PROCEDURE: EPISTAXIS EMBOLIZATION
COMPARISON: None
INDICATION: Patient with recurrent epistaxis, refractory to standard ENT management.
OPERATOR: Nasser Razack, M.D. J.D.
EQUIPMENT: 5F micropuncture set, 6 French short sheath, 5F Vertebral catheter, 6 Fr Benchmark Guide Catheter, .035 Bentson guidewire, .035 Terumo glidewire, rotating hemostatic valves, large bore stopcocks, Echelon 10 x 2 microcatheter, Synchro2 Soft microwire. Embolic material: Embospheres 300-500 microns in size/ Onyx 18/34 x _ vials, Angioseal 6 French vascular closure device
CONTRAST: ml of Isovue 300/Visipaque 320
CONTROL ANGIOGRAMS: 2
RADIATION EXPOSURE-DAP: DAP (µGy•m²)
COMPLICATIONS: None
CONSCIOUS SEDATION: Pre-procedure evaluation confirmed that the patient was an appropriate candidate for conscious sedation. Adequate sedation was maintained during the entire procedure. Vital signs, pulse oximetry, and response to verbal commands were monitored and recorded by the nurse throughout the procedure and the recovery period. The flow sheet was placed in the medical record including the medications and dosages used. No immediate sedation related complications were noted.
MANAGED ANESTHESIA CARE: Pre-procedure evaluation confirmed that the patient was an appropriate candidate for MAC sedation. Adequate sedation was maintained during the entire procedure by the anesthesia team. Vital signs and pulse oximetry were monitored and recorded by the anesthetist throughout the procedure and the recovery period. The flow sheet was placed in the medical record including the medications and dosages used. No immediate sedation related complications were noted.
GENERAL ANESTHESIA: Pre-procedure evaluation confirmed that the patient was an appropriate candidate for general anesthesia. Adequate anesthesia was maintained during the entire procedure by the anesthesia team. Vital signs and pulse oximetry were monitored and recorded by the anesthetist throughout the procedure and the recovery period. The flow sheet was placed in the medical record including the medications and dosages used. No immediate sedation related complications were noted.
CONSENT: The risks, benefits, and alternatives of the procedure were explained to the patient/patient's family and informed consent was obtained. Given the patient's condition, the patient was not able to sign their own consent. For this reason, this procedure was done emergently without consent. Risks include but are not limited to infection, bleeding, hematoma, retroperitoneal hemorrhage, vascular injury, stroke, severe stroke, contrast reaction including allergic reaction and contrast induced encephalopathy, inadvertent embolization (stroke and blindness), mucosal ulceration, skin necrosis including nasal skin necrosis and blindness.
TIMEOUT: Prior to the start of the procedure, a time-out was performed in the presence of the Neurointerventionalist, the Nurse, and the Technologist. This identified the correct patient, site, and procedure to be performed.
PROCEDURE: The risks, benefits, and alternatives to the procedure were explained to the patient and the family, and written informed consent was obtained. The patient was placed supine on the angiographic table. The right groin was prepped and draped in the usual sterile manner. Using a 5F micropuncture set, the common femoral artery was punctured and cannulated and a 5 French arterial sheath was placed over a guidewire. The sheath was attached to continuous heparinized saline flush. A diagnostic catheter was placed through the sheath and advanced over a Terumo glidewire into the aortic arch.
Selective catheterization of the following blood vessels was performed (see below). At the end of the procedure, hemostasis was achieved.
At the end of the procedure, the sheath was removed and hemostasis was obtained with the 6 French Angioseal vascular closure device.
DIAGNOSTIC ARTERIOGRAPHY AND SUPERVISION AND INTERPRETATION OF DIAGNOSTIC ARTERIOGRAMS:
LEFT INTERNAL CAROTID ARTERY: The guide catheter was then advanced into the left internal carotid artery and DSA was performed in the AP and lateral projections with filming over the intracranial circulation. Normal ophthalmic artery and choroidal blush are noted. The MCA and ACA trunks and distal branches are within normal limits. Arteriovenous transit time is normal. Main intracranial venous structures opacify appropriately.
