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Not All Embolizations Are Created Equally in the Management of Posterior Epistaxis: Discussion of Safety Measures Avoiding Neurological Complications

Not All Embolizations Are Created Equally in the Management of Posterior Epistaxis: Discussion of... Hindawi Radiology Research and Practice Volume 2020, Article ID 5710313, 8 pages https://doi.org/10.1155/2020/5710313 Clinical Study Not All Embolizations Are Created Equally in the Management of Posterior Epistaxis: Discussion of Safety Measures Avoiding Neurological Complications 1,2 3 1 1 4 Mareike Franke , Jasper Franke, Christian Saager, Sven Barthel, Randolf Riemann, and Kersten Mueckner Diagnostic and Interventional Radiology, Dr. Hancken Clinic, 21680 Stade, Germany Department of Radiology, Wesling Hospital Minden, University Hospital of the Ruhr University Bochum, 32429 Minden, Germany 53 N Studios, 21682 Stade, Germany Otorhinolaryngology, Head and Neck Surgery, Elbe Hospitals, 21680 Stade, Germany Correspondence should be addressed to Mareike Franke; mfr@hancken.de Received 20 January 2020; Revised 7 July 2020; Accepted 15 July 2020; Published 20 August 2020 Academic Editor: Paul Sijens Copyright © 2020 Mareike Franke et al. *is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Today, there are still no uniform guidelines for the treatment of epistaxis. Furthermore, it is widely debated whether embolization or surgical approaches should be the first choice of treatment for intractable posterior epistaxis after conservative measures have failed. In several meta-analyses, it is reported that endoscopic sphenopalatine artery ligation and embolization have similar success rates, but embolization was associated with more severe neurological complications. Regarding existing literature, there are many comparative analyses of surgical methods but none for embolization protocols. Against this backdrop of a lack of uniform standards in embolization techniques, we present a retrospective evaluation of what has emerged to be best procedural practice for endovascular treatment of epistaxis in our department using microsphere particles and microcoils, in particular regarding precaution measures to avoid neurological complications. In our retrospective data analysis of 141 procedures in 123 patients, performed between 2008 and 2019, we find success rates very similar to those reported in other studies (95.1% immediate-stop-of- bleeding success and 90.2% overall embolization success) but did not encounter any major neurological complication opposed to other reports. We suggest some aspects of our protocol as precaution measure to avoid neurological complications. More generally and perhaps even more importantly, we make a strong case for standardization for embolization techniques to the level of details in surgical procedure standardization to enable an apples to apples comparison of embolization techniques to each other and of intervention vs. surgery. pressure to the nostrils, chemical or electrocautery, topical 1. Introduction hemostatic or vasoconstricting agents, cryotherapy, or an- Epistaxis is a common medical condition but is rarely a terior nasal packing. However, severe, intractable bleeding direct cause for hospital admission. Up to 60% of adult usually arises from a posterior source, causing conservative population experience nasal bleeding at some stage of their measures to fail [2]. lives, but only 6% need medical help [1]. In general, for sufficient therapeutic management of In most cases, the bleeding starts from the anterior septal anterior or posterior epistaxis, a profound anatomical area (Little area), which is vascularized by Kiesselbach’s knowledge of the branches of the external carotid artery and plexus. As the Little area is readily accessible, hemorrhage arterial blood supply of the nasal cavity is absolutely nec- from this region can usually be managed by applying essary (Figure 1). APhA APA 2 Radiology Research and Practice with a surgical or endovascular approach. Different surgical methods have been described: there is a wide range from transantral artery ligation, submoucous resection, external carotid artery (ECA) ligation, and anterior ethmoidal artery ligation to endoscopic sphenopalatine artery ligation [9]. So ACA MCA far, endoscopic sphenopalatine artery ligation has the most favorable adverse effect profile and success rate compared with other surgical approaches [9–13]. OphA Endovascular treatment of epistaxis was first presented AEA PEA in 1974 as an alternative to surgery by Sokoloff et al. [14] and SPA ∗ consisted of particle embolization of the ipsilateral internal ICA maxillary artery (IMA). Later, Lasjaunias et al. [15] refined OccA the technique stressing the need for a standardized angio- IMA graphic and therapeutic protocol. Due to dangerous anas- SLA tomoses between the external and internal carotid arteries with the risk of embolic material entering the internal ca- FA rotid artery or ophthalmic artery, the procedure comes with the risk of severe neurologic complication, such as hemi- plegia, ophthalmoplegia, facial paralysis/paresthesia, or LA ECA A blindness [16, 17]. Cases of facial necrosis are published as well [18–20]. Figure 1: Arterial supply of nasal cavity. Digital subtraction an- As with surgery, there are many different protocols and giography via the common carotid artery shows branches of the techniques for embolization described (reviewed in [9] and external and internal carotid artery (ECA and ICA; 90 LAO). For [21]). Despite this multitude of techniques and protocols, no better understanding of the anatomy some anatomical structures comparing study exists. *e following methods have been like the nasal conchae, the floor of nasal cavity, nose, and fron- individually described in literature [19, 21, 22]: tobasis are drawn schematically. *e major part of blood supply for the nasal cavity is provided via branches of the ECA. Especially the (a) Embolization of the ipsilateral IMA and spheno- sphenopalatine artery (SPA), and end-branch of the internal palatine artery (SPA) or maxillary artery (IMA), is the main blood supply for the nasal cavity and for Kiesselbach’s plexus (asterisk). *e roof of the nasal (b) Embolization the ipsi- and contralateral IMA/SP or cavity is supplied by the anterior ethmoidal artery (AEA) and (c) Embolization of the ipsilateral or both ipsi- and posterior ethmoidal artery (PEA), which are branches of the contralateral IMA/SPA in combination with em- ophthalmic artery (OphA), i.e., branches of the internal carotid bolization of the ipsilateral or both ipsi- and con- artery (ICA). *e blood supply to the floor of the nasal cavity tralateral facial artery. originates from ascending palatine arteries (APA) from the facial artery (FA) and descending palatine artery (DPA) from IMA. Little *ere are also many different embolization materials supply to Kiesselbach’s plexus comes from the superior labial artery used (polyvinyl alcohol, coils, microspheres, gelfoam, etc. (SLA), an end-branch of the