Embolization in post-traumatic epistaxis

Transcription

1 Embolization in post-traumatic epistaxis Poster No.: C-2525 Congress: ECR 2012 Type: Scientific Exhibit Authors: M. Jarzabek, T. Jargiello, P. Trojanowski, K. K. Pyra, M Szczerbo-Trojanowska ; Lublin/PL, LUBLIN/PL Keywords: Head and neck, Interventional vascular, Trauma, Catheter arteriography, Fluoroscopy, Percutaneous, Arterial access, Embolisation DOI: /ecr2012/C-2525 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 18

2 Purpose Epistaxis is a common symptom in patients reporting to EIA Emergency Unit. In most cases, the bleeding originates from small vessels and it is caused by microinjury or inflamation. This type of epistaxis resolve spontanously or after tamponade placement. However, in some cases, when the bleeding is a result of external or internal carotid branches injury, with extensive cranial trauma, intractable epistaxis can be present. Around 6-10% of patients with epistaxis require medical intervention, because of a blood loss [1,2]. The current standard therapy includes tamponade placement, surgical ligation and embolisation [3-5]. When patient is not eligible for surgery and the bleeding does not respond for tamponade, embolisation is an alternative. Advantages of intravascular procedure include lack of general anaesthesia, low invasiveness and possibility of revealing the exact place of bleeding, as well as concomitant abnormalities, like pseudoaneurysms or fistulas. Most of complications after embolisation are not serious and resolve within couple of days. Among them pain, paraesthesia, edema and fever, can be present in 29-59% of cases [6-9]. As a result of non-target embolisation more serious side effects can occur in 2% of patients, including serious neurological complications, like paresis, aphasia, vision and sensory impairment [5,8,10]. We investigated safety and efficacy of selective embolisation used in patients suffering from post-traumatic epistaxis. Methods and Materials Patients 25 patients were included in the study (19 men, 6 women) with mean age of 41 years (range of years). All suffered from post-traumatic epistaxis. The patients symptoms did not resolve after conservative treatment and they were directed to interventional radiology department for embolisation. 10 patients reported to the Emergency Unit directy after trauma, 17 patients reported to the hospital after 7 days to 3 months after the injury. Procedure technique Page 2 of 18

3 Diagnostic angiography and embolization procedures were performed under local anaesthesia and conscious sedation. Vascular access was obtained using common femoral artery puncture. After sheath placement, bilateral angiography of internal and external carotid artery was performed using non-ionic contrast media (Visipaque 320mgl/ ml).the location of bleeding and additional vascular abnormalities were assessed, before embolisation. Embolization was performed exclusively in branches of the external carotid artery, but internal arteries were also visualized in all the patients in order to disclose potential vascular anastomoses, and thus to avoid the danger of displacement of embolisation material from the external to the internal artery, as well as to reveal possible bleeding from the ocular artery or ethmoidal branches. Four types of embolisation material were considered for the treatment: coils, gelfoam, polivinyl alcohol particles (PVA, Contour, Boston Scientific) and acrylic copolymer particles µm, µm (Embosphere, Biosphere Medical)(Fig.1-3). If necessary, more than one type of embolisation material was used. Selectively, using microcatheter, maxillary artery was canulated and microcatheter was positioned proximally to the place of extravasation of contrast. Arterial supply was embolised until angiographic control showed lack of extravasation of contrast media in the location where bleeding was previously present. The whole procedure has been done under fluoroscopic guidance. Arterial puncture was manually pressed. Images for this section: Page 3 of 18

4 Fig. 1: Draft of a standard platinium coil, used in interventional radiology for intravascular embolisation. Page 4 of 18

