Abstract
Background
Endovascular embolization (EE) is a treatment option for epistaxis refractory to first-line interventions. Data regarding embolization is limited to small case series and a meta-analysis has not been performed.
Methods
PubMed, Scopus, and EMBASE were used to identify studies that reported outcomes for at least 10 patients undergoing EE for epistaxis. Outcomes included procedural success, rebleeding, and complications. Pooled rates for each outcome were obtained with random effects models.
Results
A total of 44 studies comprising 1664 patients met the inclusion criteria. The mean age ranged from 28.1 to 67 years and there were 28.4% females. The pooled procedural success rate was 87% (95% CI 83.9–89.6, I 2 = 53%). Age (OR 0.95, 95% CI 0.91–1) and hereditary hemorrhagic telangiectasia ([HHT], OR 0.97, 95% CI 0.96–0.99) were associated with decreased odds of success. The pooled rebleeding rate was 16.4% (95% CI 13.6–19.6, I 2 = 48%), and HHT was associated with greater odds of rebleeding (OR 1.02, 95% CI 1–1.03). The pooled overall complication rate was 14.4% (95% CI 9.8–20.6, I 2 = 85.8%). The pooled rates of stroke and vision loss were 2.1% (95% CI 1.5–3.1, I 2 = 1.5%) and 1.8% (95% CI 1.2–2.6, I 2 = 0%), respectively.
Conclusion
EE for epistaxis has a high rate of procedural success. Interventionalists should be aware of the risk for rebleeding, especially among patients with HHT.
Keywords: Epistaxis, therapeutic embolization, endovascular procedures
Introduction
Epistaxis is estimated to occur in 60% of individuals. Most cases resolve spontaneously or are managed conservatively with nasal packing, cautery, or local application of vasoconstrictive agents. The anterior nasal septum accounts for the majority of cases in an arterial triangle known as Kiesselbach's plexus, which is supplied by distal branches of the facial, internal maxillary (IMAX), and ethmoid arteries.1,2 Epistaxis cases arising from the posterior nasal septum are less likely to resolve with conservative measures.
Common etiologies for epistaxis include idiopathic, inflammatory, trauma, coagulopathy, and structural vascular abnormalities. 3 The most common associated vascular abnormality is hereditary hemorrhagic telangiectasia (HHT); an autosomal dominant disease characterized by widespread arteriovenous malformations and telangiectasias. Up to 98% of patients with HHT experience epistaxis.4,5
When bedside interventions fail to control epistaxis, invasive techniques (including surgical ligation) are indicated. Although sphenopalatine artery (SPA) ligation is well-established, endovascular embolization (EE) has become an increasingly common option. 6 This is performed using digital subtraction angiography to evaluate for structural vascular abnormalities and guide a microcatheter to the location of interest Various embolic materials can be used to occlude the target artery, and the treatment has been refined as microcatheters, microwires, and embolic materials have evolved. 7 Numerous non-systematic literature reviews have been performed,8−10 and one systematic review has been published, 11 but a meta-analysis is lacking. The goal of this study was to perform a systematic literature review and meta-analysis to evaluate the efficacy, safety, and rebleeding rate associated with EE for epistaxis.
Methods
This study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). 12 Institutional review board approval was not required because it used data from previously published sources.
Search Strategy
We performed a comprehensive search of the literature as of 6/21/2021 using PubMed, Scopus, and EMBASE. The general search strategy was (endovascular OR emboli*) AND epistaxis. Detailed search strategies for each database are provided in Supplementary Table 1.
Selection Criteria
Studies published in English were included if the authors reported original data regarding their outcomes performing EE for epistaxis. Only series that included at least ten patients with reported success rates for embolization published from 1980 to present were considered. The year 1980 was chosen based on the publication date of the landmark paper by Lasjaunias et al. 13
Data Extraction
A standardized form was used to extract the following data from the included studies: 1) number of patients with epistaxis undergoing embolization, 2) mean age, 3) sex, 4) proportion on antiplatelet or anticoagulant medication, 5) etiology of epistaxis, 6) attempts for securing hemostasis prior to embolization, 7) embolic material used, 8) mean number of vessels embolized, 9) proportion undergoing bilateral embolization, 10) mean procedure duration, 11) proportion experiencing procedural success, defined by immediate cessation of epistaxis following the procedure, 12) rebleed rate, where rebleed was defined as epistaxis recurrence requiring an additional surgery or embolization, 13) mean time to rebleed, 14) overall and individual complication rates, 15) mean follow-up duration. Data was extracted in duplicate by two authors (N.R. and A.A.K.) and all inconsistencies were resolved by a third author (H.H.).
