Transcatheter Embolization in the Management of Epistaxis

 

 Buy Article Permissions and Reprints

Abstract

A majority of the population will experience epistaxis at some time in their life. Most cases will be from an anterior source and can be treated with pressure, anterior nasal packing, or cautery. Intractable epistaxis is generally posterior in origin and may require endoscopic cautery, posterior packing, surgical ligation, or embolization. Embolization has been used to treat epistaxis for more than 30 years and success can be achieved in approximately 90% of patients, with major complications occurring in approximately 2%. These excellent results require thorough knowledge of the regional anatomy, familiarity with the equipment and various agents used to achieve this type of embolization, as well as attention to detail and meticulous technique. There remains debate on several aspects of embolization, including the agent of choice, preferred size of the embolic, and the number of vessels to embolize. Advances in endoscopic surgery have evolved to the point that similar success rates for embolization and modern surgical techniques in treating epistaxis may be expected. This detailed review of pertinent vascular anatomy, embolization technique, and surgical alternatives should allow practitioners to formulate treatment algorithms that result in optimal outcomes at their institutions.

• References

• 1 Seiffert A. Unterbindung der Arteria maxillaris interna. Zeits-chrift fur Hals-, Nasen-, und Ohrenheilkunde 1928; (22) 323-329
  PubMedGoogle Scholar
• 2 Sokoloff J, Wickbom I, McDonald D, Brahme F, Goergen TC, Goldberger LE. Therapeutic percutaneous embolization in intractable epistaxis. Radiology 1974; 111 (2) 285-287
  CrossrefPubMedGoogle Scholar
• 3 Schaitkin B, Strauss M, Houck JR. Epistaxis: medical versus surgical therapy: a comparison of efficacy, complications, and economic considerations. Laryngoscope 1987; 97 (12) 1392-1396
  PubMedGoogle Scholar
• 4 Small M, Murray JA, Maran AG. A study of patients with epistaxis requiring admission to hospital. Health Bull (Edinb) 1982; 40 (1) 20-29
  PubMedGoogle Scholar
• 5 Koh E, Frazzini VI, Kagetsu NJ. Epistaxis: vascular anatomy, origins, and endovascular treatment. AJR Am J Roentgenol 2000; 174 (3) 845-851
  CrossrefPubMedGoogle Scholar
• 6 Ho EC, Chan J-Y. Front-line epistaxis management: let's not forget the basics. J Laryngol Otol 2008; 122 (7) 696-699
  PubMedGoogle Scholar
• 7 Douglas R, Wormald PJ. Update on epistaxis. Curr Opin Otolaryngol Head Neck Surg 2007; 15 (3) 180-183
  CrossrefPubMedGoogle Scholar
• 8 Corbridge RJ, Djazaeri B, Hellier WPL, Hadley J. A prospective randomized controlled trial comparing the use of Merocel nasal tampons and BIPP in the control of acute epistaxis. Clin Otolaryngol Allied Sci 1995; 20 (4) 305-307
  PubMedGoogle Scholar
• 9 Badran K, Malik TH, Belloso A, Timms MS. Randomized controlled trial comparing Merocel and Rapid Rhino packing in the management of anterior epistaxis. Clin Otolaryngol 2005; 30 (4) 333-337
  CrossrefPubMedGoogle Scholar
• 10 Moumoulidis I, Draper MR, Patel H, Jani P, Price T. A prospective randomised controlled trial comparing Merocel and Rapid Rhino nasal tampons in the treatment of epistaxis. Eur Arch Otorhinolaryngol 2006; 263 (8) 719-722
  CrossrefPubMedGoogle Scholar
