Endoscopic Endonasal Ligation of the Internal Carotid Artery: A Cadaveric Study and Case Series

OBJECTIVE: Internal carotid artery (ICA) sacrifice is occasionally required in complex skull-base pathology. Endovascular techniques remain the primary strategy, but intravascular metallic devices may complicate subsequent surgery and imaging surveillance in selected patients. We evaluated the anatomical feasibility and clinical application of endoscopic endonasal ICA ligation. METHODS: Three fresh cadaveric heads (6 sides) were dissected to identify accessible distal ligation sites and define the requirements for circumferential ICA dissection and direct ligation. The technique was subsequently applied in 5 selected patients, whose records were retrospectively reviewed. RESULTS: Circumferential ICA exposure and mobilization were achieved on all 6 sides. The lower paraclival ICA, caudal to its entry into the cavernous sinus, provided reproducible working space for ligature passage. A fibrous band extending from the middle cranial fossa dura toward the foramen lacerum was consistently identified and provisionally termed the meningolingual band; its division facilitated circumferential ICA mobilization. Endoscopic endonasal ICA ligation was completed in all 5 patients without stroke, embolic complication, or major neurological deficit; one patient developed ipsilateral postoperative miosis. CONCLUSIONS: Endoscopic endonasal ICA ligation may provide direct vascular control in highly selected patients who already require an endonasal approach and direct management of the diseased ICA. The paraclival ICA below the cavernous sinus is a practical distal ligation target when safe circumferential dissection and secure ligation are possible. This technique should be considered complementary to contemporary endovascular strategies.