الفهرس 
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Abstract
Historically, internal maxillary artery ligation via a transantral approach and ligation of the ethmoidal vessels and the external carotid artery have been the treatment of choice when conservative management failed (Gandomi et al., 2013)
Ligation of the internal maxillary artery has a success rate of 90%.The rate of complications is 28% and these are mainly due to the surgical approach, since it is done through a Caldwell---Luc technique. They can include pain during chewing, dental numbness, oroantral fistula, sinusitis, facial pain, facial or dental paresthesia, infraorbital nerve injury, blindness, ophthalmoplegia and xerophthalmia (Simmen et al., 2006).
Ligation of the external carotid, in addition to all the side effects due to the lack of distal irrigation and the complicated surgery, may damage the vagus and hypoglossal nerves, (Agreda et al., 2011).
Over the past decade, with the widespread popularization of endoscopic sinus surgery and the deeper understanding of local regional anatomy, endoscopic ligation of the sphenopalatine artery (SPA) has been advocated as an effective alternative for the control of posterior epistaxis (Abdelkader et al.,2007).
The success rate of sphenopalatine artery ligation is 95% and the failure rate is thus 5%---10% (Midilli et al., 2009).This technique has no serious complications. The most common is nasal crusting ( Seno et al., 2009).
Sphenopalatine artery ligation is an effective, fast and secures option, as well as a first-line procedure to treat cases of incoercible posterior epistaxis (Reza et al., 2007).
Therefore, some authors even recommend its use as a first option, without waiting for the failure of posterior tamponade. Its advantages, in addition to its effectiveness in the resolution of epistaxis, are that it reduces hospital stay and hospital costs and eliminates the morbidity caused by posterior tamponades (Agreda et al., 2011).
Arterial embolization appears comparable with TESPAL for success in controlling intractable epistaxis, as several recent studies have shown success rates between 80 and 90% (Sadri et al., 2006).
Percutaneus embolization of the maxillary artery requires expertise of an experienced interventional radiologist which is not uniformly available. It is also associated with serious neurological complication (Thakar and Sharan, 2005).
Numerous publications have suggested over the last few years that posterior epistaxis should be managed surgically (Stankiewicz, 2004) (Kumar et al., 2003).
The success rate of the initial surgical intervention is greater than that of initial non-surgical management (Hernández and Ordóñez, 2004).
Because of reduced patient morbidity and excellent success rates, surgical and endovascular techniques to control intractable epistaxis have become standard practice. However, the decision to pursue surgical
arterial ligation versus arterial embolization is complex. When considering the lower risk of major complications and reduced economic impact, surgical ligation (TESPAL _ AEA ligation) may be the preferable option before attempting arterial embolization for intractable epistaxis. Embolization may be a better initial option in patients unfit for general anesthesia, in those who are anticoagulated, and in surgical failures (Rudmik and Smith, 2012).