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Ghosn Y, Khdhir M, Jabbour Y, Dushfunian D, Kobeissi I, Abbas N, Akkari C, Kahwaji EM, Muallem N. Factors affecting radiation dose, radiation exposure time and procedural time in arterial embolization for active hemorrhage. Emerg Radiol 2024; 31:641-652. [PMID: 38955874 DOI: 10.1007/s10140-024-02262-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 06/26/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE To evaluate patient and procedure-related factors contributing to the radiation dose, cumulative fluoroscopy time (CFT), and procedural time (PT) of Arterial Embolization (AE) for suspected active bleeding. METHODS Data on patients who underwent AE for suspected bleeding was retrospectively gathered between January 2019 and April 2022. Data collected included the dependent variables consisting of dose-area product (DAP), CFT, PT, and independent variables consisting of demographic, bleeding-specific, and procedure-specific parameters. All statistical computations were performed in SPSS statistics. The alpha value was set at 0.05. RESULTS Data from a total of 148 AE were collected with an average patient's age of 61.06 ± 21.57 years. Higher DAP was independently associated with male sex (p < 0.002), age ranges between 46 and 65 years (p = 0.019) and > 66 years (p = 0.027), BMI above 30 (p = 0.016), attending with less than 10 years of experience (p = 0.01), and bleeding in the abdomen and pelvis (p = 0.027). Longer CFT was independently associated with attending with less than 10 years of experience (p < 0.001), having 2 (p = 0.004) or > 3 (p = 0.005) foci of bleed, and age between 46 and 65 years (p = 0.007) and ≥ 66 years (p = 0.017). Longer PT was independently associated with attending with less than 10 years of experience (p < 0.001) and having 2 (p = 0.014) or > 3 (p = 0.005) foci of bleed. CONCLUSION The interventionist experience influenced radiation dose, CFT and PT. Dose was also affected by patients' sex, age, BMI, as well as bleeding location. CFT was also affected by patients' age, and both CFT and PT were also affected by the number of bleeding foci. These findings highlight the multifaceted factors that affect radiation dose and procedural time, emphasizing the importance of interventionist expertise, patient's age, sex, BMI, location and number of bleeds.
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Affiliation(s)
- Youssef Ghosn
- Department of Diagnostic Radiology, American University of Beirut, Riad El-Solh, P.O.Box 11-0236, Beirut, 1107 2020, Lebanon
| | - Mihran Khdhir
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, USA
| | - Yara Jabbour
- Department of Diagnostic Radiology, American University of Beirut, Riad El-Solh, P.O.Box 11-0236, Beirut, 1107 2020, Lebanon
| | - David Dushfunian
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Iyad Kobeissi
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Nada Abbas
- American University of Beirut, Beirut, Lebanon
| | - Chantal Akkari
- Department of Diagnostic Radiology, American University of Beirut, Riad El-Solh, P.O.Box 11-0236, Beirut, 1107 2020, Lebanon
| | - Eva-Maria Kahwaji
- Faculty of Health Science, American University of Berirut, Beirut, Lebanon
| | - Nadim Muallem
- Department of Diagnostic Radiology, American University of Beirut, Riad El-Solh, P.O.Box 11-0236, Beirut, 1107 2020, Lebanon.
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2
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Kitamura R, Maruhashi T, Woodhams R, Suzuki K, Kurihara Y, Fujii K, Asari Y. Carbon dioxide-enhanced angiography for detection of colonic diverticular bleeding and clinical outcomes. CVIR Endovasc 2024; 7:67. [PMID: 39269529 PMCID: PMC11399504 DOI: 10.1186/s42155-024-00481-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2024] [Accepted: 09/05/2024] [Indexed: 09/15/2024] Open
Abstract
PURPOSE To determine the ability of CO2-enhanced angiography to detect active diverticular bleeding that is not detected by iodinated contrast medium (ICM)-enhanced angiography and its impact on clinical outcomes when used to confirm embolization, particularly the risks of rebleeding and ischemic complications. MATERIALS AND METHODS We retrospectively identified a cohort of patients with colonic diverticular bleeding who underwent catheter angiography between August 2008 and May 2023 at our institution. We divided them according to whether they underwent CO2 angiography following a negative ICM angiography study or to confirm hemostasis post-embolization (the CO2 angiography group) or ICM angiography alone in the absence of active bleeding or for confirmation of hemostasis post-embolization (the ICM angiography group). The ability to detect active colonic diverticular bleeding and clinical outcomes were compared between the two groups. RESULTS There were 31 patients in the ICM angiography group and 29 in the CO2 angiography group. The rate of detection of active bleeding by CO2 angiography that was not identified by ICM angiography was 48%. The rebleeding rate was 23% in the ICM angiography group and 6.9% in the CO2 angiography group. Among the patients who underwent TAE, the ischemic complications rate was 7.1% in the ICM angiography group and 4.5% in the CO2 angiography group. CONCLUSIONS CO2 angiography may detect active diverticular bleeding that is not detectable by ICM angiography and appears to be associated with a lower rebleeding rate. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Ryoichi Kitamura
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, Sagamihara, Kanagawa, 252-0375, Japan.
