If epistaxis is refractory to the above treatments, more extensive and specialized techniques may be needed. These include arterial ligation or embolization. These options should only be performed by a specially trained physician.
Surgical ligation can be performed as treatment for posterior epistaxis. The external carotid artery can be ligated distal to the lingual branch. However, this is rarely successful in controlling epistaxis secondary to the extensive collateral circulation. Ligation of the ethmoidal vessels and the maxillary artery have been successful in controlling hemorrhage. Angiographic embolization of the vessels supplying the bleeding site is usually used when bleeding has failed to respond to packing or arterial ligation. A 96 percent success rate has been reported in patients with severe or intractable epistaxis. 5 The risks of embolization include neurologic and ocular complications from accidental embolization of the cerebral or ophthalmic arteries. Despite this, in experienced hands embolization results in low morbidity and negligible mortality.5
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