• 11 Jash DK. Epistaxis—topical use of epsilon-aminocaproic acid in its management. J Laryngol Otol 1973; 87 (9) 895-898
  CrossrefPubMedGoogle Scholar
• 12 Tibbelin A, Aust R, Bende M , et al. Effect of local tranexamic acid gel in the treatment of epistaxis. ORL J Otorhinolaryngol Relat Spec 1995; 57 (4) 207-209
  CrossrefPubMedGoogle Scholar
• 13 Mathiasen RA, Cruz RM. Prospective, randomized, controlled clinical trial of a novel matrix hemostatic sealant in patients with acute anterior epistaxis. Laryngoscope 2005; 115 (5) 899-902
  CrossrefPubMedGoogle Scholar
• 14 Gudziol V, Mewes T, Mann WJ. Rapid Rhino: a new pneumatic nasal tamponade for posterior epistaxis. Otolaryngol Head Neck Surg 2005; 132 (1) 152-155
  CrossrefPubMedGoogle Scholar
• 15 García Callejo FJ, Muñoz Fernández N, Achiques Martínez MT, Frías Moya-Angeler S, Montoro Elena MJ, Algarra JM. Nasal packing in posterior epistaxis. Comparison of two methods [in Spanish]. Acta Otorrinolaringol Esp 2010; 61 (3) 196-201
  CrossrefPubMedGoogle Scholar
• 16 Ho EC, Mansell NJ. How we do it: a practical approach to Foley catheter posterior nasal packing. Clin Otolaryngol Allied Sci 2004; 29 (6) 754-757
  PubMedGoogle Scholar
• 17 Wang L, Vogel DH. Posterior epistaxis: comparison of treatment. Otolaryngol Head Neck Surg 1981; 89 (6) 1001-1006
  PubMedGoogle Scholar
• 18 Ismail H, Buckland JR, Harries PG. The prevention of alar necrosis in Foley catheter fixation in posterior epistaxis. Ann R Coll Surg Engl 2004; 86 (4) 307
  PubMedGoogle Scholar
• 19 Viducich RA, Blanda MP, Gerson LW. Posterior epistaxis: clinical features and acute complications. Ann Emerg Med 1995; 25 (5) 592-596
  CrossrefPubMedGoogle Scholar
• 20 Hyde FT. Ligation of the external carotid artery for the control of idiopathic nasal hemorrhage. Laryngoscope 1925; 35 (12) 899-902
  CrossrefPubMedGoogle Scholar
• 21 Chandler JR, Serrins AJ. Transantral ligation of the internal maxillary artery for epistaxis. Laryngoscope 1965; 75 (7) 1151-1159
  PubMedGoogle Scholar
• 22 Stamm AC, Pinto JA, Neto AF, Menon AD. Microsurgery in severe posterior epistaxis. Rhinology 1985; 23 (4) 321-325
  PubMedGoogle Scholar
• 23 Budrovich R, Saetti R. Microscopic and endoscopic ligature of the sphenopalatine artery. Laryngoscope 1992; 102 (12, Pt 1) 1391-1394
  PubMedGoogle Scholar
• 24 Klotz DA, Winkle MR, Richmon J, Hengerer AS. Surgical management of posterior epistaxis: a changing paradigm. Laryngoscope 2002; 112 (9) 1577-1582
  CrossrefPubMedGoogle Scholar
• 25 Cullen MM, Tami TA. Comparison of internal maxillary artery ligation versus embolization for refractory posterior epistaxis. Otolaryngol Head Neck Surg 1998; 118 (5) 636-642
  CrossrefPubMedGoogle Scholar
• 26 Wehrli M, Lieberherr U, Valavanis A. Superselective embolization for intractable epistaxis: experiences with 19 patients. Clin Otolaryngol Allied Sci 1988; 13 (6) 415-420
  PubMedGoogle Scholar
• 27 Wormald PJ, Wee DTH, van Hasselt CA. Endoscopic ligation of the sphenopalatine artery for refractory posterior epistaxis. Am J Rhinol 2000; 14 (4) 261-264
  CrossrefPubMedGoogle Scholar
• 28 Kumar S, Shetty A, Rockey J, Nilssen E. Contemporary surgical treatment of epistaxis. What is the evidence for sphenopalatine artery ligation?. Clin Otolaryngol Allied Sci 2003; 28 (4) 360-363
  CrossrefPubMedGoogle Scholar