| | - Takaaki Maruhashi
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, Sagamihara, Kanagawa, 252-0375, Japan
| | - Reiko Woodhams
- Department of Comprehensive Medicine, Division of Interventional Radiology, Research and Development Center for New Medical Frontiers, Kitasato University School of Medicine, Kanagawa, Japan
| | - Koyo Suzuki
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, Sagamihara, Kanagawa, 252-0375, Japan
| | - Yutaro Kurihara
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, Sagamihara, Kanagawa, 252-0375, Japan
| | - Kaoru Fujii
- Department of Diagnostic Radiology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yasushi Asari
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, Sagamihara, Kanagawa, 252-0375, Japan
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Yu Q, Funaki B, Ahmed O. Twenty years of embolization for acute lower gastrointestinal bleeding: a meta-analysis of rebleeding and ischaemia rates. Br J Radiol 2024; 97:920-932. [PMID: 38364312 PMCID: PMC11075984 DOI: 10.1093/bjr/tqae037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/24/2023] [Accepted: 02/07/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Transarterial embolization (TAE) for acute lower gastrointestinal bleeding (LGIB) can be technically challenging due to the compromise between achieving haemostasis and causing tissue ischaemia. The goal of the present study is to determine its technical success, rebleeding, and post-embolization ischaemia rates through meta-analysis of published literature in the last twenty years. METHODS PubMed, Embase, and Cochrane Library databases were queried. Technical success, rebleeding, and ischaemia rates were extracted. Baseline characteristics such as author, publication year, region, study design, embolization material, percentage of superselective embolization were retrieved. Subgroup analysis was performed based on publication time and embolization agent. RESULTS A total of 66 studies including 2121 patients who underwent embolization for acute LGIB were included. Endoscopic management was attempted in 34.5%. The pooled overall technical success, rebleeding, post-embolization ischaemia rates were 97.0%, 20.7%, and 7.5%, respectively. Studies published after 2010 showed higher technical success rates (97.8% vs 95.2%), lower rebleeding rates (18.6% vs 23.4%), and lower ischaemia rates (7.3% vs 9.7%). Compared to microcoils, NBCA was associated with a lower rebleeding rate (9.3% vs 20.8%) at the expense of a higher post-embolization ischaemia rate (9.7% vs 4.0%). Coagulopathy (P = .034), inotropic use (P = .040), and malignancy (P = .002) were predictors of post-embolization rebleeding. Haemorrhagic shock (P < .001), inotropic use (P = .026), malignancy (P < .001), coagulopathy (P = .002), blood transfusion (P < .001), and enteritis (P = .023) were predictors of mortality. Empiric embolization achieved a similarly durable haemostasis rate compared to targeted embolization (23.6% vs 21.1%) but a higher risk of post-embolization ischaemia (14.3% vs 4.7%). CONCLUSION For LGIB, TAE has a favourable technical success rate and low risk of post-embolization ischaemia. Its safety and efficacy profile has increased over the last decade. Compared to microcoils, NBCA seemed to offer a more durable haemostasis rate at the expense of higher ischaemia risk. Due to the heterogeneity of currently available evidence, future prospective and comparative studies are warranted. ADVANCES IN KNOWLEDGE (1) Acute LGIB embolization demonstrate a high technical success rate with acceptable rate of rebleeding and symptomatic ischaemia rates. Most ischaemic stigmata discovered during routine post-embolization colonoscopy were minor. (2) Although NBCA seemed to offer a more durable haemostasis rate, it was also associated with a higher risk of ischaemia compared to microcoils. (3) Coagulopathy, malignant aetiology, and inotropic use were predictors of rebleeding and mortality. (4) Routine post-embolization endoscopy to assess for ischaemia is not indicated.
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Affiliation(s)
- Qian Yu
- Division of Interventional Radiology, Department of Radiology, University of Chicago, Chicago, IL, 60637, United States
- Department of Surgery, Cleveland Clinic Florida, Weston, FL, 33331, United States
| | - Brian Funaki
- Division of Interventional Radiology, Department of Radiology, University of Chicago, Chicago, IL, 60637, United States
| | - Osman Ahmed
- Division of Interventional Radiology, Department of Radiology, University of Chicago, Chicago, IL, 60637, United States
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Alali M, Cao C, Shin JH, Jeon G, Zeng CH, Park JH, Aljerdah S, Aljohani S. Preliminary report on embolization with quick-soluble gelatin sponge particles for angiographically negative acute gastrointestinal bleeding. Sci Rep 2024; 14:6438. [PMID: 38499668 PMCID: PMC10948793 DOI: 10.1038/s41598-024-56992-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 03/13/2024] [Indexed: 03/20/2024] Open
Abstract
Prophylactic embolization is usually performed using gelatin sponge particles, which are absorbed within several weeks, for managing angiographically negative gastrointestinal bleeding. This study aimed to evaluate the safety and effectiveness of transcatheter arterial embolization (TAE) with quick-soluble gelatin sponge particles (QS-GSP) that dissolve in less than 4 h for treating angiographically negative gastrointestinal bleeding. We included ten patients (M:F = 7:3; mean age, 64.3 years) who underwent prophylactic TAE with QS-GSP for angiographically negative acute gastrointestinal bleeding between 2021 and 2023. The technical success rate of TAE, clinical outcomes focusing on rebleeding, and procedure-related complications were evaluated. The embolized arteries were the gastroduodenal (n = 3), jejunal (n = 4), and ileal (n = 3) arteries. QS-GSP (150-350 µm or 350-560 µm) were used alone (n = 8) or in combination with a coil (n = 1). A 100% technical success rate was accomplished. In 1 patient (10%), rebleeding occurred 2 days after prophylactic TAE of the gastroduodenal artery, and this was managed by repeat TAE. There were no procedure-related complications. The use of QS-GSP for prophylactic TAE appears to be safe and effective for controlling bleeding among patients with angiographically negative gastrointestinal bleeding. There were no cases of related ischemic complications of the embolized bowels likely attributable to recanalization of the affected arteries following biodegradation of QS-GSP.