Critical Appraisal
The methodological quality of the studies was assessed using the JBI critical appraisal tool. 14 This is a 10 item tool designed to assess the risk of bias, adequacy of reporting, and quality of statistical analysis in case series. 14 Risk of publication bias across studies was evaluated using a funnel plot and Egger's regression test The trim-and-fill method was used to adjust for publication bias by imputing missing studies and calculating a bias-corrected estimate. 15
Statistical Analysis
Pooled estimates for outcomes were calculated using random effects models and represented with forest plots. The primary outcome was procedural success, which was defined as immediate cessation of epistaxis following the procedure. Secondary outcomes included rebleed rate, defined as recurrent epistaxis requiring an additional surgery or embolization, and complication rates. Overall complication rates and individual rates of stroke, visual loss, and tissue necrosis were evaluated. Heterogeneity was evaluated with the I-square (I 2 ) statistic. Meta-regression analyses were performed to evaluate for associations between patient or procedural factors and outcomes.
Results
Quality of Studies
The initial searches of three electronic databases yielded 1614 unique studies. After applying exclusion criteria, a total of 44 studies were included in the quantitative analysis (Figure 1), which comprised 1664 patients (Supplementary Table 2). All studies were retrospective and observational. There were 40 case series and 4 retrospective cohort studies comparing endovascular embolization and surgical ligation. There were 3 studies with >100 patients, 8 with 50–100, and 33 with 10–50. While most studies included a mix of etiologies, 1 study included only patients with hereditary hemorrhagic telangiectasia (HHT), 3 with only post-traumatic etiology, 1 with only tumor-related epistaxis, and 8 with only idiopathic cases. The weighted mean follow-up duration was 17 months, although this data was not provided in 14 studies. Assessment of methodological quality for each study is provided in Table 1. Clear criteria for inclusion were provided in 38 (86.4%) studies. Consecutive and complete inclusion of participants was performed in 38 (86.4%) and 31 (70.5%) studies, respectively. All studies clearly reported outcomes.
Figure 1.
PRISMA flow diagram demonstrating results of the literature review.
Table 1.
Assessment of methodological quality using the JBI critical appraisal tool.
| Authors | Year | 1. Were there clear criteria for inclusion in the case series? | 2. Was the condition measured in a standard, reliable way for all participants included in the case series? | 3. Were valid methods used for identification of the condition for all participants included in the case series? | 4. Did the case series have consecutive inclusion of participants? | 5. Did the case series have complete inclusion of participants? | 6. Was there clear reporting of the demographics of the participants in the study? | 7. Was there clear reporting of clinical information of the participants? | 8. Were the outcomes or follow-up results of cases clearly reported? | 9. Was there clear reporting of the presenting sites’/clinics’ demographic information? | 10. Was statistical analysis appropriate? |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Parnes et al. | 1987 | Y | Y | N/A | Y | N | N | Y | Y | N | N/A |
| Wehrli et al. | 1988 | Y | Y | N/A | Y | N | Y | Y | Y | Y | N/A |
