The Development and Validation of a Live Porcine Model for Endoscopic Endonasal Management of Internal Carotid Artery Injury With Fluorescence-Based Flow Assessment.

Background and objective Internal carotid artery (ICA) injury during endoscopic endonasal skull base surgery is a rare but catastrophic complication. Simulation platforms are critical for training and for evaluating hemostatic strategies under realistic hemodynamic conditions. This study aimed to develop and validate a live porcine model for ICA injury that reproduces catastrophic hemorrhage, to compare vascular patency following repair with a crushed skeletal muscle patch versus an aneurysm clip, and to evaluate post-repair blood flow using endonasal endoscopic intraoperative fluorescence videoangiography. Methods Forty-five Large White pigs were studied between 2021 and 2024. Five animals were used in a pilot phase to assess the feasibility of the model and its hemodynamic reproducibility. In the experimental phase, 40 animals (80 carotid arteries) underwent standardized carotid injury, sequential hemostasis with crushed muscle and aneurysm clip, and perfusion assessment using indocyanine green (ICG) or fluorescein sodium (FNa). Outcomes included immediate hemostasis and distal vessel patency. Results All repairs achieved primary hemostasis. Patency was significantly higher after muscle patch (79/80, 98.8%) compared with aneurysm clip (64/80, 80.0%; McNemar p<0.001). Both ICG and FNa confirmed distal perfusion; despite unequal distribution of cases, FNa did not demonstrate statistical inferiority compared with the widely used ICG/near-infrared (ICG/NIR) system. Conclusions This porcine model reliably simulates catastrophic ICA injury and enables objective comparison of repair strategies. Crushed muscle preserved vessel patency at higher rates compared with aneurysm clip within this experimental model. Fluorescence angiography with ICG or fluorescein offers practical intraoperative flow verification, with fluorescein representing a cost-effective alternative. This model offers a consistent experimental environment that may support both translational research and surgical training.