- Department of Neurological Surgery, University of Pittsburgh Medical Center 200 Lothrop Street, 15207, Pittsburgh, PA, USA
- Department of Dermatology, University of Pittsburgh Medical Center 200 Lothrop Street, 15207, Pittsburgh, PA, USA
- Department of Dermatopathology, University of Pittsburgh Medical Center 200 Lothrop Street, 15207, Pittsburgh, PA, USA
- Department of Neurological Surgery, Pennsylvania Brain and Spine Institute, Pittsburgh, PA, USA
Department of Neurological Surgery, Pennsylvania Brain and Spine Institute, Pittsburgh, PA, USA
DOI:10.4103/2152-7806.115388Copyright: © 2013 Grandhi R Thtis is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Grandhi R, Panczykowski D, Zwagerman NT, Gehris R, Villasenor-Park J, Ho J, Grandinetti L, Horowitz M. Facial necrosis after endovascular Onyx-18 embolization for epistaxis. Surg Neurol Int 22-Jul-2013;4:95
How to cite this URL: Grandhi R, Panczykowski D, Zwagerman NT, Gehris R, Villasenor-Park J, Ho J, Grandinetti L, Horowitz M. Facial necrosis after endovascular Onyx-18 embolization for epistaxis. Surg Neurol Int 22-Jul-2013;4:95. Available from: http://sni.wpengine.com/surgicalint_articles/facial-necrosis-after-endovascular-onyx-18-embolization-for-epistaxis/
Background:Evolution in techniques and equipment has expanded the role, effectiveness, and safety of endovascular transarterial embolization for the treatment of severe epistaxis. Risks from this treatment approach include major ischemic complications. To date, there have been only a few reports of soft tissue necrosis following endovascular embolization for severe epistaxis; none involve the use of Onyx-18.
Case Description:We report the case of a 52-year-old woman who presented with epistaxis that was refractory to medical and surgical management, which lead to endovascular intervention and embolization with Onyx-18. The patient subsequently developed nasal ala and facial necrosis as a result of the procedure.
Conclusion:We report the use of Onyx-18 for the endovascular embolization of a patient with severe epistaxis and subsequent complications. In cases of severe epistaxis that warrant intervention in the form of embolization, ischemic complications are rare; however, ischemic complications may be unavoidable and should factor into the discussion regarding procedural risks.
Keywords: Endovascular embolization, epistaxis, Onyx, soft tissue necrosis
The treatment of severe epistaxis often involves endovascular embolization. Major ischemic complications following super-selective embolization for the treatment of epistaxis include tissue necrosis, cerebral infarction, and blindness; however, there have been no necrotic complications reported with the use of Onyx-18 (Covidien, Irvine, CA), a copolymer consisting of ethylene vinyl alcohol, dimethylsulfoxide (DMSO), and tantalum powder. The properties of Onyx-18 make it suitable for embolization of high-flow vascular lesions, though complications relating to distal embolization with resultant tissue ischemia from the occlusion of small arterioles warrant consideration. We report the use of Onyx-18 for the endovascular embolization of a patient with severe epistaxis and subsequent complications.
A 52-year-old African-American woman with a history of aortic valve replacement, mitral valve repair, and deep venous thrombosis on chronic anticoagulation therapy with warfarin and aspirin presented after developing epistaxis from her right naris. She received blood products, underwent packing, ligation of the sphenopalatine artery, and silver nitrate cauterization with no resolution of her epistaxis.
