Superselective transcatheter arterial embolization in patients with acute peripancreatic bleeding complications: review of 44 cases

Comparative efficacy of sequential treatment and open abdomen approaches for corrosive abdominal hemorrhage due to inadequate drainage of duodenal leakage: a cohort study

BACKGROUND

Intra-abdominal bleeding resulting from inadequate drainage of duodenal leakage (DL) is typically caused by the corrosiveness of duodenal fluid. Open abdomen (OA) treatment addresses both the drainage and bleeding simultaneously. However, a sequential treatment (ST) approach involving hemostasis through transcatheter arterial embolization (TAE) followed by percutaneous drainage of source control has emerged as an alternative method. This study aimed to evaluate the prognosis of ST in cases of DL-induced intra-abdominal bleeding.

METHODS

This retrospective cohort study included 151 participants diagnosed with DL-induced intra-abdominal bleeding from January 2004 to December 2010, and January 2013 to December 2021. The ST and OA groups were established based on the treatment method applied. Propensity score-matching (PSM) matched patients in the ST group with those in the OA group.

RESULTS

Among the 151 patients, 61 (40.4%) died within 90 days after the bleeding episode. ST was associated with a lower mortality rate (28.2% vs. 51.3% adjusted odds ratio [OR] = 0.34; 95% confidence interval [CI] 0.17-0.68; P = 0.003) compared to OA. Following PSM, ST remained the only factor associated with reduced mortality (OR = 0.32; 95% CI 0.13-0.75; P = 0.009). Moreover, ST demonstrated a higher rate of initial hemostasis success before (90.1% [64/71] vs. 77.5% [62/80]; adjusted OR = 2.84; 95% CI 1.07-7.60; P = 0.04) and after PSM (94.4% [51/54] vs. 77.8% [42/54], adjusted OR = 3.85; 95% CI 2.15-16.82; P = 0.04). Additionally, ST was associated with a lower incidence of rebleeding within 90 days after the initial bleeding, before (7 vs. 23; adjusted OR 0.41; 95% CI 0.18-0.92; P = 0.03) and after PSM (5 vs. 14; adjusted OR 0.37; 95% CI 0.15-0.93; P = 0.03).

CONCLUSIONS

Applying ST involving TAE and subsequent percutaneous drainage might be superior to OA in lowering the mortality in DL-induced intra-abdominal hemorrhage.

Major and minor complications of the pancreas after transcatheter arterial embolization using n-butyl-2-cyanoacrylate for acute bleeding from pancreatic arteries

PURPOSE

The purpose is to investigate the major and minor complications of the pancreas after transcatheter arterial embolization (TAE) using n-butyl-2-cyanoacrylate (NBCA) for bleeding from pancreatic arteries.

MATERIALS AND METHODS

Thirty-three patients who underwent TAE using NBCA for acute bleeding from pancreatic arteries and their parent arteries followed by contrast-enhanced computed tomography (CE-CT) were evaluated retrospectively. Complications and risk factors were assessed using Mann-Whitney U test or Fisher's exact test for the univariate analysis. Patients' characteristic, embolized artery, procedure details, and clinical outcomes were examined as possible risk factors.

RESULTS

TAE was performed successfully in all patients. Minor pancreatic complications occurred in 10 patients (30%), including acute mild pancreatitis (n = 4) and focal lack of pancreatic parenchymal enhancement on CE-CT without pancreatitis (n = 6). No cases of major pancreatic complications, such as moderate/severe pancreatitis, were reported. Embolized artery was the only significant risk factor. The rate of complications per embolized artery were 15% (three out of 20 patients) in the arteries of the pancreatic head and 54% (seven out of 13 patients) in the arteries of pancreatic body and tail (p = 0.025).

CONCLUSION

TAE using NBCA for acute bleeding from pancreatic arteries is efficacious and safe. Mild pancreatic complications were observed more frequently in case of embolization of the pancreatic body and tail region than the pancreatic head.

