Intraoperative Artery Ligation Reduces Bleeding during Juvenile Nasopharyngeal Angiofibroma Surgery: An Alternative to Preoperative Embolization
02 February 2018 (online)
Background Juvenile nasopharyngeal angiofibroma (JNA) is a rare, locally invasive and highly vascularized benign neoplasm. It is usually vascularized by the ipsilateral internal maxillary artery, but up to 50% of tumors may present accessory vascular supply from the internal carotid artery, or bilateral arteries. Therefore, intraoperative bleeding is common and may hinder the surgical resection. Preoperative embolization is commonly used to try and reduce surgical bleeding, but it is related to additional risks and costs. Alternatively, intraoperative ligation of the tumor's feeding arteries has been advocated and used in some centers. However, the efficacy of artery ligation has rarely been compared with that of embolization.
Objective Compare the efficacy of intraoperative artery ligation to that of preoperative embolization to reduce bleeding during JNA surgery.
Methods Retrospective cohort study including 32 surgeries for JNA in a tertiary referral center between 1993 and 2015. Group 1 (n = 17) underwent preoperative selective arterial embolization, whereas in Group 2 (n = 15) intraoperative artery ligation was used to try and reduce bleeding. The number of blood units transfused, and the decrease of intraoperative hematocrit levels, was used to calculate and compare blood loss between groups.
Results All patients were male adolescents (mean age: 16.7 years). Recurrent epistaxis was the most common clinical manifestation (87.8%), followed by nasal obstruction (63.3%). Most patients (57.5%) had a Fisch´s stage II tumor, and 93% underwent an open access surgery. The Degloving approach was the most commonly used in 44.2 and 66,6% of patients in Groups 1 and 2, respectively. The median volume of blood loss was 1,440 mL for embolized patients, compared with 1,680 mL for patients who underwent artery ligation (p = 0.81). The median numbers of 2.2 and 1.8 of blood component units received by patients in Groups 1 and 2 were also not significantly different. Although, the 38.8% recurrence rate observed for embolized patients was higher than that of 25% in patients who underwent artery ligation, which was also not significantly different.
Conclusion Intraoperative ligation of the arterial vascular supply of JNA is a safe and simple technique. It may effectively reduce surgical bleeding, similarly to that observed after intravascular embolization.