| Breda et al. | 1989 | N | Y | N/A | Y | Y | Y | N | Y | N | N/A |
| Strutz & Schumacher | 1990 | Y | Y | N/A | Y | Y | Y | Y | Y | N | N/A |
| Vitek | 1991 | N | Y | N/A | N | N | Y | Y | Y | N | N/A |
| Siniluoto et al. | 1993 | Y | Y | N/A | Y | Y | Y | Y | Y | N | N/A |
| Elden et al. | 1994 | N | N | N/A | N | Y | Y | Y | Y | N | N/A |
| Elahi et al. | 1995 | Y | Y | N/A | Y | N | Y | Y | Y | N | N/A |
| Strong et al. | 1995 | Y | Y | N/A | Y | Y | Y | Y | Y | Y | N/A |
| Moreau et al. | 1998 | Y | Y | N/A | Y | Y | Y | Y | Y | N | N/A |
| Tseng et al. | 1998 | Y | Y | N/A | Y | Y | Y | Y | Y | N | N/A |
| Cullen et al. | 1998 | Y | Y | N/A | Y | N | Y | N | Y | N | N/A |
| Leppänen et al. | 1999 | N | Y | N/A | Y | Y | Y | N | Y | N | N/A |
| Oguni et al. | 2000 | Y | Y | N/A | Y | Y | Y | Y | Y | N | N/A |
| Scaramuzzi et al. | 2001 | Y | Y | N/A | Y | Y | Y | N | Y | Y | N/A |
| Klotz et al. | 2002 | Y | Y | N/A | Y | N | Y | N | Y | Y | N/A |
| Scroop et al. | 2003 | Y | Y | N/A | Y | Y | N | Y | Y | Y | N/A |
| Vokes et al. | 2004 | Y | Y | N/A | Y | Y | Y | Y | Y | Y | N/A |
| Duncan et al. | 2004 | Y | Y | N/A | Y | Y | Y | Y | Y | Y | N/A |
| Gurney et al. | 2004 | Y | N | N/A | Y | N | Y | Y | Y | Y | N/A |
| Andersen et al. | 2005 | Y | Y | N/A | Y | Y | Y | Y | Y | N | N/A |
| Christensen et al. | 2005 | Y | Y | N/A | Y | N | Y | Y | Y | Y | N/A |
| Sadri et al. | 2006 | N | Y | N/A | N | Y | Y | Y | Y | N | N/A |
| Layton et al. | 2007 | Y | N | N/A | Y | Y | Y | Y | Y | Y | Y |
| Wong et al. | 2007 | Y | N | N/A | Y | Y | Y | Y | Y | N | N/A |
| Fukutsuji et al. | 2008 | Y | Y | N/A | Y | Y | Y | N | Y | Y | N/A |
| Santaolalla et al. | 2009 | Y | Y | N/A | Y | Y | Y | Y | Y | Y | Y |
| Zhang et al. | 2010 | Y | Y | N/A | Y | Y | Y | Y | Y | N | N/A |
| Lesley et al. | 2010 | Y | Y | N/A | Y | Y | Y | Y | Y | Y | N/A |
| TrojaNwski et al. | 2011 | Y | Y | N/A | Y | Y | Y | Y | Y | Y | N/A |
| Strach et al. | 2011 | Y | Y | N/A | Y | Y | Y | Y | Y | Y | N/A |
| TrojaNwski et al. | 2011 | Y | Y | N/A | N | Y | Y | N | Y | N | N/A |
| Baloch et al. | 2012 | Y | Y | N/A | Y | N | Y | Y | Y | Y | N/A |
| Haroon et al. | 2012 | N | Y | N/A | N | Y | Y | N | Y | N | N/A |
| Schrock et al. | 2012 | Y | Y | N/A | Y | N | Y | Y | Y | N | N/A |
| Cohen et al. | 2012 | Y | Y | N/A | Y | N | Y | Y | Y | N | N/A |
| Chen et al. | 2013 | Y | Y | N/A | Y | Y | Y | Y | Y | Y | N/A |
| Gottumukkala et al. | 2013 | Y | Y | N/A | Y | N | Y | Y | Y | N | Y |
| Seidel et al. | 2015 | Y | Y | N/A | Y | Y | Y | Y | Y | Y | Y |
| Wang et al. | 2016 | Y | Y | N/A | Y | Y | Y | Y | Y | N | Y |
| Robinson et al. | 2017 | Y | Y | N/A | Y | Y | Y | Y | Y | N | Y |
| de Bonnecaze et al. | 2018 | Y | Y | N/A | Y | Y | N | Y | Y | N | Y |
| Huyett et al. | 2019 | Y | Y | N/A | Y | N | Y | Y | Y | Y | N/A |
| Franke et al. | 2020 | Y | Y | N/A | N | Y | Y | Y | Y | N | N/A |
Patient and Procedure Characteristics
The mean age in the studies ranged from 28.1 to 67 years and there were 28.4% females. A minority of patients (13%) were on antiplatelet or anticoagulant medication, although this data was only provided in 20 studies. The most common etiology was idiopathic (58.5%), followed by trauma (11.7%), tumor (7.2%), HHT (5.8%), postoperative complication (4.6%), and coagulopathy (0.9%). Packing was described as an initial measure for hemostasis in most patients (92.5%). Surgical ligation was performed sparingly (6.4%).