Effects of Cyanoacrylate in Rabbits with Induced Achilles Tendon Rupture

BACKGROUND In this study, we aimed to investigate the effects of N-butyl-2-cyanoacrylate (cyanoacrylate) on the biomechanical and histopathological aspects of tendon healing in a rabbit model of Achilles tendon injury. MATERIAL AND METHODS In total, 36 rabbits were randomized to experimental (cyanoacrylate) and control groups (n=36 tendons in each group). A simple suture was used in the control group and a simple suture plus cyanoacrylate was used in the experimental group. Nine rabbits from each group were euthanized at week 4 and week 6 after surgery for histopathological and biomechanical testing. RESULTS Granulation tissue formation was significantly greater in the experimental group in week 4 and week 6 than in the control group. Foreign body giant cell formation was significantly higher in the experimental group in week 4 and week 6. The maximum rupture force was significantly higher in the experimental group in week 4 and week 6 than in the control group. Elasticity and stiffness were comparable between groups in week 4; however, stiffness, but not elasticity, was significantly higher in the experimental group in week 6. CONCLUSIONS In the short term, cyanoacrylate enhanced tendon endurance in both a histopathological and biomechanical manner. We conclude that the early initiation of rehabilitation in patients may be safe in cases of cyanoacrylate use for surgical repair of tendon injury.

Immediate and Long-Term Outcomes of Percutaneous Radiological Interventions for Hemorrhagic Complications in Acute and Chronic Pancreatitis

PURPOSE

To evaluate and compare the immediate and long-term outcomes of radiological interventions for hemorrhagic complications in patients with acute and chronic pancreatitis.

MATERIALS AND METHODS

This retrospective study, conducted between January 2014 and June 2020, included all patients with acute and chronic pancreatitis presenting with hemorrhagic complications who underwent angiography and/or embolization. Their clinical, angiographic, and embolization details were evaluated and correlated with procedure success, complications, recurrence, and mortality. The patients were subgrouped into groups A (acute pancreatitis) and C (chronic pancreatitis), and comparisons were made.

RESULTS

The study included 141 patients (mean age, 36.3 ± 11.2 years; 124 men), of whom 106 patients had abnormal angiography findings and underwent embolization. Of them, group A had 50 patients (56 lesions) and group C had 56 patients (61 lesions). All the patients in group A had severe acute pancreatitis, with a mean computed tomography severity index of 7.6. The technical and clinical success rates of embolization, complications, recurrence, and long-term outcomes were not significantly different between the groups. Group A had significantly higher mortality due to sepsis and organ failure. Embolic agents did not have any significant association with complications, recurrence, and mortality. After a mean follow-up of 2 years, 72.5% of the patients were asymptomatic, and none had symptoms attributable to embolization.

CONCLUSIONS

Success, complications, and recurrence after embolization for hemorrhagic complications were comparable between acute and chronic pancreatitis. Acute pancreatitis was associated with significantly higher mortality. Embolic agents did not significantly influence the outcomes. None had long-term adverse effects attributable to embolization.

[Interventions for pancreatitis]

Approximately 20% of patients with acute pancreatitis develop complications that require surgical or radiological intervention. Radiology plays a central role, not only for imaging (course of the disease, detection of superinfection and their related complications, and development of necrosis) but also for the treatment of vascular and nonvascular complications. In the treatment of severe or necrotizing pancreatitis, a multidisciplinary staged approach with minimally invasive therapies such as endoscopic or percutaneous drainage should be used. Applying a sufficient number of drains of sufficient size, strict irrigation therapy under computed tomographic (CT) control and repositioning of the drains can successfully treat pancreatic and peripancreatic necrosis often without the need for subsequent surgical debridement. Arterial complications affect 1-10% of all patients with pancreatitis, most of which are ruptured pseudoaneurysms, which represent the most dangerous bleeding complication of pancreatitis and can be treated with a high technical success rate through embolization and/or use of an endovascular stent-graft.

