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Indications & Contraindications
Patient selection, injury patterns, when to embolize
Indications
- Facial fracture with active arterial bleeding — Le Fort fractures (I, II, III), mandible fractures with hemorrhage not controlled by packing or surgery
- Epistaxis refractory to packing — post-traumatic epistaxis failing anterior and posterior nasal packing; typically from sphenopalatine artery territory
- Penetrating neck injury with active contrast extravasation or pseudoaneurysm (PSA) on CTA
- Carotid artery injury — pseudoaneurysm, dissection with progressive neurologic deficit, AV fistula (carotid-cavernous or cervical)
- Vertebral artery injury — pseudoaneurysm, dissection, AV fistula, active extravasation
- Blunt cerebrovascular injury (BCVI) failing medical management — enlarging pseudoaneurysm, recurrent embolization despite anticoagulation
Contraindications
- Airway compromise requiring surgical intervention first — secure airway before any endovascular procedure
- ICA sacrifice without balloon test occlusion — do NOT sacrifice ICA without first demonstrating adequate collateral circulation via BTO
- Hemodynamic instability requiring immediate surgical exploration (zone II neck injury with expanding hematoma)
- Severe contrast allergy without premedication (relative)
- Relative: coagulopathy — correct if possible, but do not delay life-saving embolization for coag correction
Neck Zone Classification (Penetrating Trauma)
| Zone | Boundaries | Key Structures | Management |
|---|---|---|---|
| Zone I | Clavicle / thoracic inlet to cricoid cartilage | Subclavian vessels, vertebral artery origin, proximal CCA, thoracic duct, lung apex | Difficult surgical access — endovascular preferred |
| Zone II | Cricoid cartilage to angle of mandible | CCA, ICA/ECA bifurcation, jugular vein, vagus nerve | Most surgically accessible — traditionally explored |
| Zone III | Angle of mandible to skull base | Distal ICA, vertebral artery (V3), cranial nerves IX–XII | Difficult surgical access — endovascular preferred |
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Pre-Procedure Planning
Imaging, airway, labs, consultations
Imaging & Labs
- CTA head and neck — critical first-line imaging; identify site of extravasation, pseudoaneurysm, dissection, AV fistula, or vessel occlusion
- Assess injury grade (Biffl scale for BCVI): Grade I (intimal irregularity <25% stenosis) through Grade V (complete transection)
- Evaluate collateral circulation — circle of Willis patency, contralateral vertebral dominance
- Labs: CBC, PT/INR, PTT, fibrinogen, type & crossmatch (active hemorrhage — anticipate transfusion)
- Consider CT head to rule out intracranial hemorrhage before anticoagulation
Patient Preparation
- AIRWAY FIRST — intubation if any concern for airway compromise; facial fractures and neck hematoma can rapidly progress
- For epistaxis: anterior and posterior nasal packing should be attempted first (Foley catheter, Rapid Rhino)
- ENT / OMFS consultation for facial fracture management and surgical planning
- Neurosurgery consultation for intracranial vascular injury
- Large-bore IV access ×2; blood products available; activate massive transfusion protocol if indicated
- Arterial line for continuous BP monitoring
Airway secured. Intubation performed if any concern for compromise from facial fractures, expanding neck hematoma, or ongoing oropharyngeal hemorrhage.
CTA head/neck reviewed. Site of injury identified, zone of neck injury classified, collateral circulation assessed.
Nasal packing attempted (for epistaxis). Anterior and posterior packing placed; continued bleeding confirms need for embolization.
Labs drawn. CBC, coags, T&C. Blood products ordered and available in IR suite.
Consultations placed. ENT/OMFS for facial fractures, neurosurgery for intracranial injury, trauma surgery as primary team.
Consent obtained (if time permits). Key risks: stroke, blindness, cranial nerve injury, facial skin/mucosal necrosis, non-target embolization.
