Primary Preoperative Coil Embolization of a Juvenile Nasopharyngeal Angiofibroma: A Minimally Invasive Strategy to Reduce Surgical Blood Loss

Abstract

A teenage patient with recurrent right-sided epistaxis was found to have a juvenile nasal angiofibroma (JNA). Preoperative coil embolization was performed to reduce surgical blood loss. Angiography revealed tumor blush primarily supplied by the right internal maxillary and ascending pharyngeal arteries, which were selectively catheterized and embolized using detachable coils. Additional supply from the left internal maxillary artery was also treated. The ability to retract and reposition coils and partially prolapse them into adjacent small branches allowed broad tumor coverage without individually catheterizing each branch, thereby reducing both procedure time and radiation exposure. Postembolization angiography showed minimal residual vascularity, and the patient underwent surgical resection the following day with an estimated blood loss of 100 mL. He was discharged without complications. This case demonstrates the effectiveness of coil embolization in devascularizing JNAs while minimizing off-target embolization and reducing operative blood loss.

Keywords

juvenile nasopharyngeal angiofibroma - preoperative embolization - coil embolization - nasopharyngeal tumors - tumor devascularization - external carotid artery embolization

Introduction

Juvenile nasal angiofibromas (JNA) are benign yet locally aggressive nasal cavity tumors, with surgical resection as the definitive treatment.[1] Their hypervascularity often leads to significant blood loss during surgery, making preoperative transarterial embolization a common strategy to reduce intraoperative bleeding.[2] Although these tumors primarily receive blood supply from the external carotid artery, anastomoses with the internal carotid artery (ICA) can result in off-target embolization, potentially causing vision loss, cranial nerve palsy, or stroke. A variety of embolic agents can be used, including particles, glue, Onyx, and coils.[3] Among these, coils have not only the lowest risk of accidental intracranial embolization, but also the least penetration into the tumor vasculature. Here, we describe a primary coil embolization technique for JNA that achieves effective tumor devascularization with minimal risk of intracranial arterial complications.

Procedure

A teenage patient with recurrent right-sided epistaxis over several months was found to have a hypervascular nasopharyngeal mass (4 × 3 × 2 cm) consistent with a JNA ([Fig. 1A]). Preoperative coil embolization was planned under general anesthesia to reduce intraoperative blood loss.

Fig. 1 (A) Axial contrast-enhanced CT demonstrating a hypervascular right nasal cavity mass (juvenile nasal angiofibroma). (B and C) Right external carotid artery (AP, B; lateral, C) digital subtraction angiograms showing extensive tumor hypervascularity fed by multiple arterial branches. AP, anteroposterior; CT, computed tomography.

Using a right femoral artery approach, a 5F Berenstein catheter was advanced for angiography, revealing avid tumor blush in the right nasal cavity supplied by the right internal maxillary (IMAX) and ascending pharyngeal arteries (APhA), with no contribution from the right ICA. A Headway Duo microcatheter was navigated into the distal pterygopalatine segment of the right IMAX, and multiple Kaneka i-ED coils (2–5 mm in diameter, 6–10 cm in length) were deployed into the feeding branches until there was minimal residual tumor blush ([Fig. 2]). During the embolization, coils were deliberately prolapsed into small adjacent feeding arteries to maximize their effect.

Fig. 2 (A) AP digital subtraction angiogram of the right internal maxillary artery (IMAX) revealing multiple feeding branches. (B) Postcoil embolization angiogram of the right IMAX showing resolution of tumor hypervascularity, preserving the main trunk and uninvolved branches. (C) Lateral digital subtraction angiogram of the right ascending pharyngeal artery (APhA) illustrating extensive tumor hypervascularity. (D) Postcoil embolization lateral angiogram of the APhA demonstrating resolution of tumor hypervascularity, with preservation of the main trunk and the neuromeningeal branch (white arrow). AP, anteroposterior.

Next, the right APhA was catheterized, showing marked tumor blush via multiple branches arising from its pharyngeal trunk. Similarly, coil embolization (2–5 mm diameter, 6–15 cm length) was performed, avoiding the neuromeningeal trunk origin. Postembolization angiography confirmed complete occlusion of the pharyngeal trunk and resolution of the tumor blush. Left common carotid angiography then demonstrated additional supply from the pterygopalatine and pterygoid portions of the left IMAX ([Fig. 3]). Coil embolization of these branches (3–5 mm diameter, 15–20 cm length) again resulted in minimal residual tumor blush.

Fig. 3 (A) AP digital subtraction angiogram of the left IMAX showing marked tumor hypervascularity. (B) Fluoroscopy (roadmapping) demonstrating coils prolapsed into multiple small distal branches of the left IMAX. (C) Postcoil embolization angiogram of the left IMAX showing near-complete resolution of tumor hypervascularity and preservation of the main trunk and uninvolved branches. (D) Final AP spot radiograph showing coils in the distal branches of the right IMAX, right APhA, and left IMAX. AP, anteroposterior; APhA, ascending pharyngeal artery; IMAX, internal maxillary artery.

Final fluoroscopy time was 26.5 minutes, with a cumulative total air Kerma was 1766.36 mGy. Surgical resection the following day had an estimated blood loss of 100 mL, and the patient was discharged home without complications.

