Original Article

American Journal of Rhinology &

Allergy
Transnasal Endoscopic Sphenopalatine 2018, Vol. 32(3) 188–193
! The Author(s) 2018
Artery Ligation Compared With Reprints and permissions:
sagepub.com/journalsPermissions.nav
Embolization for Intractable Epistaxis: DOI: 10.1177/1945892418768584
journals.sagepub.com/home/ajr

A Long-term Analysis

G. de Bonnecaze, MD, PhD1, Y. Gallois, MD1,

F. Bonneville, MD, PhD2, S. Vergez, MD, PhD1,
B. Chaput, MD, PhD3, and E. Serrano, MD1

Abstract
Background: Transnasal endoscopic sphenopalatine artery ligation (TESPAL) and selective embolization both provide
excellent treatment success rate in the management of intractable epistaxis. Few long-term studies comparing these
approaches have been previously published. Recommendations often present these techniques as alternatives, but there
is no clear consensus.
Objective: The purpose of this study was to evaluate and compare the clinical efficacy of sphenopalatine artery ligation
versus embolization to control intractable epistaxis.
Methods: We performed a retrospective study including all patients referred to our tertiary medical center for severe
epistaxis and treated by surgical ligation and/or embolization. The patients were classified into 2 groups: those who under-
went TESPAL only and those who underwent endovascular embolization only. We evaluate and compare long-term clinical
outcomes after surgical ligation or embolization for the control of intractable epistaxis in terms of effectiveness (recurrence
rate) and safety (complication rate).
Results: Forty-one procedures of supraselective embolization and 39 procedures of surgical ligation for intractable epistaxis
are reported and analyzed. No significant difference was observed between the groups in terms of demographic factors,
comorbidities, or average length of hospital stay. The 1-year success rate was similar (75%) in both groups. Complications
(minor and/or major) occurred in 34% cases in the embolization group and in 18% in the surgical group (P ¼.09, ns).
Bilateral embolization including facial artery was the only treatment method associated with a significant risk of
complications (P ¼.015).
Conclusion: TESPAL seems to provide a similar control rate with a decrease in the number of complications compared to
selective embolization in the context of intractable epistaxis. Further studies are required.

Keywords
epistaxis, embolization, surgical ligation, long-term outcome, comorbidities, recurrences, complications, sphenopalatine
artery, facial artery, intractable epistaxis

