Refractory epistaxis treatment
Superselective endovascular embolization proved safe and effective in controlling idiopathic epistaxis, refractory to other maneuvers 1).
Indications
Epistaxis that has not responded to treatment including manual compression, nasal packing, local vasoconstrictors, endoscopic cauterization or surgical ligation of sphenopalatine artery.
Preoperative management
Verify lab values including Platelet count, BUN, CR, APTT, PT/INR, and Beta human chorionic gonadotropin for females of reproductive age group. In renal insufficiency, diabetes, CHF etc., use diluted non-ionic contrast agent and pre-plan carefully to maintain contrast load to minimum.
Liquids only on morning of procedure. NPO (for ≈ 6 hours) when procedure performed under general anesthesia.
Obtain informed consent for angiography and embolization of ECA branches Ensure two I.V. lines inserted. Insert Foley. The patient will be more comfortable and cooperative with an empty bladder, if the procedure becomes prolonged.
Technique
Position patient on the neuroangiography table. Attach pulse oximetry and ECG leads for monitoring O2 saturation, HR, cardiac rhythm respiratory rate and BP.
A sheath is placed in the femoral artery. A guide catheter is positioned in the proximal ECA on the side of bleeding or pathology. Angiography and roadmapping are performed through the guide catheter. Using fluoroscopy and road mapping, a microcatheter is advanced over the wire into the sphenopalatine artery branches. Angiography is performed through the microcatheter to ascertain appropriate positioning and to ensure no concerning collaterals with intracranial circulation exist. Contrast extravasation, tumor blush or pseudoaneurysms may be detected. A blank road map is obtained and embolization of the offending vessel commenced. PVA particles (250–300 mcgm) or Onyx (18 or 34) may be used. In case of Onyx, a DMSO compatible catheter is used. PVA may be cheaper and quicker to use.
Postoperative management
Post-op orders:
● Admit to ICU for overnight observation. Typically, nasal packing is left intact overnight and removed for inspection for bleeding the next day
● IV:0.9% NS + 20 meq KCl @ 150cc/hr X 2 hrs,then decrease to 100cc/hr,if patient is NPO.
● Activity: Keep right/left leg (whichever side was used for procedure) straight for 2 hrs (in case of Angioseal closure), or 6–8 hours (in case manual compression was applied), with HOB elevated 15o. This is achieved by placing a pillow under the patient’s head. There should be no flexion in the femoral region. If more head elevation is required, place bed in reverse-Trendelenburg position.
● Checkgroins,DP’s,vitals and neurochecks q 15min X 4,q 30 min X 4,then q hr.
● Advance diet as tolerated. Review/resume preprocedure medications (except oral hypoglycemics, until good PO intake established).