Treatment protocol used at our institution for the embolization of idiopathic posterior epistaxis

StepActionClarification
1Angiogram of il* ICAVerify supply to the OphA and choroidal blush from the ICA; rule out an ICA source of bleeding; check for extensive supply to nasal mucosa from the EAs
2Angiogram of il ECARule out vascular anomalies; check for dangerous anastomoses between ECA and ICA; rule out nonidiopathic causes of epistaxis
3Embolization of il IMASelective catheterization of IMA, distal to MDTA, and embolization with suspension of PVA particles (250–350 μm) in contrast medium; sometimes followed by 1 or 2 Gelfoam pledgets
4Embolization of il FAPerformed if significant supply to nasal mucosa from FA; selective catheterization of FA, distal to SMA, and embolization with suspension of PVA particles (250–350 μm) in contrast medium
5Repeat 1–4 on cl* sideDue to collaterals between il and cl vasculature, we routinely include the cl side in our protocol
6Transfer to ENT departmentThe packs are usually removed the following day by the ENT department
  • Note:—il indicates ipsilateral; cl, contralateral; ENT, ear-nose-throat; EAs: ethmoidal arteries (anterior and posterior); ICA, internal carotid artery; OphA, ophthalmic artery; ECA, external carotid artery; IMA, internal maxillary artery; MDTA, middle deep temporal artery; PVA, polyvinyl alcohol; FA, facial artery; SMA, submandibular artery.

  • * il and cl indicate the side of bleeding or, if the patient bleeds from both nostrils, the side where bleeding started.