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A 74-year-old man was referred to the emergency department and admitted for recurrent epistaxis of the right nostril. He had a history of mechanical aortic valve replacement, for which he had been on Coumadin for many years. A prior attempt at cautery had been unsuccessful.
The consulting ENT noted the following history: "He has been having recurrent epistaxis on the right side of the nose. ... He has had numerous episodes that have landed him in the emergency room with brisk bleeding that stopped suddenly. The only findings were of a vessel on the septum that looked like a arterial pumper so this was treated with silver nitrate. Subsequently the patient developed another episode of epistaxis and was treated in the emergency department with a large pack placed in his nose. When we remove the pack the blood was not in the area where the cauterization had occurred, it was posterior. The area of cauterization was actually healing nicely. There is a mild ooze in the posterior nasal cavity, thought to be mild trauma from the pack which was treated with some nasopore (absorbable) packing. This controlled the bleeding for about 5 days and the patient suddenly had another episode of brisk bleeding again. He was seen in the [other hospital's] emergency room and initially they tried Epinephrine on a cotton pledget but he had another episode of epistaxis about an hour later. The patient states when the pack was removed again the bleeding site was posterior on the pack. They replaced this pack with a long pack soaked in transexamic acid. The patient's clinical picture is one of posterior epistaxis with intermittent brisk bleeds that stop briskly from vasospasm." The ENT's notes reflect that the patient's right nasal cavity was packed with cotton pack. The recommendation was for embolization.
That night, the patient had another episode of "active profuse bleeding," and he was taken for an emergent angiogram and embolization by a vascular neurologist. During this procedure, the neurologist embolized the patient's right sphenopalatine and facial branches using 100-200 um particles, and embolized the left sphenopalatine artery using 300-500 um particles. The procedure note reads in part: "... Very distal anastomosis with slow filling of the ophthalmic artery is noted. At this point it was seemed safe to slowly embolize the sphenopalatine branch using because of particles suggest [sic] 300 500 um. Embolization of the sphenopalatine branch of the left internal maxillary artery was then performed very slowly and limited.... A follow-up angiogram of the left external carotid artery was then performed following embolization from existing catheter position and no obvious embolic complication was noted."
After the procedure, the patient awoke with left vision loss. The same vascular neurologist took the patient back to the cath lab for another angiogram and reported that "specific attention was paid to the left ophthalmic and central retinal arteries and both appear to be patent." All other findings were also within normal limits.
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Do you believe there might have been medical error?
In the setting of these dangerous anastamoses one should never use particles. There was likely embolization through ethmoidals to the ophthalmic artery. Many times these dangerous anastamoses are not visualized unless one has the microcatgeter wedged. If they are visualized through a more proximal runs then this indicates the shuntibg is more robust that one can assess visually. Although the Interventionalist upsized the particles, the decision to use oartivmcles was orobably incorrect and alternative strategies should have been used. In this scenario, it would be difficult to see where the particles are going or if there is an evidence of reflux. A lot also depends on the concentration of the contrast that the particles were mixed with. The central retinal artery is very difficult to be seen unless the ophthalmic arterimy is specifically catheterization. Was that done? If this was monocular blindness, were any intraarterial vasodilators seen? Was the blindness complete? Did ophthalmology evaluate the patients emergently? Lots of questions
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There was likely embolization through ethmoidals to the ophthalmic artery. Many times these dangerous anastamoses are not visualized unless one has the microcatgeter wedged. If they are visualized through a more proximal runs then this indicates the shuntibg is more robust that one can assess visually. Although the Interventionalist upsized the particles, the decision to use oartivmcles was orobably incorrect and alternative strategies should have been used. In this scenario, it would be difficult to see where the particles are going or if there is an evidence of reflux. A lot also depends on the concentration of the contrast that the particles were mixed with. The central retinal artery is very difficult to be seen unless the ophthalmic arterimy is specifically catheterization. Was that done? If this was monocular blindness, were any intraarterial vasodilators seen? Was the blindness complete? Did ophthalmology evaluate the patients emergently? Lots of questions
What makes you a good expert for this case?
I am a triple trained neurologist, neurointensivist and neuroendovascular surgeon currently practicing in a level 1 trauma center and comprehensive stroke center. Being in a traumacenter affords me the ability to see many similar cases of epistaxis and although this was not a traumatic epistaxis case, the principles are the same.
How often do you encounter cases similar to this one in your practice?
I see atleast 2 of these a month.. some occur spontaneously, others are in the setting of trauna, radiation or cancer.
Do you believe there might have been medical error?
Inadvertent embolization of other branches is a known bur rare risk of this type of particle embolization procedure for treatment of epistaxis. There are certain precautions one can take to minimize this. Based on the description it is unclear if these were done.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It is likely that particles embolized to treat the bleeding reached the artery supplying the left eye.
What makes you a good expert for this case?
I have a decade of experience in performing such cases including a two year ACGME certified fellowship.
How often do you encounter cases similar to this one in your practice?
On average 5 to 10 times per year roughly
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