Particles were used in 37 studies, coils in 22, and Onyx in 1. The mean number of vessels embolized ranged from 1 to 3. The IMAX or its branches were embolized in 93.1% of cases and the facial artery or its branches were embolized in 32.5%. Bilateral embolization was performed in 49.8% of cases.
Assessment of Efficacy
As shown in Figure 2, procedural success was achieved in 87% (95% CI 83.9–89.6, I 2 = 53%). In the meta-regression, age (OR 0.95, 95% CI 0.91–1) and HHT (OR 0.97, 95% CI 0.96–0.99) were associated with decreased odds of success. Rebleeding rates were reported in 43 studies. As shown in Figure 3, the pooled rebleeding rate was 16.4% (95% CI 13.6–19.6, I 2 = 48%). The mean time to rebleeding was 103 days after the index procedure, however this was only included in 7 studies. HHT was associated with greater odds of rebleeding in the meta-regression (OR 1.02, 95% CI 1–1.03). The influence of HHT on outcomes is shown in Figure 4.
Figure 2.
Forest plot for procedural success showing results from individual studies and the pooled rate calculated from the random effects model.
Figure 3.
Forest plot for rebleeding rate showing results from individual studies and the pooled rate calculated from the random effects model.
Figure 4.
Results from the meta-regression demonstrating the effect of hereditary hemorrhagic telangiectasia (HHT) on procedural success and rebleeding.
Assessment of Safety
Complication rates were reported in 43 studies. The pooled overall complication rate was 14.4% (95% CI 9.8–20.6, I 2 = 85.8%) and none of the predictors were associated with complication rate. The forest plot is shown in Figure 5. The pooled rates of stroke, visual loss, and tissue necrosis were 2.1% (95% CI 1.5–3.1, I 2 = 1.5%), 1.8% (95% CI 1.2–2.6, I 2 = 0%), and 2.7% (95% CI 1.8–4, I 2 = 18.1%), respectively.
Figure 5.
Forest plot for overall complication rate showing results from individual studies and the pooled rate calculated from the random effects model.
Publication Bias
Funnel plots for publication bias are shown in Figure 6 and are indicative of publication bias with respect to procedural success, rebleeding, and overall complication rates. This is suggested by the asymmetry around the pooled estimate favoring higher success rates with lower rebleeding and complication rates in smaller studies. Egger's test confirmed funnel plot asymmetry for procedural success (p < 0.001), rebleeding (p < 0.001), and complication rates (p < 0.001). For procedural success, trim-and-fill analysis indicated that 11 studies were missing on the left side of the plot and yielded a rate of 84.8 (95% CI 81.4–87.8). For rebleeding rate, 11 studies were missing on the right side of the plot and the adjusted rate was 18.9 (95% CI 15.8–22.4). For the overall complication rate, 12 studies were missing on the right side of the plot and the adjusted rate was 22.4 (95% CI 15.2–31.6).
Figure 6.
Funnel plots demonstrating publication bias for procedural success, rebleeding, and complication rates. The funnel plots on the right include imputed missing studies obtained with the trim-and-fill method.
Comparison to Surgical Treatment
Among the four studies comparing EE and surgical ligation, procedural success was 79.2% and 83.3% for each group, respectively. The surgical arms consisted of trans nasal endoscopic SPA ligation, 16 mostly IMAX with or without ethmoid ligation, 17 and trans antral IMAX ligation.9,10 As shown in Figure 7, there was no difference in the odds of success for EE compared to surgical ligation (OR 0.86, 95% CI 0.42–1.75, I 2 = 0%).
Figure 7.
Forest plot comparing the procedural success of endovascular embolization to surgical ligation. (EE + : Number of patients who underwent successful endovascular embolization, EE-: Unsuccessful endovascular embolization, S + : Successful surgery, S-: Unsuccessful surgery).
