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FIGURE 5 The technique of anterior ethmoid artery ligation via a Lynch incision.

intractable epistaxis. Since that time, multiple reports utilizing this basic technique with various catheters and embolic materials have been reported.

The use of this technique is seen in many areas including arteriovenous malformations, pseudoaneurysms, bleeding varices, shrinking of fibroids, and vascular tumors of the head and neck. Diagnostic angiography with embolization is commonly performed under local anesthesia via the femoral approach. A variety of catheters and microcatheters have been developed to get to the different sources of epistaxis. Once in the proper location, an embolic material is injected via the catheter to occlude the offending vessel. The type of embolic utilized depends on the desired level of occlusion, desired duration of occlusion, and catheter system compatibility (Table 1).

The technique most commonly used at our institution is as follows: Prior to embolization, complete diagnostic arteriography of the internal and external carotid circulations is performed bilaterally, and, if indicated, the vertebral arteries' circulation is studied, as well. This is usually performed from a femoral artery approach, utilizing a 4- or 5-French diagnostic catheter. If embolization is to be performed, an open-ended guiding catheter usually is used. The catheter is advanced through a groin sheath and positioned in either the common carotid artery or the external carotid artery trunk. A microcatheter of under 2.8-French in diameter, in conjunction with micro-guidewires, is then utilized for selective catheterization of the appropriate vessel(s).

Embolization is then performed with an appropriate agent. In the case of epistaxis or preoperative tumor embolization, particulate agents are generally employed. Following embolization, which is performed during observation with real-time fluoroscopy, completion arteriography is generally performed through the microcatheter and/or guiding

TABLE 1 Embolic Agents

Absorbable material Gelfoam

Autologous blood clot Avitene Ethibloc Nonabsorbable material Particulate agents Autologous fat and muscles PVA

Spherical PVA Acrylics Injectable agents

NBCA [Onyx (not currently available in United States), silicone] Sclerosing agents Boiling contrast ETOH (absolute alcohol) Sodium morrhuate Sotradecol Occlusion devices Detachable balloons Coils, microcoils Detachable coils Spider, clamp shells Amplatzer

Abbreviations: PVA, polyvinyl alcohol; NBCA, N-butyl cyanoacrylate; ETOH, ethyl alcohol.

catheter, and, depending on the vascular territory and level of embolization, collateral circulation might be evaluated with respect to the need for further embolization.

This technique, even in the best hands, is not without the risk of complication. The major complications reported in the literature have included stroke, blindness, facial paralysis, grand mal seizure, trismus, soft-tissue necrosis, and swelling of the cheek. Most of these cases occurred when utilizing permanent embolic agents such as PVA. Minor complications have been reported to range from 2.2% to 25% (31,49-51). These may include mild-to-moderate temporal pain, headache, and temporofacial pain.

JUVENILE ANGIOFIBROMAS

JA is a benign, highly vascular tumor that almost exclusively occurs in the nasopharynx of adolescent males. The average age of onset is 15 years. JA typically originates in the superior margin of the sphenopalatine foramen. It accounts for only 0.5% of all head and neck tumors (11,12,52). The most common presenting symptoms are severe recurrent epistaxis with nasal obstruction. The histologic origin of these tumors is uncertain, but they

FIGURE 6 (A) Catheter in internal maxillary artery (arrow). (B) Right ECA preembolization. The tumor mass can be seen (arrow) (C) Right ECA postembolization. The tumor blush is gone. Abbreviation: ECA, external carotid artery.

have a highly vascularized and proliferative nature (12,53). Bone erosion may occur in the region of the orbit and the skull base. If the disease process is allowed to progress, facial deformity, proptosis, blindness, and cranial nerve palsy may occur. Fisch classified JAs into four types. The stages may help plan the correction (54).

Removal of the tumor depends on its extent and the training of the surgeon. Previously, the majority of these tumors were removed through an open approach, commonly via a lateral rhinotomy (11). Craniofacial resections have been utilized in advanced JAs (52,55,56). More recently, endoscopic removal has been popularized for lower-stage lesions (57). With the increase in interventional radiology and selective embolization, removal of these tumors can be accomplished without major blood loss. Effective preoperative embolization is most important when one wants to attempt endoscopic removal of these tumors (Fig. 6A-C).

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