• 29 Asanau A, Timoshenko AP, Vercherin P, Martin C, Prades J-M. Sphenopalatine and anterior ethmoidal artery ligation for severe epistaxis. Ann Otol Rhinol Laryngol 2009; 118 (9) 639-644
  CrossrefPubMedGoogle Scholar
• 30 Feusi B, Holzmann D, Steurer J. Posterior epistaxis: systematic review on the effectiveness of surgical therapies. Rhinology 2005; 43 (4) 300-304
  PubMedGoogle Scholar
• 31 Duggan CA, Brylski JR. Angiographic demonstration of bleeding in intractable traumatic epistaxis. Radiology 1970; 97 (3) 605-606
  PubMedGoogle Scholar
• 32 Gottumukkala R, Kadkhodayan Y, Moran CJ, Cross DWT, Derdeyn CP. Impact of vessel choice on outcomes of polyvinyl alcohol embolization for intractable idiopathic epistaxis. J Vasc Interv Radiol 2012; 24 (2) 234-239
  PubMedGoogle Scholar
• 33 Vitek J. Idiopathic intractable epistaxis: endovascular therapy. Radiology 1991; 181 (1) 113-116
  CrossrefPubMedGoogle Scholar
• 34 Fukutsuji K, Nishiike S, Aihara T , et al. Superselective angiographic embolization for intractable epistaxis. Acta Otolaryngol 2008; 128 (5) 556-560
  CrossrefPubMedGoogle Scholar
• 35 Ricci G, Molini E, Hamam M , et al. Treatment of severe epistaxis by superselective embolization: a review of 22 cases. Rev Laryngol Otol Rhinol (Bord) 2004; 125 (4) 247-251
  PubMedGoogle Scholar
• 36 Strutz JSM, Schumacher M. Uncontrollable epistaxis. Angiographic localization and embolization. Arch Otolaryngol Head Neck Surg 1990; 116 (6) 697-699
  CrossrefPubMedGoogle Scholar
• 37 Oguni T, Korogi Y, Yasunaga T , et al. Superselective embolisation for intractable idiopathic epistaxis. Br J Radiol 2000; 73 (875) 1148-1153
  CrossrefPubMedGoogle Scholar
• 38 Lasjaunias P, Marsot-Dupuch K, Doyon D. The radio-anatomical basis of arterial embolisation for epistaxis. J Neuroradiol 1979; 6 (1) 45-53
  PubMedGoogle Scholar
• 39 Mahmoud NA. Traumatic aneurysm of the internal carotid artery and epistaxis. (Review of literature and report of a case). J Laryngol Otol 1979; 93 (6) 629-656
  CrossrefPubMedGoogle Scholar
• 40 Karkanevatos A, Karkos PD, Karagama YG, Foy P. Massive recurrent epistaxis from non-traumatic bilateral intracavernous carotid artery aneurysms. Eur Arch Otorhinolaryngol 2005; 262 (7) 546-549
  CrossrefPubMedGoogle Scholar
• 41 Elden L, Montanera W, Terbrugge K , et al. Angiographic embolization for the treatment of epistaxis: a review of 108 cases. Otolaryngol Head Neck Surg 1994; 111 (1) 44-50
  PubMedGoogle Scholar
• 42 Strach K, Schröck A, Wilhelm K , et al. Endovascular treatment of epistaxis: indications, management, and outcome. Cardiovasc Intervent Radiol 2011; 34 (6) 1190-1198
  CrossrefPubMedGoogle Scholar
• 43 Cohen JE, Moscovici S, Gomori JM, Eliashar R, Weinberger J, Itshayek E. Selective endovascular embolization for refractory idiopathic epistaxis is a safe and effective therapeutic option: technique, complications, and outcomes. J Clin Neurosci 2012; 19 (5) 687-690
  CrossrefPubMedGoogle Scholar
• 44 Kendall B, Moseley I. Therapeutic embolisation of the external carotid arterial tree. J Neurol Neurosurg Psychiatry 1977; 40 (10) 937-950
  CrossrefPubMedGoogle Scholar
• 45 Renn WH, Rhoton Jr AL. Microsurgical anatomy of the sellar region. J Neurosurg 1975; 43 (3) 288-298
  CrossrefPubMedGoogle Scholar
• 46 Simpson Jr RK, Harper RL, Bryan RN. Emergency balloon occlusion for massive epistaxis due to traumatic carotid-cavernous aneurysm. Case report. J Neurosurg 1988; 68 (1) 142-144