Discussion
EE is an increasingly popular option for cases of epistaxis refractory to bedside interventions. 6 In this systematic review and meta-analysis of 44 studies and 1664 patients we characterized the procedural success rates, risks of rebleeding, and rates of complications associated with EE for epistaxis. We found a high rate of immediate procedural success but a rebleeding rate of 16.4%. EE is a safe and effective treatment option for intractable epistaxis, but one must remain cognizant of rebleeding risk, especially in patients with HHT.
Summary of Evidence
The pooled procedural success rate was 87%, although moderate heterogeneity and publication bias were present. Success of EE depends on multiple factors including the embolic material used, the artery embolized, the number of arteries embolized, the location of the microcatheter with which embolization is performed, and the etiology of the epistaxis. 18 Although the SPA is the usual source of bleeding, diagnostic cerebral angiography allows for identification of the source as well as any underlying structural vascular abnormality. Recent advances in developing more navigable microwires and microcatheters, as well as embolic materials that can be injected with greater precision and visualization may continue to improve the efficacy of the procedure. In the meta-regression, older age was associated with lower odds of procedural success. This could be due to greater use of anticoagulation, greater incidence of comorbidities such as hypertension, or reluctance to perform more aggressive embolization. Patients with hereditary hemorrhagic telangiectasia (HHT) also had decreased odds of procedural success. Epistaxis related to HHT may be more difficult to treat due to the presence of mucosal telangiectasias and greater degree of supply from ethmoidal artery branches. 4 The ethmoidal artery's origin from the ophthalmic artery makes this a dangerous vessel to catheterize and embolize from. Multiple studies report higher rates of success in patients without HHT as compared to those with HHT.1,19
The pooled rebleeding rate was found to be 16.4%, and HHT was associated with greater odds of rebleeding. Rebleeding after endovascular embolizations may occur due to patient or procedural factors. Patient factors include anticoagulation, HHT, or nasopharyngeal malignancy. Procedurally, rebleeding may be related to proximal arterial occlusions in the IMAX or external carotid artery trunk that fail to penetrate the distal sources of bleeding. The nasal mucosa has redundant vascular supply with potential for collateral formation, which can lead to rebleeding. Recognition of the correct artery that is the source of bleeding is also crucial. Although primary embolization of multiple arteries may be an effective way to prevent recurrence of epistaxis, this must be weighed with the risk of causing mucosal or skin necrosis. The choice of embolic material may also influence rebleeding rates. Most studies in our analysis used particles, followed by coils, and Onyx. Although coils have the benefit of controlled deployment without risk of penetrating ophthalmic or intracranial collaterals, they have been associated with rebleeding. 20 No association between embolic material and rebleeding was seen in this analysis. Multiple series of EE for epistaxis in patients with HHT have been characterized by high rates of rebleeding necessitating repeat embolization,4,19,21 and HHT has been described as a risk factory previously. In this population, EE is considered palliative to reduce the frequency of rather than cure bleeding events. Early rebleeding events in patients with HHT could originate from separate points as the index event given the presence of numerous telangiectasias.
The pooled overall complication rate in our analysis was 14.4%, which includes major and minor complications. Heterogeneity was high, which could be related to differences in classification of complications, embolic materials, number of vessels embolized, and patient populations. Minor complications after EE for epistaxis include headache and facial pain while major complications are stroke, visual loss, and tissue necrosis. Based on the low incidence of each major complication, the overall complication rate was largely comprised of minor complications. Extracranial-intracranial collaterals account for the risk of stroke, which was 2.1%. These connections are often difficult to assess angiographically but can be opened when injecting embolysates. The use of particles larger than 300 µm may reduce the risk of penetrating these collaterals. Likewise, occlusion of collaterals to the ophthalmic artery can account for vision loss. The ethmoidal and facial arteries represent sources of potential collateralization encountered during EE for epistaxis. A greater number of vessels embolized could increase the risk of tissue necrosis, although the rarity of this complication makes it difficult to establish a statistical association. The number of vessels embolized was not reported in most studies, which prevented us from assessing for this association.
Based on the four studies comparing treatment modalities, EE had similar efficacy as surgical ligation. This comparison is limited by the inclusion of only four studies and the fact that three of the four studies were performed on or before 2002. Considerable advances in endovascular technology have been made since then, including the introduction of Onyx. Additionally, all four studies were retrospective without randomization or uniform selection criteria for each treatment. Potential benefits of EE include its minimally invasive nature, the ability to visualize structural vascular abnormalities and bleeding locations, and the opportunity to occlude multiple arteries or perform repeat interventions if necessary.
