General Description

Epistaxis is a common condition, with more than half of adults experiencing nasal bleeding at some point. Few cases will require endovascular intervention because most can be treated with pressure, nasal packing, or cauterization. Typically, conservative management will suffice for anterior nosebleeds, which are supplied by the Keisselbach triangle. More commonly, posterior nasal bleeds may require nasal packing and/or intervention.

There are many causes of uncontrollable epistaxis including idiopathic, traumatic (most commonly an external carotid artery [ECA] branch or a pseudoaneurysm), postsurgical (e.g., after nose and throat procedures, transsphenoidal surgery), neoplasm-related, or associated with ruptured internal carotid artery (ICA) cavernous aneurysms, arteriovenous malformations or fistulas, and congenital syndromes such as Osler-Weber-Rendu syndrome.

Indications

Endovascular embolization is indicated for any case of epistaxis that cannot be controlled by conservative measures.

Neuroendovascular Anatomy

Most endovascular treatments commence with diagnostic cerebral angiography of the ICA and ECA vessels. The images are carefully analyzed to determine whether an extracranial–intracranial (EC–IC) anastomosis is present. The important anatomical entity when embolizing nasal bleeding is collateral blood supply. Unidentified EC–IC collaterals can be a source of morbidity, including cranial nerve deficits and blindness.

Anterior nasal hemorrhages are supplied by the Keisselbach plexus, which is formed by the following ECA branches: sphenopalatine, superior labial, angular, ascending palatine, and anterior ethmoidal arteries. Posterior nasal hemorrhages are supplied by posterior ethmoidal arteries that arise from the ophthalmic artery (a direct branch of the ICA) as well as sphenopalatine (a direct branch from the internal maxillary [IMAX] artery and ECA), ascending pharyngeal (branch of the ECA), and ascending palatine vessels (branch of the facial artery). Posterior pharyngeal hemorrhages can originate from the facial artery and any embolization procedure should be performed beyond the submandibular gland branch.

Embolization of posterior nasal hemorrhages involves unilateral distal IMAX embolization. If the hemorrhage persists, contralateral IMAX embolization is performed. If the hemorrhage is severe, the facial artery distal to the submandibular gland branch can be also embolized. We avoid bilateral facial artery embolization because patients could experience facial skin sloughing or tingling.

Important Anastomoses

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  Meningohypophyseal trunk and/or inferolateral trunk (branch of the ICA) and the artery of foramen rotundum and/or ovale, or accessory meningeal artery (branch of the IMAX).

  
  
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  Recurrent ophthalmic (branch of the ophthalmic artery) and infraorbital artery (branch of the IMAX).

  
  
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  Meningo-ophthalmic artery (branch of the middle meningeal artery) and ophthalmic artery (branch of the ICA).

  
  
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  Ethmoid vessels from ophthalmic and middle meningeal or IMAX supply can also contribute to EC–IC connections.

  
  
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  The ophthalmic artery can be supplied solely by the middle meningeal vessel in a small percentage of people.

  
  
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  Remember that as embolization proceeds, increased pressure can open a previously unseen anastomosis, so one must always be vigilant.

Perioperative Anesthesia and Medications

General anesthesia can be utilized for intubated patients, especially for patients who are hemodynamically unstable or have a compromised airway; otherwise, procedures are performed in awake patients (conscious sedation). We routinely administer systemic heparin to an activated coagulation time above 250 s, unless the hemorrhage is still active.

Specific Technique and Key Steps

1. 
   

   After the femoral angiogram has been performed to confirm the absence of any irregularity or dissection, the diagnostic catheter is placed over a curved wire (0.035-inch angled Glidewire, Terumo) and advanced into the aorta under fluoroscopic guidance.

   
   
2. 
   

   A diagnostic study of the ECAs and ICAs is performed (see diagnostic Chapter 6).

   
   
3. 
   

   If the hemorrhage is related to a cavernous ICA aneurysm, see Chapters 23–26. If the hemorrhage is related to a primary or metastatic tumor, see Chapters 37–39.

   
   
4. 
   

   A diagnostic catheter is navigated over a wire, and the IMAX arteries and the facial artery are selected. Angiograms in anteroposterior (AP) and lateral views are obtained of each vessel ( Fig. 36.1, 36.2, Video 36.1, 36.2 ).

   
   
5. 
   

   The more symptomatic side is selected first for distal IMAX artery embolization.

   
   
6. 
   

   A microcatheter can be placed through the diagnostic catheter or a guide catheter can be placed in the ECA under roadmap fluoroscopy ( Video 36.1, 36.2 ).

   
   
7. 
   

   The microcatheter is navigated over the microwire past the temporal branches of the IMAX artery, and a superselective angiogram is obtained. This allows identification of any EC–IC anastomosis ( Video 36.1, 36.2 ).

   
   
8. 
   

   Embolization is then performed with polyvinyl alcohol (PVA) articles or a liquid embolic agent.

   
   
9. 
   

   The PVA particles (with contrast material) can then be injected until stasis of the distal vessel is present.

   
   
10. 
    

    Liquid embolic agents, such as Onyx 18 or 34 (Medtronic), can be administered under subtracted fluoroscopy after filling the microcatheter dead space (usually 0.3 mL) with dimethyl sulfoxide (DMSO) and injecting at 0.1 mL/min DMSO and the initial Onyx (clearing the catheter dead space of DMSO) ( Video 36.1, 36.2 ).

    
    
11. 
    

    The other IMAX artery can be embolized in a similar fashion, and the facial artery on one side can be embolized if the epistaxis did not subside.

    
    
12. 
    

    The catheters are then removed. The nasal packing should be in place for at least 24 h and the patient monitored in the intensive care unit.