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Affiliation(s)
- Meshari Alali
- Department of Radiology, Majmaah University, Almajmaah, Saudi Arabia
| | - Chuanwu Cao
- Department of Radiology, The Tenth People's Hospital, Shanghai, China
| | - Ji Hoon Shin
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
| | - Gayoung Jeon
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Chu Hui Zeng
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jung-Hoon Park
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Shakir Aljerdah
- Department of Radiology, Najran University, Najran, Saudi Arabia
| | - Sultan Aljohani
- Department of Radiology, King Salman Bin Abdulaziz Medical City, Medina, Saudi Arabia
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5
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Sengupta N, Kastenberg DM, Bruining DH, Latorre M, Leighton JA, Brook OR, Wells ML, Guglielmo FF, Naringrekar HV, Gee MS, Soto JA, Park SH, Yoo DC, Ramalingam V, Huete A, Khandelwal A, Gupta A, Allen BC, Anderson MA, Dane BR, Sokhandon F, Grand DJ, Tse JR, Fidler JL. The Role of Imaging for GI Bleeding: ACG and SAR Consensus Recommendations. Radiology 2024; 310:e232298. [PMID: 38441091 DOI: 10.1148/radiol.232298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
Gastrointestinal (GI) bleeding is the most common GI diagnosis leading to hospitalization within the United States. Prompt diagnosis and treatment of GI bleeding is critical to improving patient outcomes and reducing high health care utilization and costs. Radiologic techniques including CT angiography, catheter angiography, CT enterography, MR enterography, nuclear medicine red blood cell scan, and technetium-99m pertechnetate scintigraphy (Meckel scan) are frequently used to evaluate patients with GI bleeding and are complementary to GI endoscopy. However, multiple management guidelines exist, which differ in the recommended utilization of these radiologic examinations. This variability can lead to confusion as to how these tests should be used in the evaluation of GI bleeding. In this document, a panel of experts from the American College of Gastroenterology and Society of Abdominal Radiology provide a review of the radiologic examinations used to evaluate for GI bleeding including nomenclature, technique, performance, advantages, and limitations. A comparison of advantages and limitations relative to endoscopic examinations is also included. Finally, consensus statements and recommendations on technical parameters and utilization of radiologic techniques for GI bleeding are provided. © Radiological Society of North America and the American College of Gastroenterology, 2024. Supplemental material is available for this article. This article is being published concurrently in American Journal of Gastroenterology and Radiology. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Citations from either journal can be used when citing this article. See also the editorial by Lockhart in this issue.
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Affiliation(s)
- Neil Sengupta
- From the Department of Gastroenterology and Hepatology, University of Chicago Pritzker School of Medicine, Chicago, Ill (N.S.); Department of Gastroenterology and Hepatology (D.M.K.) and Department of Radiology (F.F.G., H.V.N.), Thomas Jefferson University Hospital, Philadelphia, Pa; Department of Gastroenterology and Hepatology (D.H.B.) and Department of Radiology (M.L.W., A.K., J.L.F.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Gastroenterology and Hepatology (M.L.) and Department of Radiology (B.R.D.), NYU Langone Medical Center, New York, NY; Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Ariz (J.A.L.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.S.G., M.A.A.); Department of Radiology, Boston University Medical Center, Boston, Mass (J.A.S., A.G.); Department of Radiology, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI (D.C.Y., D.J.G.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, William Beaumont University Hospital, Royal Oak, Mich (F.S.); and Department of Radiology, Stanford University School of Medicine, Stanford, Calif (J.R.T.)
| | - David M Kastenberg
- From the Department of Gastroenterology and Hepatology, University of Chicago Pritzker School of Medicine, Chicago, Ill (N.S.); Department of Gastroenterology and Hepatology (D.M.K.) and Department of Radiology (F.F.G., H.V.N.), Thomas Jefferson University Hospital, Philadelphia, Pa; Department of Gastroenterology and Hepatology (D.H.B.) and Department of Radiology (M.L.W., A.K., J.L.F.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Gastroenterology and Hepatology (M.L.) and Department of Radiology (B.R.D.), NYU Langone Medical Center, New York, NY; Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Ariz (J.A.L.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.S.G., M.A.A.); Department of Radiology, Boston University Medical Center, Boston, Mass (J.A.S., A.G.); Department of Radiology, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI (D.C.Y., D.J.G.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, William Beaumont University Hospital, Royal Oak, Mich (F.S.); and Department of Radiology, Stanford University School of Medicine, Stanford, Calif (J.R.T.)