Efficacy of endovascular embolization of arterial pseudoaneurysms in pancreatitis: A systematic review and meta-analysis

BACKGROUND

There is a significant variability in the reported outcomes following endovascular embolization of arterial pseudoaneurysms in pancreatitis. The objective of this systematic review and meta-analysis is to evaluate the efficacy of endovascular embolization of pancreatitis-related pseudoaneurysms.

METHODS

Searches of MEDLINE, EMBASE, and SCOPUS databases were performed through July 1, 2019 in accordance with PRISMA guidelines. All studies with ≥10 patients reporting technical success, clinical success, complications, and mortality were included. Generalized linear mixed method with random effects model was used for assessing pooled incidence rates and corresponding 95% confidence intervals (CIs).

RESULTS

A total of 29 studies (n = 840 with 638 pseudoaneurysms) were included. The pooled incidence rates of pseudoaneurysms in acute and chronic pancreatitis were 0.05% and 0.03%, respectively (odds ratio, 0.91, 95% CI-0.24-3.43). The most common site of pseudoaneurysm was splenic artery (37.7%). The most common embolization agent was coil (n = 415). The follow up period was 54.7 months (range, 21 days to 40.5 months). Pooled technical success rate was 97% (95% CI-92-99%, I² 83%). Clinical success rates at ≤3 months, 3-12 months, and >12 months were 82% (95% CI-70-90%, I² 42%), 86% (95% CI-75-92%, I² 44%), and 88% (95% CI-83-91%, I² 0%), respectively. There was no significant difference in the technical or clinical success between acute and chronic pancreatitis on subgroup analysis. Mortality was lower in chronic pancreatitis (OR 4.27 (95% CI 1.35-13.53, I² 0%)). Splenic infarction was the most common complication (n = 47).

CONCLUSION

Endovascular embolization is associated with a high technical and clinical success.

Safety and efficacy of transarterial embolisation for treatment of dorsal pancreatic artery haemorrhage

AIM

To evaluate the safety and efficacy of transarterial embolisation (TAE) of dorsal pancreatic artery (DPA) haemorrhage.

MATERIALS AND METHODS

Nineteen consecutive patients (M:F = 16:3, mean age 59.6 years) who underwent TAE of DPA in three tertiary medical centres between January 2001 to January 2020 were reviewed retrospectively. Angiographic features and the technical and clinical outcomes of TAE were analysed.

RESULTS

The clinical presentations were a bloody drain from the Jackson-Pratt drainage tube (n=8), melaena (n=7), abdominal pain (n=4), and haematochezia (n=3). Angiographic findings included pseudoaneurysm (n=14), contrast media extravasation (n=4), or abrupt cut-off of the arterial branch (n=1). The NBCA (N-butyl-cyanoacrylate; n=4), microcoils (n=4), and a combination of these agents (n=7) were used as embolic agents. The most common origin of the DPA in the present study cohort was the splenic artery (n=7), followed by the coeliac trunk (n=4), common hepatic artery (n=4), and superior mesenteric artery (n=4). Technical and clinical success rates were 100% and 84.2% (16/19), respectively. Of the three clinically unsuccessful cases, two patients were revealed to have newly developed bleeding from another artery. The other patient expired 1 day after the TAE procedure due to a progression of hepatic failure. In one patient, an asymptomatic non-target embolisation occurred in the right posterior tibial artery as a procedure-related complication. No major complications were observed.

CONCLUSION

TAE is safe and effective for the management of bleeding from the DPA. It is important to be aware of the DPA as a potential bleeding source, including the relevant clinical characteristics.

Transcatheter Arterial Embolization in the Treatment of Abdominal Bleeding in Patients Being Treated with Open Abdomen Due to Duodenal Fistula

BACKGROUND

This study aimed to investigate the transcatheter arterial embolization (TAE) in treatment of abdominal bleeding in patients being treated with open abdomen due to duodenal fistula.

METHODS

This was a retrospective study performed at our center. From January 2005 to November 2010, all patients with abdominal bleeding were treated with surgical hemostasis (SH) and included in SH group. From January 2012 to December 2018, all patients with a bleeding were treated with TAE and included in the TAE group. Clinical data were reviewed and compared between the two groups. The effect of TAE in the management of abdominal bleeding was evaluated.