FA. And, finally minor supply to the [21]). In general, the success rates of endovascular therapy posterior area of the nasal cavity is provided by the ascending have been reported between 75 and 92% [9, 21]. pharyngeal artery (APhA), which originates from the ECA. Note Today, the possible treatment options for intractable the calcification of proximal ICA (arrow). Also shown are occipital epistaxis are widely debated. While endovascular treatment artery (OccA), ophthalmic artery (OPhA), and intracranial arteries is arguably easier on the patient requiring no general an- like anterior and middle cerebral artery (ACA and MCA). As ICA esthesia and has a shorter hospital stay [23], the presence of and ECA both contribute to the blood supply of the nasal cavity sometimes, there are some “dangerous” anastomoses, which can “dangerous anastomoses” and the associated risk of cere- cause blindness or stroke when accidentally embolized during the brovascular accident (CVA) is feared [3, 16]. procedure. *ese potentially “dangerous” anastomoses include the We believe the main contribution of this paper to be two- artery of the foramen rotundum, the middle meningeal artery, the fold: (1) we retrospectively evaluated 141 mostly micro- accessory meningeal artery, the ethmoidal arteries, the APhA, and sphere-based procedures performed on 123 patients at our of course the communications between the FA and OPhA[3]. hospital, thus contributing to a still very thin report base. (2) We find that—besides an encouragingly high success rate and a tolerable rate of rebleedings—not a single CVA oc- An option to control such posterior bleeding is the curred in our sample. We believe this to be due to the application of anterior and posterior packs (AP packs). precautionary measures developed as part of our inter- *ese packs have been reported to have a success rate be- ventional protocol using calibrated microspheres and coils. tween 48% and 83% [4–6]. As they can lead to nasal trauma, vagal response, aspiration, infection, allergic reactions, and airway obstruction they should be applied with care and 2. Materials and Methods under patient monitoring [7, 8]. If conservative measures fail, reducing the blood supply Between 2008 and 2019, 141 percutaneous endovascular to the sinonasal area is an option. *is can be achieved either embolization procedures for epistaxis were performed on Radiology Research and Practice 3 123 patients (80 male, 43 female, mean age 66, ranging from or double-sided embolization safely controlled hemorrhage 18 to 90 years). Patients were referred to us by the hospital’s in 111 of 123 patients, which needed no further surgery otorhinolaryngologist after failed conventional treatment, (Table 4). Technical success rate was 99.3% with one tech- involving anterior and posterior nasal packing and/or nical failure. In this case, a catheterization of the IMA was cauterization. Preinterventional imaging was not manda- not possible. Immediate-stop-of-bleeding success could be torily performed. Patients suffered from severe epistaxis (as achieved in 117 of 123 patients (95.1%). Early rebleeding classified in [24]). Approximately 20% of patients required within the first five days after first embolization could be blood transfusion due to chronic blood loss over a time observed in six patients (4.8%). In 16 cases, rebleeding period of several days with a drop in hemoglobin levels. occurred more than five days after embolization (13.0%). Interventions were performed with AP packs in situ. None of No life-threatening adverse event occurred (Table 4). the patients which underwent intervention were in hem- Especially no CVA could be observed. *e average proce- orrhagic shock. dure duration (i.e., duration of vulnerable period with All interventions were performed on an emergency basis catheters in carotid arteries) was 17.4minutes, ranging from in the angiographic facility of our department (until 2008 4 to 31 minutes. using a Siemens Axiom Artis angiography unit; from 2008 until today using a Philips Allura XP angiography unit). 3.2. Discussion. *ere are some meta-analyses stating that Patients received a mild sedation (1–2.5mg Midazolam i.v.). Monitoring of blood pressure and pulse oximetry was there are more neurological complications for endovascular treatment of epistaxis compared to surgery [3] (in contrary performed during the procedure. Patient assessment was performed according to Table 1. to other [26]) and case series/reports showing neurological and facial complications of endovascular treatment [16, 18]. Pathologic coagulation parameters had to be balanced by the referring department (INR<1.5, platelets>60,000 per *is leads to the opinion that endoscopic ligation of the sphenopalatine artery should be the method of choice and μl). *e embolization procedure was performed according to Table 2 (Figure 2). embolization should be performed in cases where surgical treatment fails or the patient has a high anesthetic risk. In For synergistic effects, AP packs were left overnight and our center, however, the endovascular treatment after failure removed the next day. 6 Patients had an embolization only with coils, without particles due to re-embolization of con- of conservative measure is routine, which emerged also from the discussion with our otorhinolaryngologists. It has been tralateral side during the first five days or an embolization of other arteries than SPA/distal IMA (Figures 3 and 4). investigated that there is a high risk of contamination of medical staff with patient`s blood during surgery [27, 28]. Data were analyzed in terms of etiologies of epistaxis, duration of procedure (i.e., duration of vulnerable time with Since we are frequently asked to treat epistaxis, we developed a protocol with high safety standards to avoid CVA. All catheters in the carotid arteries), overall embolization suc- cess, immediate-stop-of-bleeding success, and complica- patients were hemodynamically stable with nasal packs in situ. *e INR/platelet count had to be normalized before tions. Overall embolization success of endovascular treatment was defined as successful one- or double-sided therapy (INR<1.5 and platelets >60,000 μl). Despite being embolization of IMA/SPA avoiding surgery during a follow- admitted with diagnosis of intractable epistaxis, all patients received a dose of 5,000 I.E. heparin at the procedure’s up period of at least 6 months. Note that this definition of success also includes cases of patients which had to be re- beginning to avoid clot formation in catheters or adherent to the wires [29]. As complication rate increases with arte- embolized as the first embolization did in some cases not stop the bleeding immediately, but in all cases of emboli- riosclerotic vessel changes and procedure time [30–32], we try to keep the time of carotid catheterization as low as zation success, the patient avoided the more invasive treatment of surgery. Immediate-stop-of-bleeding success possible. *erefore, we prefer a “no-touch of ICA” strategy: In contrary to other publications (e.g., [15, 33]), we do