Modified Endoscopic Sphenopalatine Artery Ligation Technique Reduces Persistent Epistaxis

OBJECTIVES: Endoscopic sphenopalatine artery ligation (ESPAL) is standard for refractory posterior epistaxis, yet persistent bleeding and need for reintervention remain common. We evaluated a modified ESPAL technique incorporating posterior septal artery (PSA) cautery and assessed outcomes versus traditional ESPAL. METHODS: We performed a retrospective cohort study of adults undergoing ESPAL for posterior epistaxis at a tertiary referral center. Patients underwent either modified ESPAL (PSA cautery) or traditional ESPAL (SPAL only). The primary outcome was persistent epistaxis within 30 days requiring major intervention (repeat surgery, embolization, or hospital admission). Secondary outcomes included salvage strategies and rebleeding after unilateral versus bilateral modified procedures. Multivariable logistic regression evaluated predictors of persistent epistaxis (surgical technique, anticoagulation, alcohol use, and COPD). RESULTS: A total of 292 patients were included (modified, n = 257; traditional, n = 35). Persistent epistaxis occurred less frequently after modified ESPAL than traditional ESPAL (7.8% vs. 28.6%), yielding an absolute risk reduction of 20.8% and a number needed to treat of 4.8. Anticoagulation use was higher in the modified cohort (33% vs. 17%). On multivariable analysis, traditional ESPAL was associated with higher odds of persistent epistaxis compared with modified ESPAL (OR: 6.50, 95% CI: 2.45-17.3; p < 0.001), and anticoagulation was independently associated with persistent epistaxis (OR: 3.22, 95% CI: 1.41-7.62; p = 0.006). Among modified cases, rebleeding did not differ between bilateral and unilateral procedures (9.8% vs. 5.6%; p = 0.2). CONCLUSIONS: Modified ESPAL incorporating PSA cautery was associated with substantially lower 30-day persistent epistaxis compared with traditional ESPAL, including in anticoagulated patients. Bilateral intervention appears safe when the bleeding side is uncertain.