1
Otolaryngology, Head and Neck Surgery Department, University Hospital
Introduction Rangueil-Larrey, Toulouse, France
2
Neuroradiology Department, Pierre-Paul Riquet Hospital, University of
Intractable epistaxis is a common otolaryngological Toulouse, Toulouse, France
3
emergency. Surgical ligation of the internal maxillary Plastic and Aesthetic Surgery Department, University Hospital Rangueil-
artery or external carotid artery has been the historically Larrey, Toulouse, France
preferred treatment method,1 but endovascular emboli- Corresponding Author:
De Bonnecaze Guillaume, Otolaryngology, Head and Neck Surgery
zation has recently emerged as a viable and effective Department, University Hospital Rangueil-Larrey, 24 Chemin de
treatment alternative.2,3 On the other hand, advance- Pouvourville, 31059 Toulouse, France.
ments in endoscopic surgery have enabled selective Email: guidb31@yahoo.fr
de Bonnecaze et al.
ligation such as transnasal endoscopic sphenopalatine
artery ligation (TESPAL).4
The literature provides some insight into selecting the
ideal treatment option, which can be challenging.
Recommendations often present TESPAL and emboli-
zation as alternatives,5,6 but there is no clear consensus.
The few studies that have compared TESPAL with
embolization have been retrospective, uncontrolled studies
that focused on surgical ligation or embolization.
Furthermore, comorbidities and long-term outcomes are
poorly documented, especially after embolization. In 2013,
Brinjikji et al.7 published the largest retrospective study
comparing surgical ligation and embolization in which
64,289 patients underwent surgical ligation. However,
most of them underwent cautery to stop the epistaxis,
and few selective arterial ligations were actually per-
formed. They also retrospectively analyzed 4440 cases of
embolization, but the follow-up period was very short.
The purpose of this study was to evaluate and
compare the clinical efficacy of SPA ligation versus
embolization to control intractable epistaxis. A second-
ary aim was to investigate the impact of treatment
methods on success/complication rates.
Methods
We performed a retrospective analysis comparing these
techniques in terms of safety and efficacy. Some patients
were interviewed over the phone in order to limit missing
data and gave their agreement for medical research via a
mail or a letter addressed to their home. Others signed
the consent when they came for follow-up. Finally, all
patients expressed informed consent. The patients were
stratified according to the etiology of bleeding, and the
data were analyzed with respect to demographic factors
(eg, age and sex), comorbidities, origin and clinical
impact of bleeding, duration of hospitalization, treat-
ment approach (eg, target artery and embolization strat-
egies), therapy-related complications and short- and
long-term outcomes. The medical records of all patients
who were diagnosed with epistaxis and hospitalized
from January 1, 2000, to December 31, 2015, were ana-
lyzed retrospectively. The patients were classified into 2
groups: those who underwent TESPAL only and those
who underwent endovascular embolization only as first-
line treatment. Decisions between surgery and emboliza-
tion were made by discussion using a multidisciplinary
approach, including input by ENT surgeons, neuroradi-
ologists, and anesthetists. This study was approved by
our local ethics committee (ref n 1314703).
Treatment Success
Embolization or TESPAL was used only in patients with
intractable epistaxis, which was defined as that requiring
189
a transfusion or cases in which bleeding continued
despite anterior/posterior packs.
Patients were considered cured if they did not show
any significant recurrence during follow-up. We consid-
ered that treatment had failed if patients had a signifi-
cant recurrence during follow-up. Significant recurrence
was defined as repeat bleeding managed by the applica-
tion of anterior or anterior/posterior packs with or with-
out hospitalization.
Complications
Procedural complications were classified as major or
minor. Major complications included cerebral vascular
accidents, blindness, ophthalmoplegia, facial nerve
palsy, and soft tissue necrosis. Minor complications
included those that were transient, including facial
pain, headaches, mental confusion, paresthesia, jaw
pain, groin pain, numbness, and facial edema.8,9
Statistical Analysis
For the comparison of categorical variables, v2 tests
were performed. For the comparison of continuous var-
iables, Student’s t tests were performed. All statistical
analyses were performed using the SAS-based statistical
software package JMP9.0 (SAS, Cary, NC).
Results
Demographic Data
The surgical ligation (TESPAL) group included 39
patients. The follow-up period ranged from 12 to 37
months with a median of 26 months. The average age
of the patients was 70 years.
The average duration of hospitalization was 6 days,
and 66% of the patients presented with at least one
comorbidity. Bilateral ligation was performed in 10
cases (localization of bleeding was not possible).
The embolization group included 41 patients.
The follow-up period ranged from 6 to 57 months with
a median of 22 months. The average age was 66 years.
The average length of hospitalization was 7 days, and
56% of the patients presented with at least one comor-
bidity. Embolization of distal branches of the internal
maxillary artery was systematically performed. The left
distal branches of the maxillary artery were embolized in
70% of cases and the right distal branches of the max-
illary artery in 65% of cases. Additional facial artery
embolization was often performed (45% on the right
side and 49% on the left). Bilateral embolization was
performed in 20% of cases.
Table 1 summarizes the demographic and treatment
data. No significant difference was observed between the
190 American Journal of Rhinology & Allergy 32(3)

Table 1. Demographics and Treatment Data. Table 3. Outcomes.

Surgical Surgical Embolization

ligation Embolization Outcome ligation (%) (%) P
group group Total P
Major complications 7 17 .3
Age 70 66 68 .6 Minor complications 15 29 .13
Comorbidities 66% 56% 61% .12 Total complications 18 34 .09
Coagulation disorder 7% 7% 7% 1 Recurrences 25 24 .8
Drug-related adverse 38% 34% 36% .6
side effect
Hereditary hemorrhagic 5% 13% 8% .3
Table 4. Complication Risk Factors.
telangiectasia
Trauma 17% 13% 16% .7 No
Mean Comorbidities Complication complications P
Total length of stay 6 7 6 .12
Preprocedure stay 2.5 3.1 2.7 .2 Drug-related adverse 4 21 .6
Postprocedure stay (days) 3.5 3.8 3.4 .17 side effects
Mean follow-up (months) 26 22 24 .3 Coagulation disorder(s) 1 4 1
Hereditary hemorrhagic 2 3 .12
telangiectasia
Trauma 2 9 .7
Table 2. Recurrence Risk Factors.
Treatment method
No Bilateral ligationa 3 7 .7
Comorbidities Recurrence recurrences P Facial artery embolizationb 7 13 .12
Bilateral embolizationb 6 2 .015
Drug-related adverse 8 20 .7
a
side effects TESPAL only.
b
Coagulation disorder(s) 1 4 1 Embolization only.
Hereditary hemorrhagic 5 5 .029
telangiectasia
Trauma 4 7 .2
At least one comorbidity 15 39 .6

groups in terms of demographic factors, comorbidities,

or average length of hospital stay.

