Angiographic correlates of blood loss in endoscopic excision of juvenile nasopharyngeal angio-fibroma

Objective: To evaluate the angiographic findings with relation to intraoperative blood loss in a series of juvenile nasopharyngeal angiofibroma ( JNA) operated endoscopically.Methods: Retrospective chart review of clinical, angiographic and operative details was done of all consecutive patients of Radkowski grade IIC or IIIA JNA who had undergone superselective polyvinyl alcohol (PVA) particle embolisation of external carotid artery (ECA) feeders in single session followed by endoscopic excision during the period of August 2014 to March 2019.Results: 22 cases (14.7 ± 2.7 years, range 10 -24 years) with mean tumour size 6.7 cm (5.8-12.5 cm range) were identified.15/22 cases had bilateral ECA territory blood supply and 7/22 had additional supply from internal carotid artery (ICA) branches.Mean tumour devascularisation was 60% (50-100% range) and intraoperative blood loss was 362ml ± 176.2ml (range 50 ml -1500 ml).Isolated unilateral or bilateral internal maxillary artery (IMA) and/or ascending pharyngeal artery (AscPhA) supply had least blood loss (average 150 ml), and patients with additional ICA supply had disproportionate increase in blood loss (700 ml in unilateral and 1350 ml in bilateral ICA supply).No neurological complications were seen.Complete endoscopic tumour removal was obtained in 19 cases. 2 cases underwent repeat surgery with complete excision, and one kept on follow up.Two patient received autologous blood transfusion.Conclusions: Unilateral or bilateral IMA and AScPhA artery supply is associated with high embolization rates and low blood loss.ICA supply contributes to lower embolization rates and increased blood loss.