Management of Hemorrhagic Pseudoaneurysmal Arteriovenous Fistula of the Sphenopalatine Artery

n-Butyl cyanoacrylate (n-BCA) embolization of a hemorrhagic pseudoaneurysmal arteriovenous fistula of the sphenopalatine artery in a patient with paranasal sinus squamous cell carcinoma treated with regional surgery and radiation has, to our knowledge, not been previously reported. 1. Introduction Pseudoaneurysms of external carotid artery branch vasculature are rare and occur consequent to trauma, infection, iatrogenic injury, and radiation therapy. Concurrent presence of a pseudoaneurysm with an arteriovenous fistula is unusual. This to our knowledge is the first report describing n-butyl cyanoacrylate embolization of a sphenopalatine artery pseudoaneurysmal arteriovenous fistula to arrest active oronasal bleeding in a patient with recurrent paranasal sinus squamous cell carcinoma. 2. Case Report A 53-year-old female chronic smoker presented to the emergency room with acute onset large volume active oronasal bleeding. She was diagnosed previously with (T4 N2？M0, AJCC Stage IVA, 1997) moderately differentiated invasive squamous cell carcinoma of the left alveolar ridge, left nasal cavity, and maxillary sinus. Gross total surgical resection of the tumor was performed with subsequent radiation and chemotherapy 6 months prior to presentation. Radiotherapy was given by 3 dimensional external-beam radiation with a dose of 68？Gy to the head and neck region. Concurrent chemotherapy consisted of cisplatin. Recurrence of her malignancy was identified 1 month prior to presentation and she was treated initially with Bisphosphonate and subsequently with Carboplatin and Taxol. Her medications included Omeprazole, Acetaminophen/Hydrocodone, Prochlorperazine, and Ibuprofen. She was on self-medicated Ibuprofen of 6400？mg per day for pain relief. Her blood pressure on admission was 134/41？mm of Hg and her heart rate 128？bpm. She was not in apparent distress with normal blood oxygen saturation. On direct inspection, active bleeding within the oral cavity was noted from the the posterior buccal margin of the left maxillary region. Her physical examination was otherwise noncontributory. Her hemoglobin was 10.9？gm/dL, and the hematocrit was 32.4%. Her platelet count was 198？K/uL. A platelet function test was not performed. An emergency room attempt to arrest the bleeding by localized epinephrine injection and direct pressure failed. The bleeding was initially attributed to platelet dysfunction from Ibuprofen usage. Due to ongoing refractory hemorrhage, a catheter-based diagnostic angiogram was requested for. This was performed under endotracheal general anesthesia with