  CrossrefPubMedGoogle Scholar
• 47 Chen D, Concus AP, Halbach VV, Cheung SW. Epistaxis originating from traumatic pseudoaneurysm of the internal carotid artery: diagnosis and endovascular therapy. Laryngoscope 1998; 108 (3) 326-331
  CrossrefPubMedGoogle Scholar
• 48 Sautter NB, Smith TL. Hereditary hemorrhagic telangiectasia-related epistaxis: innovations in understanding and management. Int Forum Allergy Rhinol 2012; 2 (5) 422-431
  CrossrefPubMedGoogle Scholar
• 49 Mahadevia AA, Murphy KJ, Obray R, Gailloud P. Embolization for intractable epistaxis. Tech Vasc Interv Radiol 2005; 8 (3) 134-138
  CrossrefPubMedGoogle Scholar
• 50 Smith TP. Embolization in the external carotid artery. J Vasc Interv Radiol 2006; 17 (12) 1897-1912 , quiz 1913
  CrossrefPubMedGoogle Scholar
• 51 Scaramuzzi N, Walsh RM, Brennan P, Walsh M. Treatment of intractable epistaxis using arterial embolization. Clin Otolaryngol Allied Sci 2001; 26 (4) 307-309
  PubMedGoogle Scholar
• 52 Leppänen M, Seppänen S, Laranne J, Kuoppala K. Microcatheter embolization of intractable idiopathic epistaxis. Cardiovasc Intervent Radiol 1999; 22 (6) 499-503
  CrossrefPubMedGoogle Scholar
• 53 Elahi MM, Parnes LS, Fox AJ, Pelz DM, Lee DH. Therapeutic embolization in the treatment of intractable epistaxis. Arch Otolaryngol Head Neck Surg 1995; 121 (1) 65-69
  CrossrefPubMedGoogle Scholar
• 54 Moreau S, De Rugy MG, Babin E, Courtheoux P, Valdazo A. Supraselective embolization in intractable epistaxis: review of 45 cases. Laryngoscope 1998; 108 (6) 887-888
  CrossrefPubMedGoogle Scholar
• 55 Strong EB, Bell DA, Johnson LP, Jacobs JM. Intractable epistaxis: transantral ligation vs. embolization: efficacy review and cost analysis. Otolaryngol Head Neck Surg 1995; 113 (6) 674-678
  CrossrefPubMedGoogle Scholar
• 56 Tseng EY, Narducci CA, Willing SJ, Sillers MJ. Angiographic embolization for epistaxis: a review of 114 cases. Laryngoscope 1998; 108 (4, Pt 1) 615-619
  Google Scholar
• 57 Christensen NP, Smith DS, Barnwell SL, Wax MK. Arterial embolization in the management of posterior epistaxis. Otolaryngol Head Neck Surg 2005; 133 (5) 748-753
  CrossrefPubMedGoogle Scholar
• 58 Metson R, Hanson DG. Bilateral facial nerve paralysis following arterial embolization for epistaxis. Otolaryngol Head Neck Surg 1983; 91 (3) 299-303
  PubMedGoogle Scholar
• 59 Bynoe RP, Kerwin AJ, Parker III HH , et al. Maxillofacial injuries and life-threatening hemorrhage: treatment with transcatheter arterial embolization. J Trauma 2003; 55 (1) 74-79
  CrossrefPubMedGoogle Scholar
• 60 Liu WH, Chen YH, Hsieh CT, Lin EY, Chung TT, Ju DT. Transarterial embolization in the management of life-threatening hemorrhage after maxillofacial trauma: a case report and review of literature. Am J Emerg Med 2008; 26 (4) 516.e3-516.e5
  PubMedGoogle Scholar
• 61 Sakamoto T, Yagi K, Hiraide A , et al. Transcatheter embolization in the treatment of massive bleeding due to maxillofacial injury. J Trauma 1988; 28 (6) 840-843
  CrossrefPubMedGoogle Scholar
• 62 Yeh CH, Lin MS, Chiu MC, Chen CH, Pai YL. Endovascular treatment of a huge cervical carotid artery pseudoaneurysm with Wallgraft prosthesis. Ann Vasc Surg 2011; 25 (2) 265.e1-265.e3
  PubMedGoogle Scholar