| | - David H Bruining
- From the Department of Gastroenterology and Hepatology, University of Chicago Pritzker School of Medicine, Chicago, Ill (N.S.); Department of Gastroenterology and Hepatology (D.M.K.) and Department of Radiology (F.F.G., H.V.N.), Thomas Jefferson University Hospital, Philadelphia, Pa; Department of Gastroenterology and Hepatology (D.H.B.) and Department of Radiology (M.L.W., A.K., J.L.F.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Gastroenterology and Hepatology (M.L.) and Department of Radiology (B.R.D.), NYU Langone Medical Center, New York, NY; Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Ariz (J.A.L.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.S.G., M.A.A.); Department of Radiology, Boston University Medical Center, Boston, Mass (J.A.S., A.G.); Department of Radiology, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI (D.C.Y., D.J.G.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, William Beaumont University Hospital, Royal Oak, Mich (F.S.); and Department of Radiology, Stanford University School of Medicine, Stanford, Calif (J.R.T.)
| | - Melissa Latorre
- From the Department of Gastroenterology and Hepatology, University of Chicago Pritzker School of Medicine, Chicago, Ill (N.S.); Department of Gastroenterology and Hepatology (D.M.K.) and Department of Radiology (F.F.G., H.V.N.), Thomas Jefferson University Hospital, Philadelphia, Pa; Department of Gastroenterology and Hepatology (D.H.B.) and Department of Radiology (M.L.W., A.K., J.L.F.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Gastroenterology and Hepatology (M.L.) and Department of Radiology (B.R.D.), NYU Langone Medical Center, New York, NY; Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Ariz (J.A.L.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.S.G., M.A.A.); Department of Radiology, Boston University Medical Center, Boston, Mass (J.A.S., A.G.); Department of Radiology, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI (D.C.Y., D.J.G.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, William Beaumont University Hospital, Royal Oak, Mich (F.S.); and Department of Radiology, Stanford University School of Medicine, Stanford, Calif (J.R.T.)
| | - Jonathan A Leighton
- From the Department of Gastroenterology and Hepatology, University of Chicago Pritzker School of Medicine, Chicago, Ill (N.S.); Department of Gastroenterology and Hepatology (D.M.K.) and Department of Radiology (F.F.G., H.V.N.), Thomas Jefferson University Hospital, Philadelphia, Pa; Department of Gastroenterology and Hepatology (D.H.B.) and Department of Radiology (M.L.W., A.K., J.L.F.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Gastroenterology and Hepatology (M.L.) and Department of Radiology (B.R.D.), NYU Langone Medical Center, New York, NY; Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Ariz (J.A.L.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.S.G., M.A.A.); Department of Radiology, Boston University Medical Center, Boston, Mass (J.A.S., A.G.); Department of Radiology, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI (D.C.Y., D.J.G.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, William Beaumont University Hospital, Royal Oak, Mich (F.S.); and Department of Radiology, Stanford University School of Medicine, Stanford, Calif (J.R.T.)
| | - Olga R Brook
- From the Department of Gastroenterology and Hepatology, University of Chicago Pritzker School of Medicine, Chicago, Ill (N.S.); Department of Gastroenterology and Hepatology (D.M.K.) and Department of Radiology (F.F.G., H.V.N.), Thomas Jefferson University Hospital, Philadelphia, Pa; Department of Gastroenterology and Hepatology (D.H.B.) and Department of Radiology (M.L.W., A.K., J.L.F.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Gastroenterology and Hepatology (M.L.) and Department of Radiology (B.R.D.), NYU Langone Medical Center, New York, NY; Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Ariz (J.A.L.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.S.G., M.A.A.); Department of Radiology, Boston University Medical Center, Boston, Mass (J.A.S., A.G.); Department of Radiology, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI (D.C.Y., D.J.G.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, William Beaumont University Hospital, Royal Oak, Mich (F.S.); and Department of Radiology, Stanford University School of Medicine, Stanford, Calif (J.R.T.)
| | - Michael L Wells
- From the Department of Gastroenterology and Hepatology, University of Chicago Pritzker School of Medicine, Chicago, Ill (N.S.); Department of Gastroenterology and Hepatology (D.M.K.) and Department of Radiology (F.F.G., H.V.N.), Thomas Jefferson University Hospital, Philadelphia, Pa; Department of Gastroenterology and Hepatology (D.H.B.) and Department of Radiology (M.L.W., A.K., J.L.F.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Gastroenterology and Hepatology (M.L.) and Department of Radiology (B.R.D.), NYU Langone Medical Center, New York, NY; Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Ariz (J.A.L.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.S.G., M.A.A.); Department of Radiology, Boston University Medical Center, Boston, Mass (J.A.S., A.G.); Department of Radiology, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI (D.C.Y., D.J.G.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, William Beaumont University Hospital, Royal Oak, Mich (F.S.); and Department of Radiology, Stanford University School of Medicine, Stanford, Calif (J.R.T.)