not was classified as stopping the bleeding immediately for the next five days. While in some cases, the patients had to be re- perform a selective angiogram of the ICA because of cal- cifications in the passing region with the risk of thrombus embolized or required subsequent surgery; we considered it a success because the patient had at least five days during release and in addition increasing time of procedure. Only which they did not lose blood and did not require blood an angiogram of the carotid bifurcation is performed in every patient to identify ICA stenosis or occlusion which transfusion and could recover without AP packs. *ese two types of success are individually important but represent two could lead to recruitment of ECA/ICA collateral pathways requiring special attention. To detect the dangerous ICA/ distinct dimensions of benefit to the patient and are thus evaluated separately. Adverse effects were classified in major ECA-anastomoses, we perform an accurate angiogram of ECA and of the pterygopalatinal segment of IMA. and minor complications according to [25]. Another safety measure is continuous pressure flushing of the guiding catheter in the ECA to prevent blood clots. 3. Results and Discussion Additionally, we carefully rinse the microcatheter after application of particles before coil embolization of SPA and 3.1. Results. As described in the literature, many cases of IMA to avoid dislocation of particles. In general, you have to epistaxis were idiopathic (Table 3). keep in mind that stained micorparticles may be visible Due to noncompliance, 4 patients needed general an- through the skin if injected into superficial arteries [34]. esthesia. In terms of overall embolization success, one-sided APhA APhA SPA/IMA 4 Radiology Research and Practice Table 1: Patient assessment before and after intervention. Refractory posterior epistaxis after 48h conservative treatment, confirming indication by Indication otorhinolaryngologist and radiologist Laboratory assessment Creatinine, thyroid-stimulating hormone, platelet count, hemoglobin, INR Sedation/anesthesia Mild sedation with midazolam or general anesthesia when necessary (e.g., restless patient) *e patient placed lying down, infusion (500ml sodium chloride), head sedated with no radiopaque Assessment in the operating materials in beam path (e.g., remove dental prosthesis) suite One operator, one operator assistant, and an additional suite technician and anesthesiologist when necessary AngioSeal/ExoSeal occlusion of vessel access (common femoral artery), manual compression for 10–15 Assessment after procedure minutes, compression bandage overnight, ultrasound control of groin the next day Table 2: Standard protocol of procedure (see also Figure 2). Step 1 Femoral artery access, 5 F introducer sheath Step 2 Administration of 5000 I.E. heparin to avoid blood clots Step 3 Catheterize common carotid artery (CCA) with 5F guide catheter (100cm) and hydrophilic guide wire Step 4 Angiogram of the carotid bifurcation (40 RAO or LAO, resp.) Step 5 Catheterize external carotid artery (ECA) with guide wire and guide wire—tip of catheter approx. 2cm above the bifurcation Angiogram of ECA to find hazardous anastomoses or other unusual causes of epistaxis, e.g., AVM, tumor, pseudoaneurysm of Step 6 sinonasal arteries Step 7 Pressure flushing of guiding catheter in ECA with heparinised normal saline and introduce microcatheter and microwire Step 8 Identify internal maxillary artery (IMA) and sphenopalatine artery (SPA) and catheterize Step 9 Angiogram of IMA/SPA (“dangerous anastomoses” and MMA (Figure 2) When there are no hazardous anastomoses, embolize SPA/pterygopalatine segment of IMA with calibrated microparticles in Step 10 dilution with contrast medium (500 μm) until flow begins to slow. Important: avoid reflux, especially avoid embolization of MMA (headaches and hazardous anastomoses; Figure 2) When there are ECA-ICA anastomoses, directly go to step 12 Step 11 Rinse the microcatheter properly to avoid dislocation of microparticles Step 12 Embolize SPA and distal IMA with microcoils Step 13 Control angiogram Step 14 Quick removal of all catheters from the carotid arteries Step 15 Removal of introducer sheath, AngioSeal, or ExoSeal occlusion of vessel, compression bandage until the next day Step 16 Nasal packing is left intact overnight and removed for inspection for bleeding the next day a.p. 48° LAO 48° LAO SPA MMA TA SPA MMA IMA TA ∗ MMA IMA TA OccA DPA SLA FA BA FA LA ICA LA (a) (b) (c) Figure 2: Embolization of the left internal maxillary artery/sphenopalatine artery (IMA/SPA) in a 49-year-old female patient with he- reditary hemorrhagic telangiectasia. A.p. (a) and 48 LAO (b, c) Angiogram of left external carotid artery (ECA) shows arterial supply of nasal cavity via IMA. (a, b) Main supply of Kiesselbach’s plexus (asterisk) is provided via SPA, but there also collaterals to the superior labial artery (SLA, a branch of the facial artery FA). (c) Angiogram after embolization with micospheres and coils: there is no contrast flow in the SPA. Particle embolization of the SPA/distal IMA needs to be done very carefully to avoid accidental nontarget embolization of the middle meningeal artery (MMA) with possible hazardous anastomoses to ICA branches. Also shown is the labial artery (LA), temporal artery (TA), buccal artery (BA), occipital artery (OccA), descending palatine artery (DPA), and inferior alveolar artery (IAA). IAA IAA Radiology Research and Practice 5 SPA IOA DPA SLA FA FA LA LA (a) (b) Figure 3: Embolization of left facial artery (FA) in a 25-year-old male patient with epistaxis and hereditary hemorrhagic telangiectasia having had a double-sided embolization 5 years ago. (a) Angiogram of the external carotid artery (ECA) shows coils in both SPA/IMA (right and left; white open arrows) after a successful double-sided embolization in 2014. Examination shows an extended collateral network via the facial artery (FA) in 2019. *e collateral network consists of cross-connections of the superior labial artery (SLA)/infraorbital artery (IOA, open black arrow) and branches of FA/descending palatine artery (DPA, black arrow). (b) Coil embolization of FA was performed (black arrow). Control angiogram after embolization shows no significant contrast flow in the collateral network and Kiesselbach’s plexus. Also shown is the labial artery (LA). TA MMA IMA (a) (b) Figure 4: Re-embolization of left external carotid artery (ECA) due to an accessory artery from IMA in a 72-year-old male patient with epistaxis (risk factor: anticoagulation). (a) Angiogram of ECA shows coils in the internal maxillary artery (IMA) and sphenopalatine artery (SPA, open white arrow) after embolization 53 days earlier. However, there is an accessory artery rising from of the proximal IMA (black arrow), then running to the dorsal part of the nasal cavity, potentially being responsible for the rebleeding. (b) Decision was made to embolize the ECA to stop the blood supply to this artery. No particles were used. Embolization was performed with coils (white