CLINICAL HISTORY:
CONTRAST: 60 cc intra-arterial contrast
FLUORO TIME: 15 min
PROCEDURE:
Following discussion procedure its risks benefits and alternatives, review of readily available relevant imaging prior to the procedure informed consent was obtained witnessed and documented upon the chart. Risks for blindness, stroke, and death were discussed. A full neurologic exam was performed prior to the start of the procedure.
Standard presurgical timeout confirming patient procedure and when relevant side and site was performed. Any discrepancies were resolved via consultation with appropriate readily available data sources. The patient was prepared and draped in standard sterile fashion.
Patient was placed supine on the interventional table and the right groin was widely prepped and draped in the usual sterile fashion and local anesthesia was achieved using 1% lidocaine.
Using a micropuncture set and after profuse local anesthesia, the right common femoral artery was accessed on the first attempt under direct ultrasound guidance and a 6 French short vascular sheath was placed. Over a Bentson wire a 90 cm long pigtail catheter was advanced into the ascending aorta and an aortic flush angiogram was performed to delineate the origins of the great vessels to exclude unstable plaques. Using a vertebral catheter and a soft tipped Glidewire, the left common carotid artery origin was engaged and the common carotid artery was subselected and digital subtraction angiogram was performed to exclude unstable plaques. Over the Glidewire, the catheter was further advanced into the mid region of the left external carotid artery. Double flushing technique was always used throughout the entire procedure. Selective angiogram of the left external carotid artery was performed delineating patent major branches including the internal maxillary artery. Catheter was then further advanced into the midportion of the internal maxillary artery and repeat angiogram was performed. Using a coaxial 3 French inner microcatheter, the smaller branches of the internal maxillary artery was subselected and angiograms of each were performed.
No intracranial connection is seen. Through the existing microcatheter, embolization was performed utilizing multiple Terumo detachable coils. No particles were used for the embolotherapy to minimize reflux embolization complication of proximal branches to the retina and the orbits. Proximal normal branches were completely preserved. Completion angiogram shows no further bleeding in the area of the nasal cavity. Catheter was then carefully removed and the right common femoral artery was sealed using a Starclose device. Patient had baseline femoral and pedal pulses.
COMPLICATIONS: None. Patient had no immediate procedural or sedation complications. Patient’s neurologic status was completely stable with no change in the motor findings. Cranial nerves III, IV, V and VII all intact after the procedure. Patient had no visual changes.
IMPRESSION: Difficult but successful emergent embolotherapy of the bleeding second order branch of the left internal maxillary artery