Operative Planning

• Review history and exam for evidence of coagulopathy, trauma (iatrogenic or other), sinonasal tumor, personal/family history of hereditary hemorrhagic telangiectasia

Special Equipment

• Five to 6 French (F) 10- to 25-cm arterial introducer sheath
  
• 0.035- or 0.038-inch guide wire
  
• 5F 100-cm diagnostic vertebral curve catheter (doubles as guide catheter)
  
• 130 to 150 cm variable stiffness braided hydrophilic microcatheter–0.4- to 0.7-mm lumen
  
• 0.010- to 0.014-inch tapered construction hydrophilic micro–guide wire
  
• Nonionic iodinated radiocontrast-organic iodine content of 270 to 300 mg/mL
  
• Pressurized heparinized saline (2000 to 4000 U/mL) perfusate
  
• Polyvinyl alcohol (PVA) particles (250 to 350 μm optimal), Gelfoam, platinum coils

Operating Room Set-up

• Radiation shielding and sterile prep table with embolic materials clearly marked

Anesthetic Issues

• Local anesthesia with monitored conscious sedation as needed
  
• Intubation cart and cardioverter readily available for emergent situations
  
• Periprocedural antibiotics until nasal packing removed

Positioning

• Place patient supine on the angiography table within the appropriate field for imaging the craniofacial circulation with the fluoroscopy tubes.
  
• Shave, prepare, and drape groin region in a sterile manner.

• Perform femoral artery puncture and sheath insertion

Diagnostic Digital Subtraction Angiography

• Before embolization, study bilateral internal and external carotid arteries to identify unusual causes of bleeding (arteriovenous malformation, tumor, an eurysm of the internal carotid artery aneurysm ruptured through dehiscence in sphenoid sinus, pseudoaneurysm of sinonasal arteries), anatomic variants (e.g., ophthalmic artery or anterior cerebral artery arising from middle men ingeal artery [MMA]), and anastomoses to cerebral or retinal circulation.

Guide Catheter Placement

• Position guide catheter in external carotid artery

Microcatheter Tip Positioning in Target Vessels

• Catheterize pterygopalatine portion of the internal maxillary artery distal to the deep middle temporal artery origin
  
• Catheterize facial artery distal to glandular and labial blood supply

Embolization

• Suspend PVA in isobaric radiocontrast mixture
  
• Deliver PVA with 1 mL Luer lock syringe under fluoroscopic guidance until flow arrest
  
• For idiopathic epistaxis, embolize bilateral internal maxillary arteries at minimum; optimally embolize facial artery on side of bleeding
  
• Once complete, perform confirmatory external carotid and/or common carotid angiogram

• Monitor patient in postoperative care unit until fully recovered from conscious sedation
  
• Admit to inpatient service to remove nasal packing and to monitor for recurrent bleeding