arrow). Also shown are middle meningeal artery (MMA) and temporal artery (TA). *erefore, we make sure to use nonstained particles for head embolization. *e application should be performed in and neck embolizations. *e size of microspheres for em- highest magnification and dose of continuous fluoroscopy to bolization is carefully chosen. While smaller particles are detect a reflux instantly to prevent nontarget embolization. able to penetrate more distally into capillary beds, they can Particle embolization is halted when flow starts to slow. If there was any doubt about (1) ICA/ECA-anastomoses, (2) also cause injury to the vasa nervorum resulting in cranial nerve palsies or enter the intracranial circulation through the need for a second embolization during the first week, or ECA/ICA anastomoses. When using microspheres, it is (3) the need to embolize other arteries than IMA/SPA, no recommended to oversize these particles for head and neck particles were used at all to avoid CVA or facial necrosis. *e embolization compared with polyvinyl alcohol (PVA) par- embolization with coils only had a slightly higher failure rate ticles [20]. We use 500 μm calibrated microparticles for than particle plus coil-embolization (one of 6 patients 6 Radiology Research and Practice Table 3: Etiologies of epistaxis. Etiology No. of patients Idiopathic epistaxis (no risk factor could be detected) 45 Anticoagulant therapy 26 Hypertension 23 Anticoagulant therapy and hypertension 8 Low platelet count 1 Alcohol withdrawal 1 Surgical complication/preliminary surgery 7 Malignant tumor 8 Trauma 1 Hereditary hemorrhagic telangiectasia 3 Table 4: Outcome of patients in a follow-up period of at least 6 months. In 111 patients, embolization controlled active hemorrhage and no surgery was necessary 90.2% (i) In 101 patients, a one-sided embolization was sufficient to stop the bleeding (ii) 2 patients had a rebleeding at the third and fourth days after intervention and needed embolization of contralateral side; embolization of the contralateral site was performed without particles to avoid facial necrosis, since there was only a short interval to the first embolization th th (iii) 4 patients had a rebleeding at the 7 till 14 day after intervention and needed embolization of the contralateral side (iv) 2 patients had a rebleeding after 31 and 32 days after intervention and needed embolization of contralateral side (v) 1 patient had a rebleeding after 5 months after intervention and needed embolization of the contralateral side (vi) 1 patient with hereditary hemorrhagic telangiectasia had a successful double-sided embolization in 2014 (rebleeding after 36 days) and a rebleeding in 2019; in 2019, an embolization of the facial artery was performed without particles (Figure 3) 12 patients needed additional surgery 9.7% (i) 4 patients had surgery at the following day after one-sided embolization due to recurrence of bleeding (ii) 1 patient had a rebleeding 7 days after one-sided embolization and received surgery (iii) 3 patients had a rebleeding after 7, 22, and 28 days, respectively, after successful endovascular treatment, and contralateral embolization failed to stop the rebleeding, surgery was performed (iv) 1 patient had a rebleeding one week after successful embolization; embolization failed due to lack of possibility to catheterize contralateral IMA (technical failure); the patient received surgery (v) 2 patients with hereditary hemorrhagic telangiectasia had a rebleeding 49 and 97 days, respectively, after a successful embolization; contralateral embolization was not successful in stopping the bleeding; surgery was performed (vi) 1 patient had a successful embolization of left IMA/SPA and 53 days later had a rebleeding on the left side; an embolization of the left external carotid artery (ECA) was performed due to an atypical accessory artery (Figure 4); 7 days later, a rebleeding occurred and embolization of the right IMA/SPA was performed; due to recurrence of bleeding, surgery was performed needed further surgery; success rate: 83.3%). Some reports embolization was very efficient in most cases. All 3 patients criticize the use of coils in general, because the possibility of with hereditary hemorrhagic telangiectasia needed at least a repetition of distal embolization could be lost [23]. We use double-sided embolization, and two of them had further particle and coil embolization of SPA/IMA as we have the surgery after primary bleeding control. In general, these pa- tients are difficult to treat. impression that, by doing so, we reduce also the residual flow and pressure via the IMA in prevention of a relapse. Fur- *e only observed major complications were access site thermore, revascularization after embolization often occurs complications with a slightly increased rate of arterial oc- either via the contralateral side or via the facial artery, thus clusions (1.4% vs. 0.1–0.9% [36]). *e reason for this could these arteries can be easily embolized during a second be the introduction of vascular closure devices in 2008 with procedure. Should a revascularization occur via the eth- no extensive experience during the first month of use. A few moidal arteries, a surgical therapy would be required. cases of headache after embolization could be well handled Rebleeding is a known problem for the treatment of ep- with analgesics. istaxis. Primary double-sided or triple-artery embolizations are *e limitation of our case series is of course the small described in the literature postulating that the rate of early case number of 141 procedures. Although this is to our recurrences decreases with the number of arteries embolized knowledge one of the largest primary case series in literature, [19]. However, this group had a certain rate of nose necrosis it does not allow postulating general rules at statistical and several cases of facial edema. A case analysis from 2018 significance. Our protocol has been proved to be safe and even found out that bilateral particle embolization including effective with a primary efficiency of 95% with no neuro- facial artery was the treatment method associated with a sig- logical complications. So, we would like to present our nificant risk of complications [35]. With the exception of protocol or aspects of our protocol as a suggestion for the patients with hereditary hemorrhagic telangiectasia, one-sided reader or as basis of a further discussion. Radiology Research and Practice 7 management of adult epistaxis: systematic review,” 9e 4. 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Not All Embolizations Are Created Equally in the Management of Posterior Epistaxis: Discussion of Safety Measures Avoiding Neurological Complications

