27.1 Goal

1. 
   

   Review and critically analyze the literature that supports endovascular embolization (EE) for intractable epistaxis in adults.

27.2 Case Example

27.2.1 History of Present Illness

A 36-year-old male presented to an outside hospital with acute left-sided epistaxis. The patient underwent unilateral nasal packing and was discharged home. He re-presented later the same day with recurrent epistaxis despite nasal packing and was transferred to our facility. On presentation he was hypertensive with SBP > 170. The patient was evaluated by ENT and a clear source of hemorrhage could not be identified upon nasal inspection due to uncontrolled bleeding.

Past medical history: No significant PMH.

Past surgical history: No significant PSH.

Family history: No significant FH.

Social history: Spanish speaking.

Review of systems: Noncontributory.

Neurological examination: Unremarkable.

Imaging studies: Endoscopy, angiography (see Fig. 27.1).

27.3 Case Summary

1. 
   

   When should a patient with intractable epistaxis be treated?

   
   

   The primary source of epistaxis should be identified; patients with anterior epistaxis are not typically candidates for endovascular management; however, patients with intractable posterior epistaxis should be considered for arterial embolization. Anterior epistaxis is typically controlled with topical agents and/or anterior nasal packing. If these fail, next step is direct cauterization or ligation of the anterior or posterior ethmoidal artery. ¹ The ethmoidal arteries arise from the ophthalmic artery and embolization would carry a high risk of major complications. If a posterior source is suspected and the patient failed initial conservative management including nasal packing and attempted cauteriza-tion/ligation, a more invasive procedure as EE is a reasonable consideration. ^{1 , 2 , 3}

   
   
2. 
   

   What determines the treatment modality?

   
   

   Two definite treatment options are available for intractable posterior epistaxis: EE and surgical ligation of the sphenopalatine artery (typically “endoscopic sphenopalatine artery ligation”—ESPAL). Our patient was not a candidate for ESPAL due to difficult visualization and, respectively, patients with connections between the internal maxillary artery (IMAX) and intracranial circulation are not candidates for embolization due to the significantly increased risk of a major neurologic complication. ³ Patient’s comorbidities should be taken into consideration as EE is typically done under conscious sedation/local anesthesia, while ESPAL requires general anesthesia. On the contrary, decreased renal function could preclude EE. However, if a patient is a candidate for surgical, as well as endovascular treatment, there are no prospective controlled trials to support one over the other. ⁴ Caution is needed in interpreting available evidence. Published literature consists mostly of single-center retrospective studies with heterogenous methodology and inconsistent outcome reporting, ⁴ only a few of which compared both treatment options. The two largest studies ^{5 , 6} utilized the National Inpatient Sample database and did not report bleeding control rate or recurrences. Other studies have reported similar success rates for both techniques with an average success rate of 88% and range of 71 to 100% for EE. ⁴ ESPAL may be associated with a higher rate of minor complications, ⁷ but EE is associated with significantly higher stroke risk of 0.9% compared to 0.1% with surgical ligation. ⁵

   
   

   Cost of the procedure may also be a consideration when deciding on treatment. The largest study to date ⁵ comparing 4,440 embolization patients versus 64,289 surgical ligation patients demonstrated EE to be significantly more expensive, with mean hospital charges of $50,372 versus $17,367 in the surgical group, a trend seen in other studies as well. ^{8 , 9}

   
   
3. 
   

   What vessels should be embolized and what agent should be used?

   
   

   If laterality can be determined, then embolization of the ipsi-lateral IMAX is often sufficient. ^{10 , 11} Majority of the patients, however, receive bilateral IMAX embolization, ^{12 , 13 , 14} which should be indicated carefully, as there is a linear association between the number of treated vessels and the rate of minor complications. ¹⁵

   
   

   PVA particles of various sizes are the most frequently used agent, but there is no evidence to support one agent over another.