Endovascular Management of Epistaxis

Clinical Relevance

Epistaxis is a common condition. Hemorrhage usually occurs anteriorly in the nasal cavity from the anterior nasal septal region. Most hemorrhages are mild and self-limiting and will resolve spontaneously. If hemorrhage continues it usually can be controlled by local treatments, including nasal packing or electrocautery. Intractable severe epistaxis may be treated by transarterial embolization.

Treatment Options

Treatment options for epistaxis include nasal packing, balloon tamponade, endoscopic inspection with cautery and surgical ligation, or endoscopic cauterization. Endovascular embolization in the case of intractable epistaxis has become an increasingly common management approach. The first successful percutaneous embolization for epistaxis was reported by Sokoloff et al. in 1974. The technique was applied to patients with hereditary hemorrhagic telangiectasia (HHT) by Strother and Newton in 1976, and in 1980, Merland et al. were able to report a 97% success rate in a first series of 54 patients with severe epistaxis. The technique has since been widely accepted and its efficacy confirmed. Embolization may be considered a safe and effective therapy for epistaxis. In addition, it is particularly helpful in cases where ear, nose, and throat (ENT) surgery has failed to stop bleeding, usually after an endoscopic approach.

Anatomy

The nasal mucosa receives its blood supply principally from branches of the internal maxillary artery via the sphenopalatine artery and inferiorly from the descending palatine artery. The anterior ethmoidal artery and posterior ethmoidal arteries are branches of the ophthalmic artery and supply the roof of the nasal cavity. Additional supply to the anterior nasal cavity comes from branches of the facial artery, from the ascending palatine artery, and the superior labial artery. Endovascular management of epistaxis has classically involved bilateral sphenopalatine and sometimes bilateral facial artery angiography followed by targeted embolization of offending vessel branches ^. Collateral networks with potentially dangerous anastomoses connecting the sphenopalatine artery and its branches to the facial artery and the anterior and posterior ethmoidal arteries are well recognized ( Fig. 64.1 ).

Etiology

Most cases of epistaxis are idiopathic. Idiopathic epistaxis typically occurs in hypertensive elderly people often taking anticoagulant or antiplatelet mediations with medical comorbidities A full medical review including indications and reversal of anticoagulant and antiplatelet agents should be performed before proceeding with endovascular embolization. Idiopathic epistaxis may have certain aggravating factors, including dry air, nasal oxygen cannulas, hypertension, low platelet count, and anticoagulant or antiplatelet medications. Patients with intractable epistaxis commonly show no major focal abnormality on angiography . Unusual causes of secondary epistaxis include traumatic pseudoaneurysm, iatrogenic epistaxis postsurgery, arteriovenous malformations and fistulae ( Fig. 64.2 ), aneurysm, juvenile angiofibroma, cancer of the nose and throat, and telangiectasia in the setting of HHT. Diffuse bilateral mucosal anomalies with telangiectasia can be seen on catheter angiography in the setting of HHT ( Fig. 64.3 ).

Indications

An estimated 60% of the population experiences epistaxis at least once in their lifetime, and about 6% of these patients require treatment. Between 1% and 6% of adults experience a large posterior nosebleed. Most cases of epistaxis are managed medically, but such methods are not always effective, especially in patients with a posterior source of bleeding. When conservative management fails, the epistaxis is termed intractable .

On catheter angiography patients with intractable epistaxis may show minor diffuse bilateral mucosal anomalies often secondary to nasal packing but with no clearly identifiable source of bleeding. Endovascular management of epistaxis has therefore classically involved bilateral distal internal maxillary artery embolization. However, a focal arterial anomaly may be detectable on angiography. A focal angiographic anomaly, when identified, may be selectively embolized.

Contraindications

It is critical that a physician performing transarterial embolization have an understanding of the potentially dangerous anastomoses around the skull base. These anastomoses may allow embolic material to pass from the extracranial circulation into the intracranial circulation during the embolization and result in a stroke or unilateral blindness. Relevant anastomoses involve the inferolateral trunk, ethmoidal collaterals, and meningohypophyseal arteries. In addition to being aware of these potentially dangerous anastomoses, use of larger embolic particles can minimize stroke risk. For this reason, it is advisable to never use embolic material smaller than 200 μm during routine embolization for epistaxis.

Equipment

5F or 6F guide catheters are commonly used and placed in the proximal external carotid artery. Additionally a wide variety of intermediate catheters are available that can be placed in the internal maxillary artery or in the facial artery to aid in microcatheter placement and used to perform superselective angiograms of the targeted vessels. When selecting a microcatheter, it is important to keep in mind the goal of atraumatic access. The “smaller, softer, and safer principle” applies to all procedures and equipment. Many microcatheters are available. They vary in stiffness, tractability, and inner and outer luminal diameter. Ideally, a catheter that will push and track yet remain stable should be used. Catheter braiding increases axial rigidity and improves stability.

An appropriately sized microcatheter is selected for each procedure by considering catheter flexibility and stability, the guiding catheter, and devices to be inserted into the microcatheter. The microcatheter must be compatible with the chosen embolic agent and not easily blocked by the agent. Before beginning a procedure, ensure that all equipment sizes are compatible with one another and that everything fits (sizes of wires, coil, etc.). Perform a dry table test if necessary, especially if the equipment is unfamiliar.