Discussion

Juvenile nasopharyngeal angiofibroma (JNA) is a highly vascular, rapidly growing benign tumor typically arising in the nasopharynx of young males. Although it accounts for only 0.05% of head and neck tumors, its aggressive growth into the nasopharynx, paranasal sinuses, orbit, and skull base presents a high risk of bleeding during surgical resection.[4] Preoperative embolization reduces intraoperative blood loss, operative time, and tumor recurrence, while also minimizing the need for blood transfusions and hospital length of stay.[2] [5] Despite additional costs (∼$35,000), preoperative embolization is increasingly recognized as the gold standard in JNA management.[5]

Embolization is usually performed 24 to 72 hours prior to surgery, which helps prevent the formation of collateral vessels.[3] Several embolic agents (e.g., particles, glue, Onyx, coils) have been successfully used, with transarterial embolization being the most common approach.[3] [6] [7] No study has demonstrated clear superiority of one embolic agent over another, and there are no established standards or formal recommendations. In practice, agent selection often depends on factors such as cost, tumor vascular anatomy, and the treatment team's experience. Polyvinyl alcohol (PVA) particles remain the most commonly used embolic material.[8] Alternative or adjunctive methods to transarterial embolization include direct percutaneous embolization and direct transnasal intratumoral injection, depending on tumor anatomy. Studies show a significant reduction in intraoperative blood loss with preoperative embolization, ranging from a median of 400 mL with glue to a mean of 784 mL with polyvinyl alcohol particles and up to 1,000 mL using microspheres.[6] [7] Direct percutaneous Onyx embolization has also been described, with a mean surgical blood loss of 568 mL.[9]

Although effective, transarterial embolization carries risks such as vision loss, stroke, and cranial nerve palsies due to off-target embolization via external-to-internal carotid anastomoses.[1] [2] Most complications are transient and respond to medical management,[1] but their likelihood is lower with coils due to coil size and flow characteristics. While larger coil size reduces many of the risks associated with transarterial embolization, it limits the ability to target smaller distal vessels that would otherwise be embolized using PVA particles or microspheres. This limitation may increase the risk of recurrence. Additionally, coils are permanent, preventing re-access to perfusing vessels if tumor recurrence occurs.[10] In our case, we used detachable, soft coils (Kaneka i-ED) to achieve dense packing with minimal off-target migration. The ability to retract and reposition coils proved beneficial for navigating small distal branches and avoiding the neuromeningeal trunk in the APhA. Allowing partial coil prolapse into adjacent small branches ([Fig. 3B]) increased coverage without having to individually catheterize each branch, while also reducing both procedure time and radiation exposure. Although our patient's JNA showed no ICA supply, a balloon occlusion technique was on standby to prevent any potential coil migration intracranially and to assist in navigating into tiny feeding vessels if needed.

Conclusion

Preoperative coil embolization of JNAs can provide effective tumor devascularization with minimal risk of off-target embolization, making surgical resection safer. By adapting the approach and taking advantage of coil properties for distal penetration, clinicians can achieve optimal vascular occlusion while reducing procedural risks and operative blood loss.

Conflict of Interest

None declared.

Ethical Approval Statement

Approval was obtained from the institutional review board, with a waiver of informed consent due to its retrospective design.

• References

• 1 López F, Triantafyllou A, Snyderman CH. et al. Nasal juvenile angiofibroma: current perspectives with emphasis on management. Head Neck 2017; 39 (05) 1033-1045
• 2 Diaz A, Wang E, Bujnowski D. et al. Embolization in juvenile nasopharyngeal angiofibroma surgery: a systematic review and meta-analysis. Laryngoscope 2023; 133 (07) 1529-1539
• 3 Lutz J, Holtmannspötter M, Flatz W. et al. Preoperative embolization to improve the surgical management and outcome of juvenile nasopharyngeal angiofibroma (JNA) in a single center: 10-year experience. Clin Neuroradiol 2016; 26 (04) 405-413
• 4 Coutinho-Camillo CM, Brentani MM, Nagai MA. Genetic alterations in juvenile nasopharyngeal angiofibromas. Head Neck 2008; 30 (03) 390-400
• 5 Choi JS, Yu J, Lovin BD, Chapel AC, Patel AJ, Gallagher KK. Effects of preoperative embolization on juvenile nasopharyngeal angiofibroma surgical outcomes: a study of the kids' inpatient database. J Neurol Surg B Skull Base 2020; 83 (01) 76-81
• 6 Liu Q, Li W, Hong R. et al. Preoperative transarterial embolization of advanced juvenile nasopharyngeal angiofibroma using n-butyl cyanoacrylate: case-control comparison with microspheres. J Vasc Interv Radiol 2023; 34 (05) 856-864.e1
• 7 Giorgianni A, Molinaro S, Agosti E. et al. Twenty years of experience in juvenile nasopharyngeal angiofibroma (JNA) preoperative endovascular embolization: an effective procedure with a low complications rate. J Clin Med 2021; 10 (17) 3926
• 8 Kothari DS, Linker LA, Tham T. et al. Preoperative embolization techniques in the treatment of juvenile nasopharyngeal angiofibroma: a systematic review. Otolaryngol Head Neck Surg 2023; 169 (03) 454-466
• 9 Gemmete JJ, Patel S, Pandey AS. et al. Preliminary experience with the percutaneous embolization of juvenile angiofibromas using only ethylene-vinyl alcohol copolymer (Onyx) for preoperative devascularization prior to surgical resection. AJNR Am J Neuroradiol 2012; 33 (09) 1669-1675
• 10 Ballah D, Rabinowitz D, Vossough A. et al. Preoperative angiography and external carotid artery embolization of juvenile nasopharyngeal angiofibromas in a tertiary referral paediatric centre. Clin Radiol 2013; 68 (11) 1097-1106

Publication History

Received: 27 July 2025

Accepted: 08 September 2025

Article published online:
26 December 2025