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Hindawi Radiology Research and Practice Volume 2020, Article ID 5710313, 8 pages https://doi.org/10.1155/2020/5710313 Clinical Study Not All Embolizations Are Created Equally in the Management of Posterior Epistaxis: Discussion of Safety Measures Avoiding Neurological Complications 1,2 3 1 1 4 Mareike Franke , Jasper Franke, Christian Saager, Sven Barthel, Randolf Riemann, and Kersten Mueckner Diagnostic and Interventional Radiology, Dr. Hancken Clinic, 21680 Stade, Germany Department of Radiology, Wesling Hospital Minden, University Hospital of the Ruhr University Bochum, 32429 Minden, Germany 53 N Studios, 21682 Stade, Germany Otorhinolaryngology, Head and Neck Surgery, Elbe Hospitals, 21680 Stade, Germany Correspondence should be addressed to Mareike Franke; mfr@hancken.de Received 20 January 2020; Revised 7 July 2020; Accepted 15 July 2020; Published 20 August 2020 Academic Editor: Paul Sijens Copyright © 2020 Mareike Franke et al. *is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Today, there are still no uniform guidelines for the treatment of epistaxis. Furthermore, it is widely debated whether embolization or surgical approaches should be the first choice of treatment for intractable posterior epistaxis after conservative measures have failed. In several meta-analyses, it is reported that endoscopic sphenopalatine artery ligation and embolization have similar success rates, but embolization was associated with more severe neurological complications. Regarding existing literature, there are many comparative analyses of surgical methods but none for embolization protocols. Against this backdrop of a lack of uniform standards in embolization techniques, we present a retrospective evaluation of what has emerged to be best procedural practice for endovascular treatment of epistaxis in our department using microsphere particles and microcoils, in particular regarding precaution measures to avoid neurological complications. In our retrospective data analysis of 141 procedures in 123 patients, performed between 2008 and 2019, we find success rates very similar to those reported in other studies (95.1% immediate-stop-of- bleeding success and 90.2% overall embolization success) but did not encounter any major neurological complication opposed to other reports. We suggest some aspects of our protocol as precaution measure to avoid neurological complications. More generally and perhaps even more importantly, we make a strong case for standardization for embolization techniques to the level of details in surgical procedure standardization to enable an apples to apples comparison of embolization techniques to each other and of intervention vs. surgery. pressure to the nostrils, chemical or electrocautery, topical 1. Introduction hemostatic or vasoconstricting agents, cryotherapy, or an- Epistaxis is a common medical condition but is rarely a terior nasal packing. However, severe, intractable bleeding direct cause for hospital admission. Up to 60% of adult usually arises from a posterior source, causing conservative population experience nasal bleeding at some stage of their measures to fail [2]. lives, but only 6% need medical help [1]. In general, for sufficient therapeutic management of In most cases, the bleeding starts from the anterior septal anterior or posterior epistaxis, a profound anatomical area (Little area), which is vascularized by Kiesselbach’s knowledge of the branches of the external carotid artery and plexus. As the Little area is readily accessible, hemorrhage arterial blood supply of the nasal cavity is absolutely nec- from this region can usually be managed by applying essary (Figure 1). APhA APA 2 Radiology Research and Practice with a surgical or endovascular approach. Different surgical methods have been described: there is a wide range from transantral artery ligation, submoucous resection, external carotid artery (ECA) ligation, and anterior ethmoidal artery ligation to endoscopic sphenopalatine artery ligation [9]. So ACA MCA far, endoscopic sphenopalatine artery ligation has the most favorable adverse effect profile and success rate compared with other surgical approaches [9–13]. OphA Endovascular treatment of epistaxis was first presented AEA PEA in 1974 as an alternative to surgery by Sokoloff et al. [14] and SPA ∗ consisted of particle embolization of the ipsilateral internal ICA maxillary artery (IMA). Later, Lasjaunias et al. [15] refined OccA the technique stressing the need for a standardized angio- IMA graphic and therapeutic protocol. Due to dangerous anas- SLA tomoses between the external and internal carotid arteries with the risk of embolic material entering the internal ca- FA rotid artery or ophthalmic artery, the procedure comes with the risk of severe neurologic complication, such as hemi- plegia, ophthalmoplegia, facial paralysis/paresthesia, or LA ECA A blindness [16, 17]. Cases of facial necrosis are published as well [18–20]. Figure 1: Arterial supply of nasal cavity. Digital subtraction an- As with surgery, there are many different protocols and giography via the common carotid artery shows branches of the techniques for embolization described (reviewed in [9] and external and internal carotid artery (ECA and ICA; 90 LAO). For [21]). Despite this multitude of techniques and protocols, no better understanding of the anatomy some anatomical structures comparing study exists. *e following methods have been like the nasal conchae, the floor of nasal cavity, nose, and fron- individually described in literature [19, 21, 22]: tobasis are drawn schematically. *e major part of blood supply for the nasal cavity is provided via branches of the ECA. Especially the (a) Embolization of the ipsilateral IMA and spheno- sphenopalatine artery (SPA), and end-branch of the internal palatine artery (SPA) or maxillary artery (IMA), is the main blood supply for the nasal cavity and for Kiesselbach’s plexus (asterisk). *e roof of the nasal (b) Embolization the ipsi- and contralateral IMA/SP or cavity is supplied by the anterior ethmoidal artery (AEA) and (c) Embolization of the ipsilateral or both ipsi- and posterior ethmoidal artery (PEA), which are branches of the contralateral IMA/SPA in combination with em- ophthalmic artery (OphA), i.e., branches of the internal carotid bolization of the ipsilateral or both ipsi- and con- artery (ICA). *e blood supply to the floor of the nasal cavity tralateral facial artery. originates from ascending palatine arteries (APA) from the facial artery (FA) and descending palatine artery (DPA) from IMA. Little *ere are also many different embolization materials supply to Kiesselbach’s plexus comes from the superior labial artery used (polyvinyl alcohol, coils, microspheres, gelfoam, etc. (SLA), an end-branch of the FA. And, finally minor supply to the [21]). In general, the success rates of endovascular therapy posterior area of the nasal cavity is provided by the ascending have been reported between 75 and 92% [9, 21]. pharyngeal artery (APhA), which originates from the ECA. Note Today, the possible treatment options for intractable the calcification of proximal ICA (arrow). Also shown are occipital epistaxis are widely debated. While endovascular treatment artery (OccA), ophthalmic artery (OPhA), and intracranial arteries is arguably easier on the patient requiring no general an- like anterior and middle cerebral artery (ACA