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Relevant Anatomy
ECA branches, ICA vs ECA, dangerous anastomoses, vertebral artery
External Carotid Artery (ECA) Branches
- Internal maxillary artery — terminal branch; gives off sphenopalatine artery (primary supply for epistaxis), middle meningeal artery, inferior alveolar artery
- Facial artery — supplies lower face; important in mandible fracture bleeding
- Superficial temporal artery (STA) — terminal ECA branch; scalp lacerations
- Ascending pharyngeal artery — MOST DANGEROUS ECA branch; direct anastomoses to ICA (via caroticotympanic) and vertebral artery (via neuromeningeal trunk)
- Occipital artery — anastomoses with vertebral artery via muscular branches at C1–C2
- Lingual artery — tongue bleeding; risk of airway compromise
- Superior thyroid artery — first anterior ECA branch
ICA vs. ECA Distinction
- ICA — NO branches in the neck (critical distinguishing feature); posterolateral at the bifurcation; supplies brain and orbit
- ECA — multiple branches in the neck; anteromedial at the bifurcation; supplies face, scalp, meninges
- Carotid body — chemoreceptor at CCA bifurcation; manipulation can cause bradycardia
- CCA bifurcation — typically at C3–C4 level (hyoid bone); variable
Dangerous ECA–ICA Anastomoses
- Middle meningeal artery → ophthalmic artery (via lacrimal/recurrent meningeal) → ICA
- Ascending pharyngeal artery → caroticotympanic branch → ICA; also → neuromeningeal trunk → vertebral artery
- Occipital artery → muscular branches at C1–C2 → vertebral artery
- Internal maxillary artery → middle meningeal → ophthalmic artery → ICA
- Facial artery / ascending palatine → ascending pharyngeal → ICA
- These anastomoses are the primary cause of non-target intracranial embolization during ECA procedures
Vertebral Artery
- V1 segment: origin to C6 transverse foramen
- V2 segment: within transverse foramina C6–C2; vulnerable to cervical spine fractures
- V3 segment: C2 to foramen magnum; tortuous, vulnerable at atlantoaxial joint
- V4 segment: intradural; gives PICA
- Dominant vs. non-dominant vertebral artery must be assessed before sacrifice
- ECA collaterals to vertebral via occipital and ascending pharyngeal arteries
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Technique
Access, catheterization, embolization approaches by injury type
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Arterial Access & Diagnostic Angiography
Common femoral artery (CFA) access. Place 5F or 6F sheath. Diagnostic aortogram of arch vessels followed by selective CCA injection (bilateral). Identify injury site, active extravasation, pseudoaneurysm, AV fistula, or dissection. Evaluate collateral circulation (circle of Willis via contralateral ICA and vertebral injections). For vertebral injury, selective vertebral catheterization.
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Selective ECA Catheterization
Advance 5F catheter (JB1, Simmons, or Berenstein) into ECA. Perform selective ECA angiography. Identify the bleeding branch. ALWAYS evaluate for dangerous ECA–ICA anastomoses before embolizing — look for opacification of ICA territory or vertebral artery via ECA branches.
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Epistaxis Embolization
Advance microcatheter (2.0–2.8F) into the distal internal maxillary artery, targeting the sphenopalatine artery territory. Embolize with PVA particles 300–500 µm or Gelfoam pledgets. For midline epistaxis: BILATERAL embolization is required (contralateral sphenopalatine supply via midline anastomoses). Never use particles <300 µm (risk of crossing ECA–ICA anastomoses to ophthalmic/intracranial circulation).
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Facial Fracture Hemorrhage
Identify the bleeding ECA branch (maxillary, facial, or other). Superselective microcatheter positioning as distal as safely possible. Embolize with coils, Gelfoam, or PVA 300–500 µm depending on vessel size. For transected vessels: coil embolization proximal and distal to transection site (sandwich technique). NBCA glue may be used in emergent settings for rapid hemostasis.
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Pseudoaneurysm / AV Fistula (ECA Territory)
For PSA: coil embolization of the pseudoaneurysm sac and parent vessel (trapping). For AV fistula: coil embolization at the fistula site. Ensure adequate proximal AND distal occlusion to prevent retrograde filling.
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ICA Injury Management
ICA-preserving strategies are preferred. Options include: covered stent to exclude PSA/fistula while maintaining flow, flow-diverting stent for dissection/PSA, stent-assisted coiling for wide-necked PSA. If ICA sacrifice is necessary: balloon test occlusion (BTO) FIRST — inflate balloon in ICA for 20–30 min with neurologic monitoring. Only sacrifice if BTO passed. Sacrifice with coils from distal to proximal (trap technique). ALWAYS involve neurointerventional.
