1. EMBOLOTHERAPY IN EPISTAXIS
Sasa Ristic
Center of Radiology, Clinical center Nis, Serbia

2. INTRODUCTION Bleeding from nostril, nasal cavity or nasopharynx
common medical problem, with approximately 60% of the adult population having experienced at least 1 episode during their lives
fortunately, most cases resolve spontaneously
only 6% of epistaxis cases require medical attention
Most often self limited, but can often be serious and life threatening

3. INTRODUCTION equally frequent in males and females
The prevalence is increased for children less than 10 years of age and then rises again after the age of 40 years (increase of vascular disease, hypertension, iatrogenic and pathologic bleeding, and trauma)

4. ETIOLOGY
Local factors
Systemic factors
Combination of both

5. ETIOLOGY LOCAL FACTORS: Anatomic defect of the nasal septum Trauma
Surgical complication
Vascular malformation
Inflammatory
Neoplasm

6. ETIOLOGY SYSTEMIC FACTORS: Hypertension
Antiinflammatory analgesic medication (NSAID)
Cardiac, pulmonary, GI and renal disorders
Hereditary hemorrhagic telangiectasia
Hemostatic disorders

7. BLOOD SUPPLY OF THE NASAL CAVITY
Branches of internal carotid system :
Anterior ethmoidal artery
Posterior ethmoidal artery
Branches of external carotid system :
Sphenopalatine artery - major branch
Greater palatine artery
Superior labial branch of facial artery
Infraorbital branch of maxillary artery

8. KIESSELBACH’S PLEXUS (Little’s area)
Most common site for anterior epistaxis
In anterior inferior part of nasal septum
Mainly anterior epistaxis
septal br. of sphenopalatine
anterior ethmoidal
septal br. of superior labial
greater palatine arteries anastomose here
readily accessible area
hemorrhage from this region can usually be managed conservatively

9. WOODRUFF’S PLEXUS Most common site for posterior epistaxis
Posterior end of middle turbinate
Sphenopalatine artery anastomoses with posterior pharyngeal artery

10. CLASSIFICATION Anterior epistaxis Posterior epistaxis More common
Occurs in children and young adults
Usually due to nasal mucosal dryness
Alarming as bleeding seen readily but generally less severe
Posterior epistaxis
Usually older population
HTN and ASVD are the most common causes
Significant bleeding in posterior pharynx
More severe and treatment more challenging

11. EPISTAXIS TREATMENT OPTIONS
Conservative therapy
applying pressure to the nostrils,
chemical cautery or electrocautery,
vasoconstricting agents,
cryotherapy,
anterior and posterior packs (AP packs)
Surgical ligation (IMA, SPA, ECA, ethmoid arteries)
Endovascular embolization of the arteries supplying the posterior nasal fossa

12. ENDOVASCULAR TREATMENT
Endovascular treatment of epistaxis was first presented as an alternative to surgery by Sokoloff et al (1) in 1974.
consisted of particle embolization of the ipsilateral IMA
Lasjaunias et al (2) stressed the importance of obtaining a diagnostic preembolization angiogram of the ICA and ECA
1. Sokoloff J, Wickbom I, McDonald D, et al. Therapeutic percutaneous embolization in intractable epistaxis. Radiology 1974;111:285–87
2. Lasjaunias P, Marsot-Dupuch K, Doyon D. The radio-anatomical basis of arterial embolisation for epistaxis. J Neuroradiol 1979;6:45–53

13. THE IMPORTANCE OF A DG ANGIOGRAM
contrast extravasation,
tumor blush,
vascular malformation,
traumatic pseudoaneurysm,
vascular anomalies and variants,
“dangerous” anastomoses between the ECA and ICA or OphA (may open in case of increased pressure during embolization)

14. POTENTIAL CONNECTION BETWEEN ICA AND ECA
Artery of the foramen rotundum
Vidian artery
Middle meningeal artery
Accesory meningeal artery
Ascending pharingeal artery
Inferolateral trunk
Meningohypophiseal trunk
Communications between the facial artery, sphenopalatine artery and the ophtalmic artery
Filing of ECA-ICA anastomoses - risk of cerebral embolization !

15. EMBOLIZATION AGENTS pledgets of gelatin sponge (Gelfoam),
Gelfoam powder,
polyvinyl alcohol (PVA),
particles,
platinum coils,
or a combination of materials
100 – 300
300 – 500
500 – 700
700 – 900
900 – 1200

16. EMBOLIZATION TECHNIQUE
Local anaesthesia
Transfemoral aproach
Bilateral angiography of the ICA and ECA to rule out vascular variants (e.g. distal anastomosis between the ICA and ECA) or specific pathologies

17. EMBOLIZATION TECHNIQUE
Local anaesthesia
Transfemoral aproach
Bilateral angiography of the ICA and ECA to rule out vascular variants (e.g. distal anastomosis between the ICA and ECA) or specific pathologies

18. EMBOLIZATION TECHNIQUE
Selective cateterization of ECA branches – internal maxillary artery and sphenopalatine artery distal to any branches that did not supply the nasal mucosa.
Carefully monitoring under fluoroscopy and with repeated angiograms

19. EMBOLIZATION TECHNIQUE
Selective cateterization of ECA branches – internal maxillary artery and sphenopalatine artery distal to any branches that did not supply the nasal mucosa.
Carefully monitoring under fluoroscopy and with repeated angiograms

20. EMBOLIZATION TECHNIQUE
Slow and carefull injection of embolic material to avoid reflux in anastomosis of the ICA
Terminate when the flow in the capillary bed and distal branches of the embolized artery is significantly reduced or stopped

21. IDIOPATHIC POSTERIOR EPISTAXIS
Generally, at least 70% of cases are idiopathic
In most of these cases, findings of angiography will be normal !
Because embolization through the ICA and OphA cannot be considered safe, the single most important vessel to embolize is the ipsilateral IMA and its branches

22. NASOPHARINGEAL CARCINOMA

23. NASOPHARINGEAL CARCINOMA

24. OSLER-WEBER-RENDU DISEASE

25. OSLER-WEBER-RENDU DISEASE

26. OSLER-WEBER-RENDU DISEASE

27. OSLER-WEBER-RENDU DISEASE

28. JUVENILE NASOPHARYNGEAL ANGIOFIBROMA

29. JUVENILE NASOPHARYNGEAL ANGIOFIBROMA

30. COMPLICATIONS OF EMBOLIZATION
minor transient,
major transient, or
persistent

31. COMPLICATIONS OF EMBOLIZATION
MINOR TRANSIENT (25%–59%):
Headache
facial pain, trismus
facial edema
facial numbness
facial cold hypersensitivity,
paresthesias
mild palate ulceration
groin hematoma, groin pain
fever

32. COMPLICATIONS OF EMBOLIZATION
MAJOR TRANSIENT (0%–1%):
skin slough
temporary hemiparesis
temporary monocular visual field loss
mucosal necrosis

33. COMPLICATIONS OF EMBOLIZATION
PERSISTENT (up to 2%):
facial scarring following ischemia
monocular blindness
peripheral facial nerve paralysis
cerebral infarction
ischemic sialadenitis requiring surgery
NECROSIS OF ALA

34. CONCLUSION
Transarterial embolization is an accepted treatment option for intractable epistaxis, when epistaxis is refractory to conservative management
It is associated with a small risk of serious complications
be aware of possible “dangerous” anastomoses and perform diagnostic angiography before treatment
selective obliteration of the most distal blood vessels
can easily be repeated if necessary