| | - Flavius F Guglielmo
- From the Department of Gastroenterology and Hepatology, University of Chicago Pritzker School of Medicine, Chicago, Ill (N.S.); Department of Gastroenterology and Hepatology (D.M.K.) and Department of Radiology (F.F.G., H.V.N.), Thomas Jefferson University Hospital, Philadelphia, Pa; Department of Gastroenterology and Hepatology (D.H.B.) and Department of Radiology (M.L.W., A.K., J.L.F.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Gastroenterology and Hepatology (M.L.) and Department of Radiology (B.R.D.), NYU Langone Medical Center, New York, NY; Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Ariz (J.A.L.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.S.G., M.A.A.); Department of Radiology, Boston University Medical Center, Boston, Mass (J.A.S., A.G.); Department of Radiology, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI (D.C.Y., D.J.G.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, William Beaumont University Hospital, Royal Oak, Mich (F.S.); and Department of Radiology, Stanford University School of Medicine, Stanford, Calif (J.R.T.)
| | - Haresh V Naringrekar
- From the Department of Gastroenterology and Hepatology, University of Chicago Pritzker School of Medicine, Chicago, Ill (N.S.); Department of Gastroenterology and Hepatology (D.M.K.) and Department of Radiology (F.F.G., H.V.N.), Thomas Jefferson University Hospital, Philadelphia, Pa; Department of Gastroenterology and Hepatology (D.H.B.) and Department of Radiology (M.L.W., A.K., J.L.F.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Gastroenterology and Hepatology (M.L.) and Department of Radiology (B.R.D.), NYU Langone Medical Center, New York, NY; Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Ariz (J.A.L.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.S.G., M.A.A.); Department of Radiology, Boston University Medical Center, Boston, Mass (J.A.S., A.G.); Department of Radiology, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI (D.C.Y., D.J.G.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, William Beaumont University Hospital, Royal Oak, Mich (F.S.); and Department of Radiology, Stanford University School of Medicine, Stanford, Calif (J.R.T.)
| | - Michael S Gee
- From the Department of Gastroenterology and Hepatology, University of Chicago Pritzker School of Medicine, Chicago, Ill (N.S.); Department of Gastroenterology and Hepatology (D.M.K.) and Department of Radiology (F.F.G., H.V.N.), Thomas Jefferson University Hospital, Philadelphia, Pa; Department of Gastroenterology and Hepatology (D.H.B.) and Department of Radiology (M.L.W., A.K., J.L.F.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Gastroenterology and Hepatology (M.L.) and Department of Radiology (B.R.D.), NYU Langone Medical Center, New York, NY; Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Ariz (J.A.L.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.S.G., M.A.A.); Department of Radiology, Boston University Medical Center, Boston, Mass (J.A.S., A.G.); Department of Radiology, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI (D.C.Y., D.J.G.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, William Beaumont University Hospital, Royal Oak, Mich (F.S.); and Department of Radiology, Stanford University School of Medicine, Stanford, Calif (J.R.T.)
| | - Jorge A Soto
- From the Department of Gastroenterology and Hepatology, University of Chicago Pritzker School of Medicine, Chicago, Ill (N.S.); Department of Gastroenterology and Hepatology (D.M.K.) and Department of Radiology (F.F.G., H.V.N.), Thomas Jefferson University Hospital, Philadelphia, Pa; Department of Gastroenterology and Hepatology (D.H.B.) and Department of Radiology (M.L.W., A.K., J.L.F.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Gastroenterology and Hepatology (M.L.) and Department of Radiology (B.R.D.), NYU Langone Medical Center, New York, NY; Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Ariz (J.A.L.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.S.G., M.A.A.); Department of Radiology, Boston University Medical Center, Boston, Mass (J.A.S., A.G.); Department of Radiology, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI (D.C.Y., D.J.G.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, William Beaumont University Hospital, Royal Oak, Mich (F.S.); and Department of Radiology, Stanford University School of Medicine, Stanford, Calif (J.R.T.)
| | - Seong Ho Park
- From the Department of Gastroenterology and Hepatology, University of Chicago Pritzker School of Medicine, Chicago, Ill (N.S.); Department of Gastroenterology and Hepatology (D.M.K.) and Department of Radiology (F.F.G., H.V.N.), Thomas Jefferson University Hospital, Philadelphia, Pa; Department of Gastroenterology and Hepatology (D.H.B.) and Department of Radiology (M.L.W., A.K., J.L.F.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Gastroenterology and Hepatology (M.L.) and Department of Radiology (B.R.D.), NYU Langone Medical Center, New York, NY; Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Ariz (J.A.L.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.S.G., M.A.A.); Department of Radiology, Boston University Medical Center, Boston, Mass (J.A.S., A.G.); Department of Radiology, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI (D.C.Y., D.J.G.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, William Beaumont University Hospital, Royal Oak, Mich (F.S.); and Department of Radiology, Stanford University School of Medicine, Stanford, Calif (J.R.T.)