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Vertebral Artery Injury Management
Assess dominance (dominant vertebral supplies majority of posterior circulation). For non-dominant vertebral: sacrifice with coil embolization is generally safe if contralateral vertebral is patent. For dominant vertebral: covered stent or flow diversion to preserve flow. Protect PICA origin if possible. Use compliant balloon for flow control during coil packing in high-flow injuries.
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Final Angiography & Closure
Post-embolization angiography of treated vessel and adjacent territories. Confirm hemostasis, absence of non-target embolization, patency of ICA/vertebral if preserved. Remove sheath and obtain hemostasis at CFA (manual compression or closure device). Document all embolic materials used.
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Key Landmarks
Angiographic landmarks for safe catheterization
Carotid System
- CCA bifurcation — typically at C3–C4 (hyoid bone level); ICA posterolateral, ECA anteromedial
- ICA recognition — NO branches in the neck; larger caliber; posterolateral position; opacifies brain
- ECA branch origins — superior thyroid (first anterior), ascending pharyngeal (first posterior/medial), lingual, facial, occipital, posterior auricular, then terminal (STA + internal maxillary)
- Carotid bulb — mild dilation at ICA origin; site of carotid body (baroreceptor)
Epistaxis-Specific Landmarks
- Sphenopalatine artery — terminal branch of internal maxillary artery; enters nasal cavity via sphenopalatine foramen; PRIMARY target for epistaxis embolization
- Internal maxillary artery — within pterygopalatine fossa; gives middle meningeal, inferior alveolar, sphenopalatine
- Anterior ethmoidal artery (from ophthalmic/ICA) — NOT accessible via ECA; supplies anterior nasal septum; may require surgical ligation if persistent bleeding
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Troubleshooting
Intraoperative problems and solutions
Critical
ECA–ICA Anastomosis Causing Non-Target ICA Embolization
Use PVA particles ≥300 µm ONLY (larger particles cannot traverse anastomotic channels). NEVER use liquid embolic agents (NBCA, Onyx) in ECA branches without first confirming absence of ECA–ICA anastomoses. If anastomosis identified: embolize distal to the anastomotic origin, or coil-protect the anastomotic branch before particle embolization. If suspected intracranial embolization has occurred: immediate neurologic assessment, consider IV heparin, emergent intracranial angiography.
Persistent Epistaxis After Embolization
Continued Bleeding Despite Ipsilateral ECA Embolization
Check contralateral ECA (midline nasal supply crosses midline — bilateral embolization required for midline bleeding). Evaluate for ECA–ICA collateral reconstitution of the bleeding source. Consider anterior ethmoidal artery supply (from ICA/ophthalmic — not accessible endovascularly; requires surgical ligation by ENT). Reassess packing adequacy.
ICA Injury Requiring Sacrifice
ICA Cannot Be Preserved (Transection, Large Defect)
Balloon test occlusion (BTO) first if patient is neurologically evaluable. Inflate occlusion balloon in ICA for 20–30 min with continuous neurologic monitoring. If deficit develops during BTO: abort sacrifice, pursue flow-preserving strategies (covered stent, flow diverter). If BTO passed: sacrifice with coil embolization (trap technique — coils distal and proximal to injury). In emergent setting where BTO is not feasible: consider temporary balloon occlusion with deferred definitive management.
Vasospasm
Catheter-Induced Vasospasm During Navigation
Common in trauma setting, especially near bullet tracks (Fig. in literature). Wait 5–10 minutes for spontaneous resolution. Intra-arterial nitroglycerin 100–200 µg or verapamil 2.5–5 mg through microcatheter. Avoid aggressive catheter manipulation. Re-image after spasm resolves before embolizing.
High-Flow AV Fistula
Coils Migrating Through High-Flow Fistula
Use detachable coils (not pushable) for controlled deployment. Consider balloon-assisted technique: inflate compliant balloon proximal to fistula to reduce flow during coil deployment. Combine coils with Gelfoam or NBCA for complete occlusion. For carotid-cavernous fistula: transvenous approach via inferior petrosal sinus may be preferred.