The bleeding persisted and the patient underwent endovascular embolization. Under general anesthesia, transarterial embolization was carried out through a right femoral artery approach. A 6-Fr guiding catheter (Envoy; Cordis Endovascular Systems, Miami Lakes, FL) over a hydrophilic guidewire was placed into the left and right external carotid arteries (ECAs). A MarathonTMMicro Catheter (Covidien, Irvine, CA) was advanced over a X-pedionTM0.010" Guidewire (Covidien, Irvine, CA) into the left and right internal maxillary arteries and the left and right facial arteries. After confirmation that no opacification of the orbital contents was seen after injection of contrast, the catheter was slowly flushed with 0.5 cc of DMSO. Onyx-18 was injected until a cap formed over the catheter tip that allowed a small amount of reflux. After allowing the cap to solidify, the vessels were embolized with 0.8 cc of Onyx-18 over a period of minutes [
(a) Selective catheterization of the external carotid artery to just proximal to the facial artery demonstrates faint Onyx-18 cast of the ipsilateral internal maxillary artery (b) Superselective catheterization of the inferior division of the facial artery using a microcatheter with subsequent Onyx-18 embolization. Onyx-18 cast of the ipsilateral internal maxillary artery is readily visible (c) Superselective catheterization of the superior division of the Facial artery using a microcatheter with subsequent Onyx-18 embolization (d) Nonsubtracted view with roadmap guidance showing Onyx-18 casts within the Internal Maxillary and Facial arteries
On postembolization day 3, the patient noticed a hyperpigmented patch on her left cheek that appeared, prompting dermatologic evaluation [
The majority of cases of epistaxis result from hemorrhage of Kiesselbach’s plexus, the vascular supply of the lower anterior septal cartilage. Typically, tamponading the bleeding by inserting nasal packing controls the hemorrhage. When bleeding is refractory to these maneuvers, application of a topical vasoconstrictor, cryotherapy, or electrocautery may be utilized. [
The endovascular approach for treatment of epistaxis has evolved since Sokoloff et al. successfully treated a patient with intractable epistaxis using 1-2 mm sized Gelfoam (Pfizer, New York, NY) particles in 1974, particularly in the embolic agents used. [
Soft tissue necrosis after embolization for severe epistaxis is rare, owing to extensive collateral blood supply. However, cases of necrosis of the nasal ala, septum, columella, oral mucosa, and facial skin have previously been noted. Sadri et al. had tissue necrosis occur in 2 of 14 patients treated for intractable epistaxis. [
Onyx-18 is a liquid embolic composed of ethylene-vinyl alcohol and DMSO copolymer that is mixed with tantalum powder. This agent’s properties lend it to be used for treatment of intracranial arteriovenous malformations, dural vascular malformations, and direct carotid cavernous fistulas. Its use in extracranial vascular malformations has also been reported. [
Our preference to use Onyx as an embolic material in this case was due to its affording good penetration, visualization of embolic material, reduced risk of retrograde filling of collaterals, and the permanence of the material. The use of Onyx certainly offers benefits in embolization procedures, but does come with some disadvantages. First, Onyx is significantly more expensive than other embolic agents. Second, PVA particles and Gelfoam pledgets are resorbable, carrying a lower risk of permanent tissue ischemia. Finally, since Onyx is a liquid embolic agent, its use is more likely to lead to endarteriolar occlusion and necrosis, a phenomenon, which likely occurred in the case described herein.
Despite its drawbacks, our decision to use Onyx in this case owed to fact that the patient had failed both conservative and surgical management with packing, ligation of the sphenopalatine artery and silver nitrate cauterization. Thus, we believed that using a permanent liquid embolic agent would afford the best chance of resolving her epistaxis without her having to require additional blood product transfusions or surgical procedures. Also, based on our experience, we felt that using another embolic agent would have come with the same inherent risks, as evidenced by the aforementioned complications experienced by other authors when performing endovascular, transarterial embolization procedures for treatment of epistaxis.
A previous report described a patient who had ischemic necrosis to the superolateral pinna following Onyx-18 embolization of a dural arteriovenous fistula fed by the posterior auricular artery. [
We report unilateral ischemic necrosis of a patient’s nasal ala and cheek after Onyx-18 endovascular embolization of bilateral internal maxillary arteries and facial arteries for treatment of intractable epistaxis. In cases of severe epistaxis that warrant intervention in the form of embolization, ischemic complications are rare, given the extensive collateral blood supply in the maxillofacial region; however, ischemic complications may be unavoidable and should factor into the discussion regarding procedural risks.
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