| | - Don C Yoo
- From the Department of Gastroenterology and Hepatology, University of Chicago Pritzker School of Medicine, Chicago, Ill (N.S.); Department of Gastroenterology and Hepatology (D.M.K.) and Department of Radiology (F.F.G., H.V.N.), Thomas Jefferson University Hospital, Philadelphia, Pa; Department of Gastroenterology and Hepatology (D.H.B.) and Department of Radiology (M.L.W., A.K., J.L.F.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Gastroenterology and Hepatology (M.L.) and Department of Radiology (B.R.D.), NYU Langone Medical Center, New York, NY; Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Ariz (J.A.L.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.S.G., M.A.A.); Department of Radiology, Boston University Medical Center, Boston, Mass (J.A.S., A.G.); Department of Radiology, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI (D.C.Y., D.J.G.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, William Beaumont University Hospital, Royal Oak, Mich (F.S.); and Department of Radiology, Stanford University School of Medicine, Stanford, Calif (J.R.T.)
| | - Vijay Ramalingam
- From the Department of Gastroenterology and Hepatology, University of Chicago Pritzker School of Medicine, Chicago, Ill (N.S.); Department of Gastroenterology and Hepatology (D.M.K.) and Department of Radiology (F.F.G., H.V.N.), Thomas Jefferson University Hospital, Philadelphia, Pa; Department of Gastroenterology and Hepatology (D.H.B.) and Department of Radiology (M.L.W., A.K., J.L.F.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Gastroenterology and Hepatology (M.L.) and Department of Radiology (B.R.D.), NYU Langone Medical Center, New York, NY; Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Ariz (J.A.L.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.S.G., M.A.A.); Department of Radiology, Boston University Medical Center, Boston, Mass (J.A.S., A.G.); Department of Radiology, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI (D.C.Y., D.J.G.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, William Beaumont University Hospital, Royal Oak, Mich (F.S.); and Department of Radiology, Stanford University School of Medicine, Stanford, Calif (J.R.T.)
| | - Alvaro Huete
- From the Department of Gastroenterology and Hepatology, University of Chicago Pritzker School of Medicine, Chicago, Ill (N.S.); Department of Gastroenterology and Hepatology (D.M.K.) and Department of Radiology (F.F.G., H.V.N.), Thomas Jefferson University Hospital, Philadelphia, Pa; Department of Gastroenterology and Hepatology (D.H.B.) and Department of Radiology (M.L.W., A.K., J.L.F.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Gastroenterology and Hepatology (M.L.) and Department of Radiology (B.R.D.), NYU Langone Medical Center, New York, NY; Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Ariz (J.A.L.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.S.G., M.A.A.); Department of Radiology, Boston University Medical Center, Boston, Mass (J.A.S., A.G.); Department of Radiology, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI (D.C.Y., D.J.G.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, William Beaumont University Hospital, Royal Oak, Mich (F.S.); and Department of Radiology, Stanford University School of Medicine, Stanford, Calif (J.R.T.)
| | - Ashish Khandelwal
- From the Department of Gastroenterology and Hepatology, University of Chicago Pritzker School of Medicine, Chicago, Ill (N.S.); Department of Gastroenterology and Hepatology (D.M.K.) and Department of Radiology (F.F.G., H.V.N.), Thomas Jefferson University Hospital, Philadelphia, Pa; Department of Gastroenterology and Hepatology (D.H.B.) and Department of Radiology (M.L.W., A.K., J.L.F.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Gastroenterology and Hepatology (M.L.) and Department of Radiology (B.R.D.), NYU Langone Medical Center, New York, NY; Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Ariz (J.A.L.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.S.G., M.A.A.); Department of Radiology, Boston University Medical Center, Boston, Mass (J.A.S., A.G.); Department of Radiology, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI (D.C.Y., D.J.G.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, William Beaumont University Hospital, Royal Oak, Mich (F.S.); and Department of Radiology, Stanford University School of Medicine, Stanford, Calif (J.R.T.)
| | - Avneesh Gupta
- From the Department of Gastroenterology and Hepatology, University of Chicago Pritzker School of Medicine, Chicago, Ill (N.S.); Department of Gastroenterology and Hepatology (D.M.K.) and Department of Radiology (F.F.G., H.V.N.), Thomas Jefferson University Hospital, Philadelphia, Pa; Department of Gastroenterology and Hepatology (D.H.B.) and Department of Radiology (M.L.W., A.K., J.L.F.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Gastroenterology and Hepatology (M.L.) and Department of Radiology (B.R.D.), NYU Langone Medical Center, New York, NY; Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Ariz (J.A.L.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.S.G., M.A.A.); Department of Radiology, Boston University Medical Center, Boston, Mass (J.A.S., A.G.); Department of Radiology, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI (D.C.Y., D.J.G.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, William Beaumont University Hospital, Royal Oak, Mich (F.S.); and Department of Radiology, Stanford University School of Medicine, Stanford, Calif (J.R.T.)
