Facial necrosis after endovascular Onyx-18 embolization for epistaxis
A 52-year-old African-American woman with a history of aortic valve replacement, mitral valve repair, and deep venous thrombosis on chronic anticoagulation therapy with warfarin and aspirin presented after developing epistaxis from her right naris. She received blood products, underwent packing, ligation of the sphenopalatine artery, and silver nitrate cauterization with no resolution of her epistaxis.\nThe bleeding persisted and the patient underwent endovascular embolization. Under general anesthesia, transarterial embolization was carried out through a right femoral artery approach. A 6-Fr guiding catheter (Envoy; Cordis Endovascular Systems, Miami Lakes, FL) over a hydrophilic guidewire was placed into the left and right external carotid arteries (ECAs). A MarathonTMMicro Catheter (Covidien, Irvine, CA) was advanced over a X-pedionTM0.010" Guidewire (Covidien, Irvine, CA) into the left and right internal maxillary arteries and the left and right facial arteries. After confirmation that no opacification of the orbital contents was seen after injection of contrast, the catheter was slowly flushed with 0.5 cc of DMSO. Onyx-18 was injected until a cap formed over the catheter tip that allowed a small amount of reflux. After allowing the cap to solidify, the vessels were embolized with 0.8 cc of Onyx-18 over a period of minutes []. Repeat runs showed that there was adequate occlusion.\nOn postembolization day 3, the patient noticed a hyperpigmented patch on her left cheek that appeared, prompting dermatologic evaluation []. The plaque exhibited hyperpigmentation with surrounding erythema and was tender to palpation. A punch biopsy was performed at the left melonasal junction. Examination of the biopsy revealed full-thickness epidermal necrosis, as well as necrosis of the upper and mid-dermis, follicles, sebaceous glands, and eccrine glands []. Topical ointment and dressing changes were recommended, and no further treatment was required with eventual resolution of her skin necrosis months later.