Limitations
This meta-analysis is limited by the inclusion of mostly small retrospective case series, which could have been subject to non-uniform patient selection, nonconsecutive patient inclusion, and incomplete follow-up. Publication bias was present for each outcome. In addition, there was heterogeneity among the patient cohorts, with various etiologies of epistaxis and embolic materials used. As endovascular technology continues to evolve, comparison of studies from different time periods has become problematic. For example, approximately half of the studies were published before Onyx™ Liquid Embolic System (Medtronic, USA) became available in 2005. Finally, data was missing for some of the exposure variables and outcomes.
This study is the first to perform a meta-analysis of the literature regarding EE for epistaxis. As this treatment becomes performed more frequently, 6 pooled rates of safety and efficacy will be useful for counseling patients and evaluating one's own outcomes. This study also highlights a considerable rebleeding rate of 16.4%, which should be discussed with patients preoperatively when possible. Patients should be monitored for this postoperatively and be aware of the need to seek medical attention if this occurs. Our data suggests that closer monitoring for rebleeding is required in patients with HHT. As catheter, wire, and embolysate technologies continue to evolve, it is likely that even greater safety and efficacy with the procedure will be realized. Prospective studies are needed to obtain unbiased estimates of outcomes, and multicenter registries may provide new insight regarding procedural safety and efficacy.
Conclusion
EE is an effective treatment for epistaxis that carries low rates of major complications. Older patients and those with HHT may experience lower rates of treatment success. Rebleeding is not an uncommon event, and patients with HHT may be more susceptible.
Supplemental Material
Supplemental material, sj-docx-1-ine-10.1177_15910199221081715 for Endovascular embolization for the treatment of epistaxis: Systematic review and meta-analysis by Haydn Hoffman, Apeksha Ashok Kumar, Neveada Raventhiranathan, Hesham E Masoud and Grahame C Gould in Interventional Neuroradiology
Supplemental material, sj-docx-2-ine-10.1177_15910199221081715 for Endovascular embolization for the treatment of epistaxis: Systematic review and meta-analysis by Haydn Hoffman, Apeksha Ashok Kumar, Neveada Raventhiranathan, Hesham E Masoud and Grahame C Gould in Interventional Neuroradiology
Footnotes
Author contributor statement: H.H. conceived the study, performed data analysis, and drafted the article. A.A.K. and N.R. acquired data, performed data analysis, and drafted the article. H.M. and G.C.G. supervised data acquisition and analysis and revised the article. All authors approved the final version of the manuscript to be published.
Ethical approval statement: IRB approval was not required for this work because it used previously published data.
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.
ORCID iD: Haydn Hoffman https://orcid.org/0000-0002-2967-6528
Supplemental material: Supplemental material for this article is available online.
References
- 1.Koh E, Frazzini NJ K, VI. Epistaxis: vascular anatomy, origins, and endovascular treatment. AJR Am J Roentgenol 2000; 174: 845–851. [DOI] [PubMed] [Google Scholar]
- 2.Manes RP. Evaluating and managing the patient with nosebleeds. Med Clin North Am 2010; 94: 903–912. [DOI] [PubMed] [Google Scholar]
- 3.Parajuli R. Evaluation of etiology and treatment methods for epistaxis: a review at a tertiary care hospital in central Nepal. Int J Otolaryngol 2015; 2015: 283854. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Layton KF, Kallmes DF, Gray LA, et al. Endovascular treatment of epistaxis in patients with hereditary hemorrhagic telangiectasia. AJNR Am J Neuroradiol 2007; 28: 885–888. [PMC free article] [PubMed] [Google Scholar]