• 63 Santaolalla F, Araluce I, Zabala A, López A, Garay M, Sanchez JM. Efficacy of selective percutaneous embolization for the treatment of intractable posterior epistaxis and juvenile nasopharyngeal angiofibroma (JNA). Acta Otolaryngol 2009; 129 (12) 1456-1462
  Google Scholar
• 64 Mok JS, Marshall JN, Chan M, van Hasselt CA. Percutaneous embolization to control intractable epistaxis in nasopharyngeal carcinoma. Head Neck 1999; 21 (3) 211-216
  CrossrefPubMedGoogle Scholar
• 65 Low YM, Goh YH. Endovascular treatment of epistaxis in patients irradiated for nasopharyngeal carcinoma. Clin Otolaryngol Allied Sci 2003; 28 (3) 244-247
  PubMedGoogle Scholar
• 66 Celik SE, Celik S, Kelten B. Extradural meningioma presenting with severe epistaxis: a case report and review of the literature. J Neurosurg Sci 2009; 53 (1) 27-30
  PubMedGoogle Scholar
• 67 Cloutier T, Pons Y, Blancal JP , et al. Juvenile nasopharyngeal angiofibroma: does the external approach still make sense?. Otolaryngol Head Neck Surg 2012; 147 (5) 958-963
  CrossrefPubMedGoogle Scholar
• 68 Hodges JM, McDevitt AS, El-Sayed Ali AI, Sebelik ME. Juvenile nasopharyngeal angiofibroma: current treatment modalities and future considerations. Indian J Otolaryngol Head Neck Surg 2010; 62 (3) 236-247
  CrossrefPubMedGoogle Scholar
• 69 Gurney TA, Dowd CF, Murr AH. Embolization for the treatment of idiopathic posterior epistaxis. Am J Rhinol 2004; 18 (5) 335-339
  PubMedGoogle Scholar
• 70 Willems PWA, Farb RI, Agid R. Endovascular treatment of epistaxis. AJNR Am J Neuroradiol 2009; 30 (9) 1637-1645
  CrossrefPubMedGoogle Scholar
• 71 Luo CB, Teng MM, Chang FC, Chang CY, Guo WY. Radiation carotid blowout syndrome in nasopharyngeal carcinoma: angiographic features and endovascular management. Otolaryngol Head Neck Surg 2008; 138 (1) 86-91
  CrossrefPubMedGoogle Scholar
• 72 Layton KF, Kallmes DF, Gray LA, Cloft HJ. Endovascular treatment of epistaxis in patients with hereditary hemorrhagic telangiectasia. AJNR Am J Neuroradiol 2007; 28 (5) 885-888
  PubMedGoogle Scholar
• 73 Merland JJ, Melki JP, Chiras J, Riche MC, Hadjean E. Place of embolization in the treatment of severe epistaxis. Laryngoscope 1980; 90 (10 Pt 1) 1694-1704
  PubMedGoogle Scholar
• 74 Siniluoto TM, Leinonen AS, Karttunen AI, Karjalainen HK, Jokinen KE. Embolization for the treatment of posterior epistaxis. An analysis of 31 cases. Arch Otolaryngol Head Neck Surg 1993; 119 (8) 837-841
  Google Scholar
• 75 Klein GE, Kole W, Karaic R , et al. Endovascular embolization treatment for intractable epistaxis. Laryngo Rhino Otologie 1997; 76 (2) 83-87
  PubMedGoogle Scholar
• 76 Remonda L, Schroth G, Caversaccio M , et al. Endovascular treatment of acute and subacute hemorrhage in the head and neck. Arch Otolaryngol Head Neck Surg 2000; 126 (10) 1255-1262
  CrossrefPubMedGoogle Scholar
• 77 Vokes DE, Mclvor NP, Wattie WJ, Chaplin JM, Morton RP. Endovascular treatment of epistaxis. ANZ J Surg 2004; 74 (9) 751-753
  CrossrefPubMedGoogle Scholar
• 78 Duncan IC, Fourie PA, le Grange CE, van der Walt HA. Endovascular treatment of intractable epistaxis-results of a 4-year local audit. S Afr Med J 2004; 94 (5) 373-378
  PubMedGoogle Scholar
• 79 Andersen PJ, Kjeldsen AD, Nepper-Rasmussen J. Selective embolization in the treatment of intractable epistaxis. Acta Oto-laryngologica 2005; 125 (3) 293-297
  CrossrefPubMedGoogle Scholar