Epistaxis embolization

A nosebleed, called epistaxis, is very common and almost always stops with pinching the nose. Most start at the front of the nose. A small number come from further back, where larger arteries run, and these can be heavy, hard to reach and keep coming back. They are more common in older adults, people with high blood pressure, and people who take blood thinners.

The nose is fed by two sets of arteries. Most of the blood comes from branches of the external carotid artery, especially the sphenopalatine artery, which enters at the back of the nose. Some comes from branches of the internal carotid artery, the artery that also feeds the eye and brain.

Embolization means blocking a blood vessel on purpose. In epistaxis embolization, we guide a thin catheter to the small arteries feeding the nose and plug them with tiny particles or coils. The pressure of blood reaching the bleeding spot drops, and the nose can heal. Other arteries keep the nose alive, so the tissue survives.

The decision is usually made together with an ear, nose and throat (ENT) surgeon, often while you are in the hospital with packing in place.

Most nosebleeds are managed step by step: pressure, medicine sprays, cautery (sealing the spot with a chemical or heat), and nasal packing. If bleeding continues, the two main options are embolization and endoscopic surgery by an ENT surgeon, who ties or clips the sphenopalatine artery through the nose.

Both embolization and surgery work well. Embolization avoids general anesthesia in many cases and can treat several arteries on both sides at once. Surgery is preferred when the bleeding comes from arteries that are branches of the internal carotid system. Treating the underlying cause, such as high blood pressure or a blood thinner dose, is part of every plan.

Most people are already in the hospital when embolization is planned. You may have nasal packing in place, and we may check your blood count and clotting tests and give fluids or a blood transfusion if you have lost a lot of blood.

1. 1
   Getting ready

   You receive moderate sedation or, if you are bleeding heavily or need your airway protected, general anesthesia. Packing usually stays in place during the procedure.

2. 2
   Mapping the arteries

   A small tube is placed in the groin or wrist artery. We guide a catheter to the carotid arteries in the neck and inject contrast dye to see the arteries of the nose and check for dangerous connections to the eye and brain.

3. 3
   Blocking the feeding arteries

   A very thin microcatheter is advanced into the sphenopalatine artery and sometimes the facial artery. Tiny particles, sometimes with coils, are injected to slow flow to the bleeding area, often on both sides.

4. 4
   Finishing

   A final picture confirms reduced flow. The tube is removed and the pinhole is sealed with pressure or a closure device.

What we see

Before I place a single particle, I study the angiogram for small connections between the nasal arteries and the arteries that feed the eye and brain, because those are what I must protect. I choose particles large enough to stay in the nose and inject slowly while watching every frame. When I talk with patients and families, I am honest that this works very well most of the time, and that the ENT team and I will still have a plan if it bleeds again.

Fabio Komlos, MD, interventional radiologist · About Dr. Fabio Komlos

1. First 4–6 hours
   Bed rest while nurses check the puncture site, your nose and your neurological function. You can usually eat once awake.
2. Day 1–2
   Nasal packing is usually removed by the ENT team 24 to 48 hours after embolization. Most people go home 1 to 2 days after the procedure.
3. First 1–2 weeks
   Avoid blowing your nose hard, bending over, straining, heavy lifting and hot drinks or hot showers. Sneeze with your mouth open. Use saline spray and a humidifier to keep the nose moist.
4. 2–4 weeks
   Mild facial ache, jaw pain or numbness usually settles. Follow up with ENT and your primary doctor, especially for blood pressure.

Embolization stops the bleeding right away in most people, and about 8 to 9 in 10 do not bleed seriously again. Some people have a minor nosebleed later, which usually responds to simple measures. If a major bleed returns, the options are a repeat embolization or surgery.