Aims Endoscopic Sphenopalatine Artery Ligation (ESPAL) is well described as a safe and effective procedure to manage intractable epistaxis. However, in the literature, the peri-operative and patient factors which contribute to surgical success or failure have been poorly defined. The purpose of this study was to identify the patient, disease and surgical factors which influence the effectiveness of ESPAL in the management of intractable epistaxis. Methodology All ESPALs performed over a 14-year period at a single tertiary otolaryngology department to manage epistaxis refractory to conservative management were retrospectively analysed. Recurrence of epistaxis was defined as any patient who presented with epistaxis following previous ESPAL at any time post-operatively. Subjects were grouped in to a non-recurrence and recurrence group accordingly. Results 49 patients underwent ESPAL to treat intractable epistaxis. The recurrence rate was 27% within the average follow-up period of 5 years. The average time between ESPAL and epistaxis recurrence was 10 days. Patients on anticoagulation were more likely to have recurrence of epistaxis after ESPAL (P <0.05), while patients on antiplatelet therapy were not. 62% (n = 8) of patients with recurrence required revision surgical cautery, or escalation to endovascular embolisation. No patients had recurrence of epistaxis following additional surgical or radiological intervention. Conclusion Over one in four patients experienced recurrent epistaxis following ESPAL within 3-weeks of their surgery. Patients on anticoagulation are more likely to experience recurrence. If re-presenting with epistaxis following ESPAL, patients are likely to require surgical or radiological intervention.