and MCA). As ICA esthesia and has a shorter hospital stay [23], the presence of and ECA both contribute to the blood supply of the nasal cavity sometimes, there are some “dangerous” anastomoses, which can “dangerous anastomoses” and the associated risk of cere- cause blindness or stroke when accidentally embolized during the brovascular accident (CVA) is feared [3, 16]. procedure. *ese potentially “dangerous” anastomoses include the We believe the main contribution of this paper to be two- artery of the foramen rotundum, the middle meningeal artery, the fold: (1) we retrospectively evaluated 141 mostly micro- accessory meningeal artery, the ethmoidal arteries, the APhA, and sphere-based procedures performed on 123 patients at our of course the communications between the FA and OPhA[3]. hospital, thus contributing to a still very thin report base. (2) We find that—besides an encouragingly high success rate and a tolerable rate of rebleedings—not a single CVA oc- An option to control such posterior bleeding is the curred in our sample. We believe this to be due to the application of anterior and posterior packs (AP packs). precautionary measures developed as part of our inter- *ese packs have been reported to have a success rate be- ventional protocol using calibrated microspheres and coils. tween 48% and 83% [4–6]. As they can lead to nasal trauma, vagal response, aspiration, infection, allergic reactions, and airway obstruction they should be applied with care and 2. Materials and Methods under patient monitoring [7, 8]. If conservative measures fail, reducing the blood supply Between 2008 and 2019, 141 percutaneous endovascular to the sinonasal area is an option. *is can be achieved either embolization procedures for epistaxis were performed on Radiology Research and Practice 3 123 patients (80 male, 43 female, mean age 66, ranging from or double-sided embolization safely controlled hemorrhage 18 to 90 years). Patients were referred to us by the hospital’s in 111 of 123 patients, which needed no further surgery otorhinolaryngologist after failed conventional treatment, (Table 4). Technical success rate was 99.3% with one tech- involving anterior and posterior nasal packing and/or nical failure. In this case, a catheterization of the IMA was cauterization. Preinterventional imaging was not manda- not possible. Immediate-stop-of-bleeding success could be torily performed. Patients suffered from severe epistaxis (as achieved in 117 of 123 patients (95.1%). Early rebleeding classified in [24]). Approximately 20% of patients required within the first five days after first embolization could be blood transfusion due to chronic blood loss over a time observed in six patients (4.8%). In 16 cases, rebleeding period of several days with a drop in hemoglobin levels. occurred more than five days after embolization (13.0%). Interventions were performed with AP packs in situ. None of No life-threatening adverse event occurred (Table 4). the patients which underwent intervention were in hem- Especially no CVA could be observed. *e average proce- orrhagic shock. dure duration (i.e., duration of vulnerable period with All interventions were performed on an emergency basis catheters in carotid arteries) was 17.4minutes, ranging from in the angiographic facility of our department (until 2008 4 to 31 minutes. using a Siemens Axiom Artis angiography unit; from 2008 until today using a Philips Allura XP angiography unit). 3.2. Discussion. *ere are some meta-analyses stating that Patients received a mild sedation (1–2.5mg Midazolam i.v.). Monitoring of blood pressure and pulse oximetry was there are more neurological complications for endovascular treatment of epistaxis compared to surgery [3] (in contrary performed during the procedure. Patient assessment was performed according to Table 1. to other [26]) and case series/reports showing neurological and facial complications of endovascular treatment [16, 18]. Pathologic coagulation parameters had to be balanced by the referring department (INR<1.5, platelets>60,000 per *is leads to the opinion that endoscopic ligation of the sphenopalatine artery should be the method of choice and μl). *e embolization procedure was performed according to Table 2 (Figure 2). embolization should be performed in cases where surgical treatment fails or the patient has a high anesthetic risk. In For synergistic effects, AP packs were left overnight and our center, however, the endovascular treatment after failure removed the next day. 6 Patients had an embolization only with coils, without particles due to re-embolization of con- of conservative measure is routine, which emerged also from the discussion with our otorhinolaryngologists. It has been tralateral side during the first five days or an embolization of other arteries than SPA/distal IMA (Figures 3 and 4). investigated that there is a high risk of contamination of medical staff with patient`s blood during surgery [27, 28]. Data were analyzed in terms of etiologies of epistaxis, duration of procedure (i.e., duration of vulnerable time with Since we are frequently asked to treat epistaxis, we developed a protocol with high safety standards to avoid CVA. All catheters in the carotid arteries), overall embolization suc- cess, immediate-stop-of-bleeding success, and complica- patients were hemodynamically stable with nasal packs in situ. *e INR/platelet count had to be normalized before tions. Overall embolization success of endovascular treatment was defined as successful one- or double-sided therapy (INR<1.5 and platelets >60,000 μl). Despite being embolization of IMA/SPA avoiding surgery during a follow- admitted with diagnosis of intractable epistaxis, all patients received a dose of 5,000 I.E. heparin at the procedure’s up period of at least 6 months. Note that this definition of success also includes cases of patients which had to be re- beginning to avoid clot formation in catheters or adherent to the wires [29]. As complication rate increases with arte- embolized as the first embolization did in some cases not stop the bleeding immediately, but in all cases of emboli- riosclerotic vessel changes and procedure time [30–32], we try to keep the time of carotid catheterization as low as zation success, the patient avoided the more invasive treatment of surgery. Immediate-stop-of-bleeding success possible. *erefore, we prefer a “no-touch of ICA” strategy: In contrary to other publications (e.g., [15, 33]), we do not was classified as stopping the bleeding immediately for the next five days. While in some cases, the patients had to be re- perform a selective angiogram of the ICA because of cal- cifications in the passing region with the risk of thrombus embolized or required subsequent surgery; we considered it a success because the patient had at least five days during release and in addition increasing time of procedure. Only which they did not lose blood and did not require blood an angiogram of the carotid bifurcation is performed in every patient to identify ICA stenosis or occlusion which transfusion and could recover without AP packs. *ese two types of success are individually important but represent two could lead to recruitment of ECA/ICA collateral pathways requiring special attention. To detect the dangerous ICA/ distinct dimensions of benefit to the patient and are thus evaluated separately. Adverse effects were classified in major ECA-anastomoses, we perform an accurate angiogram of ECA and of the pterygopalatinal segment of IMA. and minor complications according to [25]. Another safety measure is continuous pressure flushing of the guiding catheter in the ECA to prevent blood clots. 