Treatment Success
The overall success rate was similar in both groups.
There were 10 recurrences in each group (24% vs 26%,
P ¼ .89). Hereditary hemorrhagic telangiectasia was the
only general factor associated with an elevated risk of
recurrence (P ¼ .029, Table 2).

Complications
Our results showed a documented reduction of compli-
cations in the ligation group that did not reach statistical
significance (34% vs 18%; P ¼ .09, ns; Table 3). We
noted 7 major complications in patients treated by pri-
marily selective embolization: 5 cases of soft tissue
necrosis (Figure 1), 1 case of blindness, and 1 case of
diplopia. Only 2 major complications were noted in the
surgical group: 1 case of persistent diplopia (superior
oblique muscle injury) and 1 case of soft tissue necrosis
(floor of the nasal cavity). Concerning soft tissue necro-
sis, 4 cases required reconstruction using a local flap, and
Figure 1. Right nasal alar necrosis (arrow) 2 weeks after bilateral
embolization.
3 were managed with conservative management with
wound care. In terms of minor complications, acute
sinusitis was the most frequent complication in the sur-
gical group (n ¼ 4) and severe facial pain in the emboli-
zation group (n ¼ 5). Bilateral facial artery embolization
was the only treatment method associated with an ele-
vated risk of complications (P ¼ .015, Table 4).
de Bonnecaze et al.
Discussion
Treatment Success
The primary success rate of endovascular treatment in
previous series varied from 93% to 100%, which is con-
sistent with the findings of other series in which primary
success rates ranging from 93% to 100% were
reported.10 Taking delayed recurrences into account,
our long-term success rate was concordant with that of
previously published studies in which the long-term suc-
cess rate varied from 71% to 89.2%.11 Cohen et al.12
reported their experience with endovascular procedures
and included their long-term success rate. Of 19 patients,
only 1 patient (5.3%) required a second embolization
procedure 19 days after the first embolization. Three
patients (15.8%) were readmitted for recurrent epistaxis
18 days, 7 months, and 9 months, respectively, after the
last endovascular procedure. However, the epistaxis was
not refractory in these patients and was successfully
managed with conservative measures. According to
Lepp€ anen et al.,13 embolization stopped the bleeding in
89% of cases. Three patients had mild recurrences.
However, the criteria for success were rarely defined,
and the majority of authors were interested only in the
first month of follow-up. Some of the variability in
reported success rates may be linked to different defini-
tions of “success” or “failure” related to these cases.
Furthermore, the authors rarely described the manage-
ment of relapses, especially the number of hospital read-
missions and the number and types of nasal packing.
Sadri et al.14 assessed long-term treatment success rates
as follows: all 14 cases underwent a single embolization
procedure with successful arrest of epistaxis; 4 cases
(29%) developed recurrent epistaxis at a later date, con-
sistent with our findings; 1 patient (7%) required reem-
bolization 19 months after his first procedure; 1 bled 17
days after embolization, but this decreased with hospital
admission and paraffin paste packing, and the other 2
cases developed minor epistaxis that did not require hos-
pital admission.
Failure rates of 4.3% to 33% have been reported for
surgical ligation of the internal maxillary artery.15 The
long-term success rates of TESPAL are poorly docu-
mented. In 2013, Gede et al.16 presented the longest ret-
rospective follow-up study of intractable and recurrent
epistaxis treated by surgical ligation with a mean follow-
up of 6.7 years. Among 42 patients, 33 (78%) had no
recurrent epistaxis. In 2012, George et al.17 reported the
outcomes of 19 primary endoscopic sphenopalatine
artery ligations, 2 of which required adjuvant anterior
ethmoid artery surgery. They recorded a success rate of
89.4% (17 out of 19). According to McDermott et al.,18
the overall success rate of sphenopalatine artery ligation
191
was 87% (of 45 patients, 6 had rebleeding; mean follow-
up not defined).
Complications
Brinjikji et al.7 described a 5.6% incidence of postoper-