| | - Brian C Allen
- From the Department of Gastroenterology and Hepatology, University of Chicago Pritzker School of Medicine, Chicago, Ill (N.S.); Department of Gastroenterology and Hepatology (D.M.K.) and Department of Radiology (F.F.G., H.V.N.), Thomas Jefferson University Hospital, Philadelphia, Pa; Department of Gastroenterology and Hepatology (D.H.B.) and Department of Radiology (M.L.W., A.K., J.L.F.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Gastroenterology and Hepatology (M.L.) and Department of Radiology (B.R.D.), NYU Langone Medical Center, New York, NY; Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Ariz (J.A.L.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.S.G., M.A.A.); Department of Radiology, Boston University Medical Center, Boston, Mass (J.A.S., A.G.); Department of Radiology, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI (D.C.Y., D.J.G.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, William Beaumont University Hospital, Royal Oak, Mich (F.S.); and Department of Radiology, Stanford University School of Medicine, Stanford, Calif (J.R.T.)
| | - Mark A Anderson
- From the Department of Gastroenterology and Hepatology, University of Chicago Pritzker School of Medicine, Chicago, Ill (N.S.); Department of Gastroenterology and Hepatology (D.M.K.) and Department of Radiology (F.F.G., H.V.N.), Thomas Jefferson University Hospital, Philadelphia, Pa; Department of Gastroenterology and Hepatology (D.H.B.) and Department of Radiology (M.L.W., A.K., J.L.F.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Gastroenterology and Hepatology (M.L.) and Department of Radiology (B.R.D.), NYU Langone Medical Center, New York, NY; Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Ariz (J.A.L.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.S.G., M.A.A.); Department of Radiology, Boston University Medical Center, Boston, Mass (J.A.S., A.G.); Department of Radiology, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI (D.C.Y., D.J.G.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, William Beaumont University Hospital, Royal Oak, Mich (F.S.); and Department of Radiology, Stanford University School of Medicine, Stanford, Calif (J.R.T.)
| | - Bari R Dane
- From the Department of Gastroenterology and Hepatology, University of Chicago Pritzker School of Medicine, Chicago, Ill (N.S.); Department of Gastroenterology and Hepatology (D.M.K.) and Department of Radiology (F.F.G., H.V.N.), Thomas Jefferson University Hospital, Philadelphia, Pa; Department of Gastroenterology and Hepatology (D.H.B.) and Department of Radiology (M.L.W., A.K., J.L.F.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Gastroenterology and Hepatology (M.L.) and Department of Radiology (B.R.D.), NYU Langone Medical Center, New York, NY; Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Ariz (J.A.L.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.S.G., M.A.A.); Department of Radiology, Boston University Medical Center, Boston, Mass (J.A.S., A.G.); Department of Radiology, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI (D.C.Y., D.J.G.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, William Beaumont University Hospital, Royal Oak, Mich (F.S.); and Department of Radiology, Stanford University School of Medicine, Stanford, Calif (J.R.T.)
| | - Farnoosh Sokhandon
- From the Department of Gastroenterology and Hepatology, University of Chicago Pritzker School of Medicine, Chicago, Ill (N.S.); Department of Gastroenterology and Hepatology (D.M.K.) and Department of Radiology (F.F.G., H.V.N.), Thomas Jefferson University Hospital, Philadelphia, Pa; Department of Gastroenterology and Hepatology (D.H.B.) and Department of Radiology (M.L.W., A.K., J.L.F.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Gastroenterology and Hepatology (M.L.) and Department of Radiology (B.R.D.), NYU Langone Medical Center, New York, NY; Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Ariz (J.A.L.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.S.G., M.A.A.); Department of Radiology, Boston University Medical Center, Boston, Mass (J.A.S., A.G.); Department of Radiology, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI (D.C.Y., D.J.G.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, William Beaumont University Hospital, Royal Oak, Mich (F.S.); and Department of Radiology, Stanford University School of Medicine, Stanford, Calif (J.R.T.)
| | - David J Grand
- From the Department of Gastroenterology and Hepatology, University of Chicago Pritzker School of Medicine, Chicago, Ill (N.S.); Department of Gastroenterology and Hepatology (D.M.K.) and Department of Radiology (F.F.G., H.V.N.), Thomas Jefferson University Hospital, Philadelphia, Pa; Department of Gastroenterology and Hepatology (D.H.B.) and Department of Radiology (M.L.W., A.K., J.L.F.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Gastroenterology and Hepatology (M.L.) and Department of Radiology (B.R.D.), NYU Langone Medical Center, New York, NY; Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Ariz (J.A.L.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.S.G., M.A.A.); Department of Radiology, Boston University Medical Center, Boston, Mass (J.A.S., A.G.); Department of Radiology, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI (D.C.Y., D.J.G.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, William Beaumont University Hospital, Royal Oak, Mich (F.S.); and Department of Radiology, Stanford University School of Medicine, Stanford, Calif (J.R.T.)
