Indications for selective arterial embolization in the treatment of epistaxis

After posterior packing has failed, the treatment of choice for severe, recurrent posterior epistaxis is arterial ligature, usually through a transantral approach to the Internal Maxillary artery (LTA) or selective percutaneous embolization (EP). The advantages and disadvantages of each technique are discussed by various Authors. A critical review of the literature brings to light the discrepancies between the results of various studies: in a series by Strong et al. and in a review of the literature EP proved more effective than LTA (90-94% vs. 85-89%). On the contrary, using personal data Cullen and Tami reported that the results are analogous. As regards complications, these proved slightly more frequent, but minor, with LTA while the rare complications with EP were more serious. The per-patient costs fundamentally depend on the type of hospital management and the availability of a treatment center; the results of the various studies are not analogous in this regard. The specific indications for the choice of which technique to use include: LTA: ethmoid artery hemorrhage, severe arteriosclerosis of the carotid compartment and allergy to the contrast medium; EP: cardiovascular instability, severe anemia and all conditions which are contraindications for general anesthesia. In the cases studied by the Authors, of the total 203 patients admitted to hospital for posterior epistaxis between May 1995 and November 1999, 12 (5.9%; on the average 2.6 pt/yr) showed values lower than those found at other Centers. A total of 13 EP procedures were performed and the result was positive (stopping the hemorrhage) in 11 (91.7%). In one post-traumatic case there was a recurrence which could not be controlled by EP and thus the Authors resorted to surgical ligature. All the patients underwent fibroscopy after the posterior packing was removed and before establishing the indications for EP. A full 50% of the patients treated showed arterial hypertension and in all patients except the one with multiple traumas, the pre-embolization angiography showed the presence of submucosal teleangiectasia in the site of the epistaxis. This report supports the hypothesis that, in the presence of triggering factors (hypertension, pregnancy), untreatable epistaxis is sustained by a submucosal vascular malformation. On the other hand, it also asserts that although the patient evaluation to determine the EP treatment was less invasive than that used in other Centers, it was able to identify the patients with this malformation, thus validating the clinical criteria used