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| Step 1 | Femoral artery access, 5 F introducer sheath |
| Step 2 | Administration of 5000 I.E. heparin to avoid blood clots |
| Step 3 | Catheterize common carotid artery (CCA) with 5 F guide catheter (100 cm) and hydrophilic guide wire |
| Step 4 | Angiogram of the carotid bifurcation (40° RAO or LAO, resp.) |
| Step 5 | Catheterize external carotid artery (ECA) with guide wire and guide wire—tip of catheter approx. 2 cm above the bifurcation |
| Step 6 | Angiogram of ECA to find hazardous anastomoses or other unusual causes of epistaxis, e.g., AVM, tumor, pseudoaneurysm of sinonasal arteries |
| Step 7 | Pressure flushing of guiding catheter in ECA with heparinised normal saline and introduce microcatheter and microwire |
| Step 8 | Identify internal maxillary artery (IMA) and sphenopalatine artery (SPA) and catheterize |
| Step 9 | Angiogram of IMA/SPA (“dangerous anastomoses” and MMA (Figure 2) |
| Step 10 | When there are no hazardous anastomoses, embolize SPA/pterygopalatine segment of IMA with calibrated microparticles in dilution with contrast medium (500 μm) until flow begins to slow. Important: avoid reflux, especially avoid embolization of MMA (headaches and hazardous anastomoses; Figure 2) When there are ECA-ICA anastomoses, directly go to step 12 |
| Step 11 | Rinse the microcatheter properly to avoid dislocation of microparticles |
| Step 12 | Embolize SPA and distal IMA with microcoils |
| Step 13 | Control angiogram |
| Step 14 | Quick removal of all catheters from the carotid arteries |
| Step 15 | Removal of introducer sheath, AngioSeal, or ExoSeal occlusion of vessel, compression bandage until the next day |
| Step 16 | Nasal packing is left intact overnight and removed for inspection for bleeding the next day |
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