RESULTS

A total of 131 patients were enrolled, and there were 64 in the SH group and 67 in the TAE group. The success rate of hemostasis was higher in the TAE group (89.55% vs. 73.44%, adjusted OR = 4.065, 95% CI 1.336-12.336, P = 0.013). Moreover, the recognition rate of hemorrhagic vessels in the TAE group was higher (91.04 vs. 51.56; P < 0.001). The re-bleeding occurred in 20 patients, 7(11.67%) in the TAE group and 13(27.66%) in the SH group. The re-bleeding rate in SH group was higher (adjusted HR = 2.564, 95% CI 1.023-6.428, P = 0.045) CONCLUSIONS: TAE is an effective method in treatment of abdominal bleeding in patients being treated with open abdomen due to duodenal fistula.

Coils migrate into the biliary-jejunum anastomosis: A case report

RATIONALE

Coils migration following endovascular treatment of arterial bleeding is rare. There was no clear route to deal with this complication.

PATIENT CONCERNS

A 55-year-old woman underwent choledochal cyst excision with hepaticojejunostomy. At the 18th day after operation, intra-abdominal hemorrhage occurred. Angiography showed active bleeding of 1 branch of the right hepatic artery and the gastroduodenal artery. That was treated by micro-coils embolization. 122 days after embolization, the patient was readmitted for chills, fever with temperature of 40°C, and jaundice.

DIAGNOSIS

Obstructive cholangitis.

INTERVENTIONS

Endoscopy was performed, which showed the micro-coils were embedded in biliary-jejunum anastomosis. Biliary sludges were adherent around micro-coils that were considered the cause of obstructive jaundice, which were washed by endoscopy.

OUTCOMES

Two days later endoscopy therapy, the total bilirubin (TBIL) was decreased to 58.7 μmol/L, and the patient was discharged. After 2 months of follow-up, the level of TBIL was in normal range.

LESSONS

Coils migration following endovascular treatment of arterial bleeding is rare. For cases with coils migrated into the biliary tract, further treatment is often needed because of the secondary cholangitis or stones. Endoscopy might be useful to deal with this intractable problem.

Safety and efficacy of transcatheter embolization with Glubran®2 cyanoacrylate glue for acute arterial bleeding: a single-center experience with 104 patients

PURPOSE

To assess the efficacy and the safety of Glubran^®2 n-butyl cyanoacrylate metacryloxysulfolane (NBCA-MS) transcatheter arterial embolization (TAE) for acute arterial bleeding from varied anatomic sites and to evaluate the predictive factors associated with clinical success and 30-day mortality.

METHODS

A retrospective review of consecutive patients who underwent emergent NBCA-MS Glubran^®2 TAE between July 2014 and August 2016 was conducted. Variables including age, sex, underlying malignancy, cardiovascular comorbidities, coagulation data, systolic blood pressure, and number of red blood cells units (RBC) transfused before TAE were collected. Clinical success, 30-day mortality, and complication rates were evaluated. Prognostic factors were evaluated by uni- and multivariate logistic regression analyses for clinical success, and by uni- and bivariate analyses after adjustment by bleeding sites for 30-day mortality.

RESULTS

104 patients underwent technically successful embolization with bleeding located in muscles (n = 34, 32.7%), digestive tract (n = 28, 26.9%), and viscera (n = 42, 40.4%). Clinical success rate was 76% (n = 79) and 30-day mortality rate was 21.2% (n = 22). Clinical failure was significantly associated with mortality (p < 0.0001). A number of RBC units transfused greater than or equal to 3 were associated with poorer clinical success (p = 0.025) and higher mortality (p = 0.03). Complications (n = 4, 3.8%) requiring surgery occurred only at puncture site. No ischemic complications requiring further invasive treatment occurred. Mean TAE treatment time was 4.55 min.

CONCLUSIONS

NBCA-MS Glubran^®2 TAE is a fast, effective, and safe treatment for acute arterial bleeding whatever the bleeding site.