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Complications
Risks and management of adverse events
Neurologic Complications
- Stroke — non-target embolization to ICA or intracranial circulation via ECA–ICA anastomoses; thromboembolic events during ICA/vertebral manipulation; most feared complication
- Blindness — ophthalmic artery embolization via middle meningeal → lacrimal → ophthalmic anastomosis; irreversible
- Facial nerve palsy (CN VII) — embolization of vasa nervorum; can be transient or permanent
- Other cranial nerve injury — CN IX, X, XI, XII from ascending pharyngeal or occipital artery embolization
Other Complications
- Skin / mucosal necrosis — non-target embolization of facial soft tissue supply; particularly nasal alar or lip necrosis from facial artery embolization
- Recurrent bleeding — incomplete embolization, collateral reconstitution, or missed secondary bleeding source
- Vessel dissection / perforation — from catheter manipulation in vasospastic or injured vessels
- Access site complications — CFA hematoma, pseudoaneurysm, retroperitoneal bleed (standard angiographic risks)
- Contrast-induced nephropathy — especially in polytrauma with renal injury or hypotension
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Pearls & Pitfalls
Critical safety points and clinical wisdom
✦
NEVER use particles <300 µm in ECA territory. Small particles can traverse ECA–ICA anastomoses and cause stroke or blindness. PVA 300–500 µm is the standard for ECA embolization. Gelfoam is also acceptable for temporary occlusion.
✦
Bilateral embolization for midline epistaxis. The nasal septum receives bilateral supply from both sphenopalatine arteries. Unilateral embolization will fail for midline/septal bleeding due to contralateral reconstitution.
✦
ALWAYS identify dangerous ECA–ICA anastomoses before embolizing. Perform superselective angiography and look for opacification of ICA territory. The ascending pharyngeal artery is the single most dangerous ECA branch (direct anastomoses to both ICA and vertebral artery).
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ICA injury management is COMPLEX — involve neurointerventional early. ICA-preserving strategies (covered stent, flow diverter, stent-assisted coiling) are strongly preferred over sacrifice. If sacrifice is unavoidable, balloon test occlusion must be performed first when feasible.
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NBCA glue is the fastest embolic agent in active hemorrhage. It polymerizes on contact with blood and does not rely on the patient's intrinsic clotting factors. Ideal for coagulopathic trauma patients where coil packing alone may not achieve hemostasis.
✦
Vascular injuries are dynamic. Injuries can evolve from one category to another over time (e.g., intimal flap progressing to pseudoaneurysm or occlusion). Follow-up imaging is essential even after initially stable-appearing injuries.
⚠
Do NOT use liquid embolic (NBCA, Onyx) in ECA branches without first ruling out ECA–ICA anastomoses. Liquid agents cannot be controlled once injected and will traverse any patent anastomotic channel into the intracranial circulation.
⚠
Do NOT sacrifice ICA without balloon test occlusion. ICA sacrifice without confirmed adequate collateral circulation carries unacceptable stroke risk. Even with BTO, delayed stroke can occur in up to 10% of patients.
⚠
Stent placement in trauma has a high occlusion rate. A study by Cothren et al demonstrated a 45% occlusion rate for carotid stents placed in trauma. Medical management (anticoagulation/antiplatelet therapy) should be the first-line treatment for low-grade BCVI in neurologically intact patients.
⚠
Anterior ethmoidal artery epistaxis is NOT treatable by ECA embolization. The anterior ethmoidal artery arises from the ophthalmic artery (ICA territory). If bleeding persists after bilateral sphenopalatine embolization, consider anterior ethmoidal source requiring surgical ligation.
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References & Resources
Primary sources and related procedures
Biffl Grading Scale (BCVI)
- Grade I: intimal irregularity, <25% stenosis
- Grade II: intimal injury/dissection, ≥25% stenosis or intramural hematoma
- Grade III: pseudoaneurysm
- Grade IV: vessel occlusion
- Grade V: complete transection
Primary References
- Radvany MG, Gailloud P. Endovascular management of neurovascular arterial injuries in the face and neck. Semin Intervent Radiol. 2010;27(1):44–54. DOI: 10.1055/s-0030-1247888
- Biffl WL, Moore EE, Offner PJ, Brega KE, Franciose RJ, Burch JM. Blunt carotid arterial injuries: implications of a new grading scale. J Trauma. 1999;47(5):845–853.
- Cothren CC, Moore EE, Biffl WL, et al. Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce stroke rate. Arch Surg. 2004;139(5):540–546.
- Ray CE Jr, Spalding SC, Cothren CC, et al. State of the art: noninvasive imaging and management of neurovascular trauma. World J Emerg Surg. 2007;2:1.
- Saletta JD, Lowe RJ, Lim LT, et al. Penetrating trauma of the neck. J Trauma. 1976;16(7):579–587.