5 Fig. 2: An example of syringe filled with acrylic co-polimer spheres used as an embolising material. Page 5 of 18

6 Fig. 3: Pieces of gelfoam sponge used in interventional radiology as an embolic material. Page 6 of 18

7 Results In all patients, diagnostic procedure showed direct or indirect angiographic signs of bleeding. In 8 patients examined directly after injury diagnostic angiography showed extravasation of contrast media originating from sphenopalatine artery and descending palatine artery in 6 patients, and from ethmoidal arteries in 2 patients. In 6 patients with active bleeding from maxillary artery branches, present during the procedure, PVA was injected using 350µm followed by 500µm or Embosphere µm followed by µm. Control showed technical success in all embolised vessels, resulting in lack of extravasation of contrast media (Fig.4-6). In two cases, when the bleeding was supported by ophthalmic artery branches the procedure was abandoned, because of too high risk of ophthalmic artery catheterization. Seventeen patients were admitted to hospital because of recurrent epistaxis between 7-16 days and 1-3 months after the injury. Indirect signs of bleeding were noted in those cases. In 14 cases pseudoaneurysm was present and 3 patients suffered carotid cavernous fistula. Blood supply, among 6 pseudoaneurysms was conducted by maxillary artery and in 7 cases from sphenopalatine or descending palatine arteries. In one case pseudoaneurysm was supported by posterior palatin arteries. 9 patients with pseudoaneurysms were embolized with coils. In 5 cases the arteries leading blood to the pseudoaneurysms were closed with particles of µm in diameter (Fig.7,8). Patients with cavernous carotid fistula presented with recurrent epistaxis, pulsating exophthalmos, or pulsating tinnitus, characteristic for the fistulae. Two of these patients earlier underwent surgical ligation of the internal carotid artery, which improved their status only temporarily. Carotid artery ligation impaired endovascular management, rendering microcatheter introduction to the cavernous sinus via the occluded artery impossible. One of the patients developed collateral circulation between the vertebral artery and the internal carotid artery above the surgical ligation level. This vascular anastomosis was used to introduce the catheter into the cavernous carotid fistula, which was then embolised with the aid of platinum coils (Fig.9-12). In another patient, the fistula was embolised with the same material introduced endovenously from the petrosal sinus. The fistula in the third patient was embolised with platinum coils by catheterization of the internal carotid artery, through which the catheter was introduced into the fistula itself. Endovascular procedures in all three patients with cavernous carotid fistulae were successful, with cessation of epistaxis and improvement of the patients' status. Recurrent bleeding after embolization was observed in 5 patients (20%). Three patients who were embolised immediately after the injury experienced minor recurrent bleeding on the third and ninth days following the successful closure of the sphenopalatine artery, respectively. Tamponade was applied, which controlled bleeding in one of them. However, the other two patients required another embolization procedure, which stopped Page 7 of 18

8 recurrent bleeding. Two other patients experienced recurrent bleeding two and four weeks following embolization procedures, respectively. These bleedings were caused by patency restoration in embolised vessels (maxillary artery and descending palatine artery, respectively). Successful repeated embolization procedures were performed in both patients. Eleven patients (44%) experienced adverse events following embolization procedures, including pain and swelling of the face, paresthesiae, trismus and fever, which regressed spontaneously after several days. Persistent sensory disturbances in the cheek area were noted in three patients (12%). One patient developed a small palatal ulceration, which was managed conservatively with success. No major neurological complications were noted. Images for this section: Fig. 4: External Carotid Artery (ECA) angiography with present extravasation of contrast media from sphenopalatine and descending palatine arteries in patient after bicycle accident. AP projection. Page 8 of 18

9 Fig. 5: The same patient as in figure 4. External Carotid Artery (ECA) angiography with present extravasation of contrast media from sphenopalatine and descending palatine arteries in patient after bicycle accident.lateral projection before embolisation. Page 9 of 18

10 Fig. 6: The same patient as in figure 4 and 5. ECA control angiography after PVA selective embolisation of the third part of maxillary artery in patient after bicycle accident. No signs of bleeding. Lateral projection. Page 10 of 18

11 Fig. 7: Diagnostic ECA angiography revealing pseudoaneurysm originating from maxillary artery in patient after fall from a height. AP projection. Page 11 of 18

12 Fig. 8: The same patient as in figure 7. ECA control angiography after embolisation of maxillary artery using acrylic co-polymer spheres µm. Exclusion of the pseudoaneurysm. AP projection. Page 12 of 18

13 Fig. 9: Right internal carotid artery (ICA) diagnostic angiography showing cavernous carotid fistula on the left side. Patient after car accident and surgical ligation of left ICA. AP projection. Page 13 of 18

14 Page 14 of 18

15 Fig. 10: The same patient as in figure 9. Angiography of the left vertebral artery showing collateral circulation between the vertebral artery and the internal carotid artery above the surgical ligation. AP projection Fig. 11: The same patient as in figure 9 and 10. Left vertebral/distal part of the left ICA angiography revealing cavernous carotid fistula before embolisation. Lateral projection. Page 15 of 18