- 5.Chin CJ, Rotenberg BW, Witterick IJ. Epistaxis in hereditary hemorrhagic telangiectasia: an evidence based review of surgical management. J Otolaryngol Head Neck Surg 2016; 45: 3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Brinjikji W, Kallmes DF, Cloft HJ. Trends in epistaxis embolization in the United States: a study of the nationwide inpatient sample 2003–2010. J Vasc Interv Radiol 2013; 24: 969–973. [DOI] [PubMed] [Google Scholar]
- 7.Willems PW, Farb RI. Agid R: endovascular treatment of epistaxis. AJNR Am J Neuroradiol 2009; 30: 1637–1645. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Sadri M, Midwinter K, Ahmed A, et al. Assessment of safety and efficacy of arterial embolisation in the management of intractable epistaxis. Eur Arch Otorhinolaryngol 2006; 263: 560–566. [DOI] [PubMed] [Google Scholar]
- 9.Cullen MM. Tami TA: comparison of internal maxillary artery ligation versus embolization for refractory posterior epistaxis. Otolaryngol Head Neck Surg 1998; 118: 636–642. [DOI] [PubMed] [Google Scholar]
- 10.Strong EB, Bell DA, Johnson LP, et al. Intractable epistaxis: transantral ligation vs. Embolization: efficacy review and cost analysis. Otolaryngol Head Neck Surg 1995; 113: 674–678. [DOI] [PubMed] [Google Scholar]
- 11.Swords C, Patel A, Smith ME, et al. Surgical and interventional radiological management of adult epistaxis: systematic review. J Laryngol Otol 2017; 131: 1108–1130. [DOI] [PubMed] [Google Scholar]
- 12.Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 2009; 62: 1006–1012. [DOI] [PubMed] [Google Scholar]
- 13.Lasjaunias P, Marsot-Dupuch K. Doyon D: the radio-anatomical basis of arterial embolisation for epistaxis. J Neuroradiol 1979; 6: 45–53. [PubMed] [Google Scholar]
- 14.Munn Z, Barker TH, Moola S, et al. Methodological quality of case series studies: an introduction to the JBI critical appraisal tool. JBI Evid Synth 2020; 18: 2127–2133. [DOI] [PubMed] [Google Scholar]
- 15.Shi L, Lin L. The trim-and-fill method for publication bias: practical guidelines and recommendations based on a large database of meta-analyses. Medicine (Baltimore) 2019; 98: e15987. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.de Bonnecaze G, Gallois Y, Bonneville F, et al. Transnasal endoscopic sphenopalatine artery ligation compared With embolization for intractable epistaxis: a long-term analysis. Am J Rhinol Allergy 2018; 32: 188–193. [DOI] [PubMed] [Google Scholar]
- 17.Klotz DA, Winkle MR, Richmon J, et al. Surgical management of posterior epistaxis: a changing paradigm. Laryngoscope 2002; 112: 1577–1582. [DOI] [PubMed] [Google Scholar]
- 18.Gottumukkala R, Kadkhodayan Y, Moran CJ, et al. Impact of vessel choice on outcomes of polyvinyl alcohol embolization for intractable idiopathic epistaxis. J Vasc Interv Radiol 2013; 24: 234–239. [DOI] [PubMed] [Google Scholar]
- 19.Elden L, Montanera W, Terbrugge K, et al. Angiographic embolization for the treatment of epistaxis: a review of 108 cases. Otolaryngol Head Neck Surg 1994; 111: 44–50. [DOI] [PubMed] [Google Scholar]
- 20.Hoffman H, Jalal MS, Masoud HE, et al. Outcomes after endovascular embolization for the treatment of nasal and oropharyngeal hemorrhage: safety, efficacy, and rebleeding. Neuroradiol J . Epub ahead of print 3 September 2021. DOI: 10.1177/19714009211042893. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Andersen PJ, Kjeldsen AD. Nepper-Rasmussen J: selective embolization in the treatment of intractable epistaxis. Acta Otolaryngol 2005; 125: 293–297. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplemental material, sj-docx-1-ine-10.1177_15910199221081715 for Endovascular embolization for the treatment of epistaxis: Systematic review and meta-analysis by Haydn Hoffman, Apeksha Ashok Kumar, Neveada Raventhiranathan, Hesham E Masoud and Grahame C Gould in Interventional Neuroradiology
Supplemental material, sj-docx-2-ine-10.1177_15910199221081715 for Endovascular embolization for the treatment of epistaxis: Systematic review and meta-analysis by Haydn Hoffman, Apeksha Ashok Kumar, Neveada Raventhiranathan, Hesham E Masoud and Grahame C Gould in Interventional Neuroradiology