ative hemorrhage in the embolization group and 3.4% in
the surgical group. However, they did not provide fur-
ther information regarding long-term treatment success.
According to Brinjikji et al.,7 the mortality rate for
patients who underwent endovascular embolization
was 2.1%. This mortality rate is similar to that recorded
in patients who underwent surgical ligation. They noted
higher rates of stroke (0.9%) and postoperative hemato-
ma (1.9%) and a lower rate of pneumonia and acute
sinusitis compared to the surgical ligation group, as
well as postoperative hemorrhage (5.6%). The length
of hospital stay was similar between the 2 groups.
Sadri et al.14 reported 2 major complications occurring
after arterial embolization (local ischemic complica-
tions). Other cases of necrosis are reported in the litera-
ture;19–21 in the present study, the elevated percentage
facial artery embolization might explain the high inci-
dence of soft tissue necrosis. Recently, Sylvester et al.9
focused on in-hospital complications. In their retrospec-
tive cohort analysis using the National Inpatient Sample
in the United States, the only complication that varied
significantly between the groups was intubation/trache-
ostomy, which was significantly less common in the liga-
tion group (2.8% vs 5.3%; P ¼ .009). Although
published data on post-TESPAL outcomes are sparse,
postoperative complications seem to be limited.
According to Gede et al.,16 26% of patients presented
with minor postoperative complications, primarily per-
manent nasal crusting. McDermott et al.18 did not
report any surgical or postoperative complications. We
agree with these authors that post-TESPAL complica-
tions are common but usually benign. A concise summa-
ry of clinical outcomes after TESPAL or embolization is
presented in Table 5.
This series nevertheless constitutes one of the largest
reported cohorts of patients undergoing SPA ligation or
embolization. The strengths of the study include its rela-
tively long follow-up period and the analysis of multiple
comorbidities and treatment methods. In previous stud-
ies, the criteria for success were rarely defined, and the
majority of authors were interested only in the first month
of follow-up. Other studies did not contain any informa-
tion on outcomes after discharge. Some of the variability
in reported success rates may be linked to different defi-
nitions of “success” or “failure.” Furthermore, authors
rarely described the management of relapses, especially
the number of hospital readmissions or the number and
type of nasal packing. Therefore, we were sure to clearly
define these criteria. The limitations of this study include
192
Table 5. Summary Table of Recurrences/Complications Rate in Previous Study.
Treatment modality
Author Embolization/TESPAL
Cohen et al.12 Embolization
Lepp€anen et al.13 Embolization
Sadri14 Embolization
Gede et al.16 TESPAL
George et al.17 TESPAL
McDermott et al.18 TESPAL
TESPAL, transnasal endoscopic sphenopalatine artery ligation.
its retrospective nature and heterogeneous patient cohort.
In addition, the cohort size was relatively small, the
patients were not randomized, but randomization of
patients did not meet probably the criteria for Ethics
Committee approval. Furthermore, as the choice of pro-
cedure was chosen by a multidisciplinary board, patients
included in the embolization group were probably at
higher risk generally.
In conclusion, from a risk and complication perspec-
tive, TESPAL seems to provide good control rate with
a trend decrease in the number of complications com-
pared to selective embolization. Multi-institutional
studies with cost-effectiveness analyses are required to
more fully identify the indications for first-line surgi-
cal ligation.
Authors’ Note
This study was presented as a short communication at 21st
World Congress of the International Federation of Oto-
Rhino-Laryngological Societies (IFOS), June 2017, Paris.
Compliance With Ethical Standards
This study meets the ethical considerations of the Declaration
of Helsinki.
Ethical Approval
All procedures performed in studies involving human partici-
pants were in accordance with the ethical standards of the
institutional research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical
standards and was approved by our local ethics committee
