Endovascular treatment for posterior epistaxis: should it still be considered a last-resort option? A literature review

Introduction: Posterior epistaxis is a common otorhinolaryngological emergency that often presents a clinical challenge and typically needs aggressive management. Endovascular therapy has emerged as a strong alternative to traditional approaches. However, it is still considered a last-resort option for intractable cases in most clinical guidelines and among many physicians managing this condition. The purpose of this narrative review is to provide a comprehensive overview of posterior epistaxis, with a particular focus on its vascular anatomy and the role of endovascular treatment. Methods: Articles were retrieved from MEDLINE, Scopus and Web of Science using a semi-systematic search strategy. Results: Posterior epistaxis is a challenging condition due to its variable etiologies and numerous risk factors. Effective treatment requires careful consideration of the region's complex and variable vascular anatomy, including potentially dangerous anastomoses. The results indicate that endovascular treatment is a feasible and safe option; however, it should always be preceded by a thorough angiographic assessment to identify the exact vascular anatomy and site of bleeding. This also helps to identify potentially dangerous communications around the skull base, where inadvertent embolization can lead to complications such as stroke or blindness. Conclusion: Posterior epistaxis is a complex condition that requires a comprehensive approach. Performing an angiography before treatment can help pinpoint the bleeding site, as well as identify any dangerous communications. Endovascular treatment could be a viable and safe option in cases of posterior epistaxis and should not be reserved solely as a last resort.