16 Fig. 12: The same patient as in figure 9,10 and 11. Right ICA control angiography after fistula embolisation using coils. Exclusion of the fistula. AP projection. Page 16 of 18

17 Conclusion Embolization is estimated to be successful in 71-95% of cases of post-traumatic bleeding from the external carotid artery area [1,2,5,6]. Our results confirmed this results. Unfortunately, the applicability of this management method immediately after injury is limited by its availability. Bleeding, observed a certain time after injury, is most commonly related to the presence of pseudoaneurysms [11]. These patients are thus more often treated by elective endovascular procedures. The effects of these procedures depend strongly on thorough examination of the local vascular anatomy; therefore, scrupulous angiographic bilateral investigation of the internal and external carotid arteries is crucial. Vascular anatomic details revealed by angiography, facilitate adequate choice of approach to the bleeding vessel and of embolising material. The operator's experience in neuroradiological interventions can never be underestimated in these circumstances. Although, embolisation serious adverse events are rare, assessment of possible vascular anastomoses between the external and internal carotid artery at the level of carotid siphon in the foramen rotundum or via the ocular artery is essential to diminish complication risk, since migration of the embolising material along this route may result in stroke [6-10]. Embolisation of the ethmoidal arteries carries a high risk of loss of vision because of ocular artery closure; therefore, these patients should be treated surgically. Ligation of these vessels is technically feasible since they pass through the medial orbital wall. Conclusion 1. Embolization is an effective method of treating post-traumatic epistaxis and can be considered when planning patient management. 2. Embolization of external carotid artery branches requires scrupulous assessment of the anatomy of bilateral external and internal carotid arteries. References Vis E,van den Berge H. Treatment of epistaxis without the use of nasal packing, a patient study.rhinology.2011 Dec 1;49(5): Vaamonde Lago P,Martín Martín C,Lechuga García MR,Mínguez Beltrán I,Labella Caballero T. Epidemiological notes on nasal bleeding.an Otorrinolaringol Ibero Am.2004;31(2): Page 17 of 18

18 3. Romagnoli M,Marina R,Sordo L,Gaini RM. Indications for selective arterial embolization in the treatment of epistaxis.acta Otorhinolaryngol Ital.2000 Oct;20(5): Goddard JC,Reiter ER.: Inpatient management of epistaxis: outcomes and cost.otolaryngol Head Neck Surg.2005 May;132(5): Ricci G,Molini E,Hamam M,Ciorba A,Altissimi G,Campanella S,Fiacca A,Pelliccioli G. Treatment of severe epistaxis by superselective embolization: a review of 22 cases.rev Laryngol Otol Rhinol (Bord).2004;125(4): Moreau S,De Rugy MG,Babin E,Courtheoux P,Valdazo A. Supraselective embolization in intractable epistaxis: review of 45 cases.laryngoscope.1998 Jun;108(6): Cullen MM,Tami TA. Comparison of internal maxillary artery ligation versus embolization for refractory posterior epistaxis.otolaryngol Head Neck Surg.1998 May;118(5): Rogers SN,Patel M,Beirne JC,Nixon TE. Traumatic aneurysm of the maxillary artery: the role of interventional radiology. A report of two cases.int J Oral Maxillofac Surg.1995 Oct;24(5): Tseng EY, Narducci CA, Willing SJ, Silliers MJ. Angiographic embolization for epistaxis Laryngoscope, 1998, 108: Oguni T,Korogi Y,Yasunaga T,Sadanaga T,Uozumi H,Kawanaka K,Sumi S,Takahashi M. Superselective embolisation for intractable idiopathic epistaxis.br J Radiol.2000 Nov;73(875): Rogers SN,Patel M,Beirne JC,Nixon TE. Traumatic aneurysm of the maxillary artery: the role of interventional radiology. A report of two cases.int J Oral Maxillofac Surg.1995 Oct;24(5): Personal Information Magdalena Jarzabek, MD. Department of Interventional Radiology and Neuroradiology, Medical University Hospital no 4, Lublin, Poland address: magda.jarzabek@yahoo.co.uk Page 18 of 18