(ethics committee of University Hospital of Toulouse-France:
ref n 1314703).
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of
this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
American Journal of Rhinology & Allergy 32(3)
Effectiveness
% Recurrences (follow-up) Complications
21% (21 months) No minor or major complications
11% (21 months) 8% mild transient complications
15% (not defined) Necrosis (2 cases)
22% (6.7 years) Crusting (26%)
11% (28 months) Not defined
13% (not defined) No complication
References
1. Cullen MM, Tami TA. Comparison of internal maxillary
artery ligation versus embolization for refractory
posterior epistaxis. Otolaryngol Head Neck Surg.
1998;118:636–642.
2. Maxwell AK, Barham HP, Getz AE, Kingdom TT,
Ramakrishnan VR. Landmarks for rapid localization of
the sphenopalatine foramen: a radiographic morphometric
analysis. Allergy Rhinol (Providence). 2017;8:63–66.
3. Schlosser RJ. Clinical practice. Epistaxis. N Engl J Med.
2009;360:784–789.
4. Kumar S, Shetty A, Rockey J, Nilssen E. Contemporary
surgical treatment of epistaxis. What is the evidence for
sphenopalatine artery ligation? Clin Otolaryngol Allied
Sci. 2003;28:360–363.
5. Reyre A, Michel J, Santini L, et al. Epistaxis: the role of
arterial embolization. Diagn Interv Imaging. 2015;96:757–773.
6. Lin G, Bleier B. Surgical management of severe epistaxis.
Otolaryngol Clin North Am. 2016;49:627–637.
7. Brinjikji W, Kallmes DF, Cloft HJ. Trends in epistaxis
embolization in the United States: a study of the nation-
wide inpatient sample 2003-2010. J Vasc Interv Radiol.
2013;24:969–973.
8. Tseng EY, Narducci CA, Willing SJ, Sillers MJ.
Angiographic embolization for epistaxis: a review of 114
cases. Laryngoscope. 1998;108:615–619.
9. Sylvester MJ, Chung SY, Guinand LA, Govindan A,
Baredes S, Eloy JA. Arterial ligation versus embolization
in epistaxis management: counterintuitive national trends.
Laryngoscope. 2016;127:1017–1020.
10. Gottumukkala R, Kadkhodayan Y, Moran CJ, Cross de
WT III, Derdeyn CP. Impact of vessel choice on outcomes
of polyvinyl alcohol embolization for intractable idiopath-
ic epistaxis. J Vasc Interv Radiol. 2013;24:234–239.
11. Willems PWA, Farb RI, Agid R. Endovascular treatment
of epistaxis. Am J Neuroradiol. 2009;30:1637–1645.
12. Cohen JE, Moscovici S, Gomori JM, Eliashar R,
Weinberger J, Itshayek E. Selective endovascular emboli-
zation for refractory idiopathic epistaxis is a safe and effec-
tive therapeutic option: technique, complications, and
outcomes. J Clin Neurosci. 2012;19:687–690.
13. Lepp€anen M, Sepp€anen S, Laranne J, Kuoppala K.
Microcatheter embolization of intractable idiopathic epi-
staxis. Cardiovasc Intervent Radiol. 1999;22:499–503.
14. Sadri M, Midwinter K, Ahmed A, Parker A. Assessment
of safety and efficacy of arterial embolisation in the
de Bonnecaze et al.
management of intractable epistaxis. Eur Arch
Otorhinolaryngol. 2006;263:560–566.
15. Strach K, Schr€ ock A, Wilhelm K, et al. Endovascular
treatment of epistaxis: indications, management,
and outcome. Cardiovasc Intervent Radiol.
2011;34:1190–1198.
16. Gede LL, Aanaes K, Collatz H, Larsen PL,
von Buchwald C. National long-lasting effect of endo-
nasal endoscopic sphenopalatine artery clipping for epi-
staxis. Acta Otolaryngol. 2013;133:744–748.
17. George A, Smatanova K, Joshi H, Jervis S, Oluwole M.
Sphenopalatine, anterior ethmoid and internal maxillary
artery intervention in the management of refractory epi-
staxis: their efficacy in 25 patients. Clin Otolaryngol.
2016;37:321–325.
193
18. McDermott AM, O’Cathain E, Carey BW, O’Sullivan P,
Sheahan P. Sphenopalatine artery ligation for epistaxis:
factors influencing outcome and impact of timing of sur-
gery. Otolaryngol Head Neck Surg. 2016;154:547–552.
19. Guss J, Cohen MA, Mirza N. Hard palate necrosis after
bilateral internal maxillary artery embolization for epistax-
is. Laryngoscope. 2007;117:1683–1684.
20. Ntomouchtsis A, Venetis G, Zouloumis L, Lazaridis N.
Ischemic necrosis of nose and palate after embolization
for epistaxis. A case report. Oral Maxillofac Surg.
2010;14:123–127.
21. Yilmaz M, Mamanov M, Yener, Aydin F, Kizilkilic O,
Eren A. Acute ischemia of the parotid gland and auricle
following embolization for epistaxis. Laryngoscope.
2013;123:366–368.