3. Results and Discussion Additionally, we carefully rinse the microcatheter after application of particles before coil embolization of SPA and 3.1. Results. As described in the literature, many cases of IMA to avoid dislocation of particles. In general, you have to epistaxis were idiopathic (Table 3). keep in mind that stained micorparticles may be visible Due to noncompliance, 4 patients needed general an- through the skin if injected into superficial arteries [34]. esthesia. In terms of overall embolization success, one-sided APhA APhA SPA/IMA 4 Radiology Research and Practice Table 1: Patient assessment before and after intervention. Refractory posterior epistaxis after 48h conservative treatment, confirming indication by Indication otorhinolaryngologist and radiologist Laboratory assessment Creatinine, thyroid-stimulating hormone, platelet count, hemoglobin, INR Sedation/anesthesia Mild sedation with midazolam or general anesthesia when necessary (e.g., restless patient) *e patient placed lying down, infusion (500ml sodium chloride), head sedated with no radiopaque Assessment in the operating materials in beam path (e.g., remove dental prosthesis) suite One operator, one operator assistant, and an additional suite technician and anesthesiologist when necessary AngioSeal/ExoSeal occlusion of vessel access (common femoral artery), manual compression for 10–15 Assessment after procedure minutes, compression bandage overnight, ultrasound control of groin the next day Table 2: Standard protocol of procedure (see also Figure 2). Step 1 Femoral artery access, 5 F introducer sheath Step 2 Administration of 5000 I.E. heparin to avoid blood clots Step 3 Catheterize common carotid artery (CCA) with 5F guide catheter (100cm) and hydrophilic guide wire Step 4 Angiogram of the carotid bifurcation (40 RAO or LAO, resp.) Step 5 Catheterize external carotid artery (ECA) with guide wire and guide wire—tip of catheter approx. 2cm above the bifurcation Angiogram of ECA to find hazardous anastomoses or other unusual causes of epistaxis, e.g., AVM, tumor, pseudoaneurysm of Step 6 sinonasal arteries Step 7 Pressure flushing of guiding catheter in ECA with heparinised normal saline and introduce microcatheter and microwire Step 8 Identify internal maxillary artery (IMA) and sphenopalatine artery (SPA) and catheterize Step 9 Angiogram of IMA/SPA (“dangerous anastomoses” and MMA (Figure 2) When there are no hazardous anastomoses, embolize SPA/pterygopalatine segment of IMA with calibrated microparticles in Step 10 dilution with contrast medium (500 μm) until flow begins to slow. Important: avoid reflux, especially avoid embolization of MMA (headaches and hazardous anastomoses; Figure 2) When there are ECA-ICA anastomoses, directly go to step 12 Step 11 Rinse the microcatheter properly to avoid dislocation of microparticles Step 12 Embolize SPA and distal IMA with microcoils Step 13 Control angiogram Step 14 Quick removal of all catheters from the carotid arteries Step 15 Removal of introducer sheath, AngioSeal, or ExoSeal occlusion of vessel, compression bandage until the next day Step 16 Nasal packing is left intact overnight and removed for inspection for bleeding the next day a.p. 48° LAO 48° LAO SPA MMA TA SPA MMA IMA TA ∗ MMA IMA TA OccA DPA SLA FA BA FA LA ICA LA (a) (b) (c) Figure 2: Embolization of the left internal maxillary artery/sphenopalatine artery (IMA/SPA) in a 49-year-old female patient with he- reditary hemorrhagic telangiectasia. A.p. (a) and 48 LAO (b, c) Angiogram of left external carotid artery (ECA) shows arterial supply of nasal cavity via IMA. (a, b) Main supply of Kiesselbach’s plexus (asterisk) is provided via SPA, but there also collaterals to the superior labial artery (SLA, a branch of the facial artery FA). (c) Angiogram after embolization with micospheres and coils: there is no contrast flow in the SPA. Particle embolization of the SPA/distal IMA needs to be done very carefully to avoid accidental nontarget embolization of the middle meningeal artery (MMA) with possible hazardous anastomoses to ICA branches. Also shown is the labial artery (LA), temporal artery (TA), buccal artery (BA), occipital artery (OccA), descending palatine artery (DPA), and inferior alveolar artery (IAA). IAA IAA Radiology Research and Practice 5 SPA IOA DPA SLA FA FA LA LA (a) (b) Figure 3: Embolization of left facial artery (FA) in a 25-year-old male patient with epistaxis and hereditary hemorrhagic telangiectasia having had a double-sided embolization 5 years ago. (a) Angiogram of the external carotid artery (ECA) shows coils in both SPA/IMA (right and left; white open arrows) after a successful double-sided embolization in 2014. Examination shows an extended collateral network via the facial artery (FA) in 2019. *e collateral network consists of cross-connections of the superior labial artery (SLA)/infraorbital artery (IOA, open black arrow) and branches of FA/descending palatine artery (DPA, black arrow). (b) Coil embolization of FA was performed (black arrow). Control angiogram after embolization shows no significant contrast flow in the collateral network and Kiesselbach’s plexus. Also shown is the labial artery (LA). TA MMA IMA (a) (b) Figure 4: Re-embolization of left external carotid artery (ECA) due to an accessory artery from IMA in a 72-year-old male patient with epistaxis (risk factor: anticoagulation). (a) Angiogram of ECA shows coils in the internal maxillary artery (IMA) and sphenopalatine artery (SPA, open white arrow) after embolization 53 days earlier. However, there is an accessory artery rising from of the proximal IMA (black arrow), then running to the dorsal part of the nasal cavity, potentially being responsible for the rebleeding. (b) Decision was made to embolize the ECA to stop the blood supply to this artery. No particles were used. Embolization was performed with coils (white arrow). Also shown are middle meningeal artery (MMA) and temporal artery (TA). *erefore, we make sure to use nonstained particles for head embolization. *e application should be performed in and neck embolizations. *e size of microspheres for em- highest magnification and dose of continuous fluoroscopy to bolization is carefully chosen. While smaller particles are detect a reflux instantly to prevent nontarget embolization. able to penetrate more distally into capillary beds, they can Particle embolization is halted when flow starts to slow. If there was any doubt about (1) ICA/ECA-anastomoses, (2) also cause injury