative carotid occlusion from in-stent stenosis after an obligatory interruption of antiplatelet therapy, complicated by an iatrogenic arterial injury during thrombectomy; both were managed endovascularly with recanalization. No intraoperative carotid rupture or permanent stent-related neurological deficit occurred. CONCLUSION: In carefully selected patients with BTO failure, recurrent irradiated skull-base tumors, and circumferential ICA encasement, segment-specific endoluminal ICA reinforcement is feasible and may serve as an adjunct when carotid preservation is required and bypass carries significant anticipated morbidity. Larger series are warranted.