LEFT EXTERNAL CAROTID ARTERY: The diagnostic catheter into the left external carotid artery and DSA was performed in the AP and lateral projections with filming over the extracranial circulation. Main ECA trunk is widely patent. Normal external carotid artery branch pattern is appreciated. Moderate vascular blush to the left nasal region is identified from the left sphenopalatine artery extending off the left internal maxillary artery.
RIGHT INTERNAL CAROTID ARTERY: The guide catheter was then advanced into the right internal carotid artery DSA was performed in the AP and lateral projections with filming over the intracranial circulation. Intracranial segments of the internal carotid artery are normal. Normal ophthalmic artery and choroidal blush are identified. MCA and ACA vascular territories are normal in appearance. Main intracranial venous structures opacify appropriately.
RIGHT EXTERNAL CAROTID ARTERY: The catheter was then advanced into the right external carotid artery and DSA was performed in the AP and lateral projections with filming over the intracranial circulation. The external carotid artery trunk is widely patent. Moderate vascular blush to the right nasal region is identified from the right sphenopalatine artery extending off the right internal maxillary artery.
SUPERSELECTIVE ARTERIOGRAPHY, EMBOLIZATION, AND CONTROL ANGIOGRAMS; SUPERVISION AND INTERPRETATION OF SUPERSELECTIVE ARTERIOGRAPHY, EMBOLIZATION, AND CONTROL ANGIOGRAMS:
EMBOLIZATION, LEFT SIDE: The guide catheter was placed into the left external carotid artery and utilized as a guiding catheter. This was attached to continuous heparinized saline flush. Through this, an echelon 10 microcatheter was advanced over an Syncro2 soft 014 microwire into the distal internal maxillary artery sphenopalatine branch under continuous fluoroscopic roadmap guidance. DSA was then performed from this catheter position.
LEFT SPHENOPALATINE ARTERY: DSA in the AP, lateral, and oblique working projections was performed through the microcatheter in this superselective position. The left sphenopalatine artery is normal in course and caliber with a normal branching pattern. There is no evidence of arteriovenous shunting, aneurysm, pseudoaneurysm, or telangiectasia. Hyperemia is noted which likely reflects recent nasal packing. No contrast extravasation or dangerous collaterals are identified. From this catheter position, 4 cc’s of a slurry of contrast and Embospheres 300-500 µm in size/ Onyx 18/34 vials were injected into the sphenopalatine artery in standard fashion under continuous fluoroscopic monitoring. Once considerable stasis was noted within this arterial vascular tree, a control angiogram was performed.
LEFT SPHENOPALATINE ARTERY POST PVA: DSA in the AP and lateral projections was performed through the microcatheter following embolization. This demonstrates truncation of this arterial tree with no significant residual opacification of the distal branches. Previous hyperemia is no longer identified. No evidence of a complicating feature.
EMBOLIZATION, RIGHT SIDE: The diagnostic catheter was placed into the right external carotid artery and utilized as a guiding catheter. This was attached to continuous heparinized saline flush. Through this, the microcatheter was advanced over the microwire into the distal internal maxillary artery sphenopalatine branch under continuous fluoroscopic roadmap guidance.
RIGHT SPHENOPALATINE ARTERY: DSA was performed in the AP and lateral working projections through the superselective microcatheter within the sphenopalatine artery. Normal opacification of this arterial tree is seen. No evidence of pseudoaneurysm, aneurysm, or telangiectasia. There was normal enhancement of the left nasal mucosa. No dangerous collaterals are identified. From this catheter position, 4 cc’s of a slurry of contrast and Embospheres 300-500 µm in size/ Onyx 18/34x_vials were then injected in standard fashion under continuous fluoroscopic monitoring. Once considerable stasis was noted within this arterial vascular tree, a control angiogram was performed.
RIGHT SPHENOPALATINE ARTERY POST PVA: DSA in the AP and lateral working projections was performed through the microcatheter following embolization. This demonstrates truncation of this arterial tree without significant opacification of the distal branches or residual mucosal enhancement. No evidence of complicating feature.
1. No evidence of vascular abnormality within the nasal mucosa vascular tree bilaterally to explain the patient's epistaxis. Specifically, there is no evidence of aneurysm, pseudoaneurysm, telangiectasia, or AVM.
2. Successful 300-500 µm particle size Embospheres particulate/ Onyx 18/34 embolization of the bilateral sphenopalatine arteries with significant occlusion of the vascular bed supplying the nasal mucosa without complication.