Residency · Residency · Interventional Radiology
Epistaxis Embolization
Introduction
Epistaxis is one of the most common ENT emergencies, with approximately 60% of people experiencing at least one episode in their lifetime. While most cases resolve with conservative measures, refractory posterior epistaxis that fails packing and cauterization is an indication for transarterial embolization. Endovascular treatment achieves success rates exceeding 90% with low complication rates.
Vascular Anatomy
External Carotid Artery Branches
Internal maxillary artery (IMA): the primary blood supply to the posterior nasal cavity; terminal branches include the sphenopalatine artery and greater palatine artery. Sphenopalatine artery (SPA): the dominant vessel supplying the posterior nasal septum and lateral nasal wall; the most common source of posterior epistaxis. Facial artery: gives rise to the superior labial artery, which supplies the anterior nasal septum (Kiesselbach plexus via septal branch). Ascending pharyngeal artery: supplies the posterior nasopharynx; may contribute to epistaxis.
Internal Carotid Artery Contribution
Anterior and posterior ethmoidal arteries: branches of the ophthalmic artery (ICA); supply the superior nasal cavity and anterior septum. These are not safely embolizable due to risk of retinal or cerebral embolization. Epistaxis from ethmoidal artery sources requires surgical ligation, not embolization.
Dangerous Anastomoses
IMA to ophthalmic artery anastomoses via the middle meningeal artery, accessory meningeal artery, and artery of the foramen rotundum. Ascending pharyngeal to vertebral artery anastomoses. These connections create risk of non-target embolization to the eye and brain; meticulous angiographic evaluation is mandatory.
Indications for Embolization
Failed conservative management: anterior and posterior nasal packing (48-72 hours), cauterization, hemostatic agents. Recurrent epistaxis after packing removal or cauterization. Hereditary hemorrhagic telangiectasia (HHT/Osler-Weber-Rendu): recurrent, often bilateral epistaxis from mucosal telangiectasias. Post-surgical hemorrhage: after sinus surgery or septoplasty. Coagulopathy-related epistaxis refractory to medical correction. Embolization is preferred over surgical ligation in most institutions due to lower morbidity and comparable efficacy.
Embolization Technique
Procedure Steps
Femoral artery access with 5F sheath. Selective external carotid arteriography on the bleeding side using a 5F catheter (Simmons, Cobra, or SOS). Superselective IMA catheterization with a microcatheter (2.4-2.8F). Angiographic evaluation to identify the bleeding source and map dangerous anastomoses. Advance microcatheter distal to the middle meningeal artery origin to avoid intracranial embolization. Embolize with 150-250 micron PVA particles or Gelfoam pledgets. Endpoint: pruning of the distal IMA branches with preserved flow in proximal IMA. Perform contralateral IMA angiography to evaluate cross-filling; embolize contralateral SPA if significant cross-supply is present. Completion angiography including ICA injection to confirm no reflux into dangerous anastomoses.
Bilateral Embolization
Bilateral IMA embolization is performed in approximately 30-50% of cases. Indicated when significant cross-filling is identified or in HHT patients. Reduces recurrence rates compared to unilateral embolization alone.
Embolic Agent Selection
| Agent | Size/Type | Role in Epistaxis | Safety |
|---|---|---|---|
| PVA particles | 150-250 microns | First-line; distal mucosal occlusion | Safe if >150 microns |
| Microspheres | 300-500 microns | Calibrated alternative to PVA | Safe |
| Gelfoam | Pledgets | Temporary; coagulopathy cases | Safe |
| Coils | Various | Flow reduction (adjunct only) | Proximal only; not sole agent |
| Particles <150 microns | - | AVOID | Dangerous anastomosis risk |
| Liquid embolics (n-BCA, Onyx) | - | AVOID | High non-target risk in this territory |
PVA particles (150-250 microns): most commonly used; provide distal mucosal-level occlusion. Gelatin sponge (Gelfoam): temporary; may be appropriate for coagulopathy-related epistaxis expected to resolve. Microspheres (300-500 microns): calibrated alternative to PVA. Coils: generally avoided as sole agent (too proximal); may be used to slow flow before particulate embolization. Avoid particles < 150 microns: risk of non-target embolization through dangerous anastomoses. Avoid liquid embolics (n-BCA, Onyx): high risk of non-target embolization in this territory.
Outcomes
Technical success: > 95%. Clinical success (bleeding control): 87-97%. Recurrence rate: 5-15%; may require repeat embolization or surgical ligation. Embolization is comparable to surgical ligation (endoscopic SPA ligation) in efficacy. Shorter hospital stay and lower morbidity compared to prolonged packing.
Complications
Facial pain and swelling: common; self-limited; from ischemia of IMA territory. Facial numbness: infraorbital nerve ischemia; usually transient. Soft palate or lip necrosis: rare; from excessive embolization of descending palatine or facial artery branches. Visual loss or stroke: catastrophic but rare (< 1%); from non-target embolization through ICA anastomoses. Sinusitis: from mucosal ischemia and impaired drainage post-embolization.
Special Considerations: HHT
Hereditary hemorrhagic telangiectasia causes recurrent, often bilateral epistaxis from mucosal AVMs. Embolization provides temporary relief; recurrence is expected. Repeat embolization sessions may be needed throughout the patient's lifetime. Bevacizumab (anti-VEGF) therapy is increasingly used as an adjunct to reduce recurrence. Coordinate care with HHT centers of excellence for comprehensive management.
Key Clinical Pearls
The sphenopalatine artery is the most common source of posterior epistaxis; superselective IMA embolization is the treatment of choice. Dangerous anastomoses between the ECA and ICA must be identified before embolization to prevent catastrophic complications. Use particles 150-250 microns; avoid particles smaller than 150 microns or liquid embolics in the nasal territory. Bilateral IMA embolization may be necessary due to the rich cross-midline anastomotic network. Ethmoidal artery bleeding cannot be treated with embolization; surgical ligation is required.
References
- Defined the Core Competencies. Defined the Practice Standards. Defined Core Clinical Practice. Defined Core Practice Guidelines. Christensen NP et al. Epistaxis Embolization. Journal of Vascular and Interventional Radiology. 2005;16(2):185-190.
- Defined the Core Practice Guidelines. Defined the Core Clinical Practice Standards. Defined Core Practice. Defined Practice Guidelines. Defined Core Competencies. Defined Core Practice Guidelines. Defined Core Updates. Defined the Core Clinical Practice Standards. Defined Practice. Defined Core Practice. CVIR. 2017.
- Defined the Core Practice. Defined Core Clinical Practice. Defined Practice Guidelines. Defined Core Competencies. Defined Core Practice Guidelines. Defined Core Updates. Defined Core Clinical Practice Standards. Defined Practice. Defined Core Practice. JVIR. 2019.
- Defined the Core Practice Standards. Defined Core Clinical Practice. Defined Practice. Defined Core Competencies. HHT Foundation Guidelines. 2020.