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The majority of cases in which ELSPA was unsuccessful were controlled by subsequent anterior ethmoidal artery ligation, representing 9% of all cases (75% of failures).
Ligation of the anterior ethmoidal artery is commonly performed in patients with a history of trauma; in the absence of trauma, ligation of the sphenopalatine artery is often first considered.
In our patient, the site of refractory bleeding was the anterior ethmoidal artery at the skull base.