to the vasa nervorum resulting in cranial nerve palsies or enter the intracranial circulation through the need for a second embolization during the first week, or ECA/ICA anastomoses. When using microspheres, it is (3) the need to embolize other arteries than IMA/SPA, no recommended to oversize these particles for head and neck particles were used at all to avoid CVA or facial necrosis. *e embolization compared with polyvinyl alcohol (PVA) par- embolization with coils only had a slightly higher failure rate ticles [20]. We use 500 μm calibrated microparticles for than particle plus coil-embolization (one of 6 patients 6 Radiology Research and Practice Table 3: Etiologies of epistaxis. Etiology No. of patients Idiopathic epistaxis (no risk factor could be detected) 45 Anticoagulant therapy 26 Hypertension 23 Anticoagulant therapy and hypertension 8 Low platelet count 1 Alcohol withdrawal 1 Surgical complication/preliminary surgery 7 Malignant tumor 8 Trauma 1 Hereditary hemorrhagic telangiectasia 3 Table 4: Outcome of patients in a follow-up period of at least 6 months. In 111 patients, embolization controlled active hemorrhage and no surgery was necessary 90.2% (i) In 101 patients, a one-sided embolization was sufficient to stop the bleeding (ii) 2 patients had a rebleeding at the third and fourth days after intervention and needed embolization of contralateral side; embolization of the contralateral site was performed without particles to avoid facial necrosis, since there was only a short interval to the first embolization th th (iii) 4 patients had a rebleeding at the 7 till 14 day after intervention and needed embolization of the contralateral side (iv) 2 patients had a rebleeding after 31 and 32 days after intervention and needed embolization of contralateral side (v) 1 patient had a rebleeding after 5 months after intervention and needed embolization of the contralateral side (vi) 1 patient with hereditary hemorrhagic telangiectasia had a successful double-sided embolization in 2014 (rebleeding after 36 days) and a rebleeding in 2019; in 2019, an embolization of the facial artery was performed without particles (Figure 3) 12 patients needed additional surgery 9.7% (i) 4 patients had surgery at the following day after one-sided embolization due to recurrence of bleeding (ii) 1 patient had a rebleeding 7 days after one-sided embolization and received surgery (iii) 3 patients had a rebleeding after 7, 22, and 28 days, respectively, after successful endovascular treatment, and contralateral embolization failed to stop the rebleeding, surgery was performed (iv) 1 patient had a rebleeding one week after successful embolization; embolization failed due to lack of possibility to catheterize contralateral IMA (technical failure); the patient received surgery (v) 2 patients with hereditary hemorrhagic telangiectasia had a rebleeding 49 and 97 days, respectively, after a successful embolization; contralateral embolization was not successful in stopping the bleeding; surgery was performed (vi) 1 patient had a successful embolization of left IMA/SPA and 53 days later had a rebleeding on the left side; an embolization of the left external carotid artery (ECA) was performed due to an atypical accessory artery (Figure 4); 7 days later, a rebleeding occurred and embolization of the right IMA/SPA was performed; due to recurrence of bleeding, surgery was performed needed further surgery; success rate: 83.3%). Some reports embolization was very efficient in most cases. All 3 patients criticize the use of coils in general, because the possibility of with hereditary hemorrhagic telangiectasia needed at least a repetition of distal embolization could be lost [23]. We use double-sided embolization, and two of them had further particle and coil embolization of SPA/IMA as we have the surgery after primary bleeding control. In general, these pa- tients are difficult to treat. impression that, by doing so, we reduce also the residual flow and pressure via the IMA in prevention of a relapse. Fur- *e only observed major complications were access site thermore, revascularization after embolization often occurs complications with a slightly increased rate of arterial oc- either via the contralateral side or via the facial artery, thus clusions (1.4% vs. 0.1–0.9% [36]). *e reason for this could these arteries can be easily embolized during a second be the introduction of vascular closure devices in 2008 with procedure. Should a revascularization occur via the eth- no extensive experience during the first month of use. A few moidal arteries, a surgical therapy would be required. cases of headache after embolization could be well handled Rebleeding is a known problem for the treatment of ep- with analgesics. istaxis. Primary double-sided or triple-artery embolizations are *e limitation of our case series is of course the small described in the literature postulating that the rate of early case number of 141 procedures. Although this is to our recurrences decreases with the number of arteries embolized knowledge one of the largest primary case series in literature, [19]. However, this group had a certain rate of nose necrosis it does not allow postulating general rules at statistical and several cases of facial edema. A case analysis from 2018 significance. Our protocol has been proved to be safe and even found out that bilateral particle embolization including effective with a primary efficiency of 95% with no neuro- facial artery was the treatment method associated with a sig- logical complications. So, we would like to present our nificant risk of complications [35]. With the exception of protocol or aspects of our protocol as a suggestion for the patients with hereditary hemorrhagic telangiectasia, one-sided reader or as basis of a further discussion. Radiology Research and Practice 7 management of adult epistaxis: systematic review,” 9e 4. Conclusions Journal of Laryngology & Otology, vol. 131, no. 12, Despite reports in the literature describing a higher rate of pp. 1108–1130, 2017. [10] A. Asanau, A. P. Timoshenko, P. Vercherin, C. Martin, and cerebrovascular complications compared to surgery, we J.-M. Prades, “Sphenopalatine and anterior ethmoidal artery think that when implementing the abovementioned security ligation for severe epistaxis,” Annals of Otology, Rhinology & precautions, embolization of sphenopalatine artery with Laryngology, vol. 118, no. 9, pp. 639–644, 2009. microcoils and microparticles is a safe, fast, and effective [11] V. Srinivasan, I. W. Sherman, and G. O’Sullivan, “Surgical method to stop posterior epistaxis without requiring general management of intractable epistaxis: audit of results,” 9e anesthesia. Today, there is still no uniform standard in Journal of Laryngology & Otology, vol.114, pp. 697–700, 2000. embolization of epistaxis and a complex data situation with [12] N. Umapathy, A. 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Radiology Research and PracticeHindawi Publishing Corporation

Published: Aug 20, 2020

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