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Background
Epistaxis is a common health problem affecting approximately 60% of the people in United States with about 6% requiring medical attention and 0.2% requiring hospitalization for severe epistaxis. It accounts for one third of all otolaryngology-related emergency department encounters. There is bimodal age distribution with peak frequency at <10 years of age and at 70 - 79 years. Predisposing factors include trauma, foreign body, nasal inflammation, iatrogenic and systemic factors like hypertension, inherited bleeding disorders such as von Willebrand disease or hemophilia, and Hereditary Hemorrhagic Telangiectasia (HHT) syndrome. The American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF) has created an evidence-based recommendations to improve quality and reduce variations in management. Endovascular embolization with microsphere or coil can be performed for epistaxis refractory to conservative management.

Educational Goals / Teaching Points
Computed tomography (CT) of paranasal sinuses and CT angiography can be performed in patients with unknown cause of epistaxis or recurrent epistaxis. Endovascular trans arterial embolization with microspheres or coil of Internal Maxillary Artery (IMA) or Facial Artery (FA) branches can be performed for severe or refractory epistaxis. Common Carotid Artery (CCA) and External Carotid Artery (ECA) angiogram are performed to localize the site of hemorrhage, identify possible dangerous anastomotic connection between Internal carotid artery (ICA)and ECA and retinal blush to avoid post embolization complications like blindness and stroke. Endovascular technique and choice of embolization material depends on factors such as etiology, location of hemorrhage, and presence of arterial venous shunting.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
The sphenopalatine artery which is the terminal branch of the internal maxillary artery IMA is the dominant arterial supply of nasal cavity. The superior labial artery branch of FA vascularizes part of the anterior nasal cavity. The anterior and posterior ethmoid arteries supply the roof are branches of ophthalmic artery from ICA. Identification of the possible anastomosis between ICA and ECA as well retinal blush on ECA angiogram is important to avoid post embolization complications. Distal IMA and FA branches are usually embolized. In abnormal vascular bed like in tumor or HHT distal embolization is required as proximal embolization will result in collateral formation and recurrence. For trauma or iatrogenic causes coil embolization is used when extravasation is seen on angiogram.

Conclusion
It is important to understand arterial supply to nasal cavity to localize the site of hemorrhage, identify possible dangerous anastomotic connection between ICA and ECA. Endovascular technique and choice of embolic material depends on factors such as etiology, location of hemorrhage, presence of arterial venous shunting. Here we provide background, risk factors, relevant anatomy, and review the technique for endovascular embolization for epistaxis.