| | - Justin R Tse
- From the Department of Gastroenterology and Hepatology, University of Chicago Pritzker School of Medicine, Chicago, Ill (N.S.); Department of Gastroenterology and Hepatology (D.M.K.) and Department of Radiology (F.F.G., H.V.N.), Thomas Jefferson University Hospital, Philadelphia, Pa; Department of Gastroenterology and Hepatology (D.H.B.) and Department of Radiology (M.L.W., A.K., J.L.F.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Gastroenterology and Hepatology (M.L.) and Department of Radiology (B.R.D.), NYU Langone Medical Center, New York, NY; Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Ariz (J.A.L.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.S.G., M.A.A.); Department of Radiology, Boston University Medical Center, Boston, Mass (J.A.S., A.G.); Department of Radiology, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI (D.C.Y., D.J.G.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, William Beaumont University Hospital, Royal Oak, Mich (F.S.); and Department of Radiology, Stanford University School of Medicine, Stanford, Calif (J.R.T.)
| | - Jeff L Fidler
- From the Department of Gastroenterology and Hepatology, University of Chicago Pritzker School of Medicine, Chicago, Ill (N.S.); Department of Gastroenterology and Hepatology (D.M.K.) and Department of Radiology (F.F.G., H.V.N.), Thomas Jefferson University Hospital, Philadelphia, Pa; Department of Gastroenterology and Hepatology (D.H.B.) and Department of Radiology (M.L.W., A.K., J.L.F.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; Department of Gastroenterology and Hepatology (M.L.) and Department of Radiology (B.R.D.), NYU Langone Medical Center, New York, NY; Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Ariz (J.A.L.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (M.S.G., M.A.A.); Department of Radiology, Boston University Medical Center, Boston, Mass (J.A.S., A.G.); Department of Radiology, Asan Medical Center, Seoul, South Korea (S.H.P.); Department of Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI (D.C.Y., D.J.G.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, William Beaumont University Hospital, Royal Oak, Mich (F.S.); and Department of Radiology, Stanford University School of Medicine, Stanford, Calif (J.R.T.)
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Sengupta N, Kastenberg DM, Bruining DH, Latorre M, Leighton JA, Brook OR, Wells ML, Guglielmo FF, Naringrekar HV, Gee MS, Soto JA, Park SH, Yoo DC, Ramalingam V, Huete A, Khandelwal A, Gupta A, Allen BC, Anderson MA, Dane BR, Sokhandon F, Grand DJ, Tse JR, Fidler JL. The Role of Imaging for Gastrointestinal Bleeding: Consensus Recommendations From the American College of Gastroenterology and Society of Abdominal Radiology. Am J Gastroenterol 2024; 119:438-449. [PMID: 38857483 DOI: 10.14309/ajg.0000000000002631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 12/12/2023] [Indexed: 06/12/2024]
Abstract
Gastrointestinal (GI) bleeding is the most common GI diagnosis leading to hospitalization within the United States. Prompt diagnosis and treatment of GI bleeding is critical to improving patient outcomes and reducing high healthcare utilization and costs. Radiologic techniques including computed tomography angiography, catheter angiography, computed tomography enterography, magnetic resonance enterography, nuclear medicine red blood cell scan, and technetium-99m pertechnetate scintigraphy (Meckel scan) are frequently used to evaluate patients with GI bleeding and are complementary to GI endoscopy. However, multiple management guidelines exist which differ in the recommended utilization of these radiologic examinations. This variability can lead to confusion as to how these tests should be used in the evaluation of GI bleeding. In this document, a panel of experts from the American College of Gastroenterology and Society of Abdominal Radiology provide a review of the radiologic examinations used to evaluate for GI bleeding including nomenclature, technique, performance, advantages, and limitations. A comparison of advantages and limitations relative to endoscopic examinations is also included. Finally, consensus statements and recommendations on technical parameters and utilization of radiologic techniques for GI bleeding are provided.
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Affiliation(s)
- Neil Sengupta
- Department of Gastroenterology and Hepatology, University of Chicago, Chicago, Illinois, USA
| | - David M Kastenberg
- Department of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - David H Bruining
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Melissa Latorre
- Department of Gastroenterology and Hepatology, New York University Langone Health, New York City, New York, USA
| | - Jonathan A Leighton
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Olga R Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Michael L Wells
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Flavius F Guglielmo
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Haresh V Naringrekar
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michael S Gee
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jorge A Soto
- Department of Radiology, Boston University, Boston, Massachusetts, USA
| | - Seong Ho Park
- Department of Radiology, Asan Medical Center, Seoul, South Korea
| | - Don C Yoo
- Department of Radiology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Vijay Ramalingam
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Alvaro Huete
- Department of Radiology, Pontifical Catholic University of Chile, Santiago, Chile
| | | | - Avneesh Gupta
- Department of Radiology, Boston University, Boston, Massachusetts, USA
| | - Brian C Allen
- Department of Radiology, Duke University, Durham, North Carolina, USA
| | - Mark A Anderson
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bari R Dane
- Department of Radiology, New York University Langone Health, New York City, New York, USA
| | - Farnoosh Sokhandon
- Department of Radiology, William Beaumont University Hospital, Royal Oak, Michigan, USA
| | - David J Grand
- Department of Radiology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Justin R Tse
- Department of Radiology, Stanford University, Stanford, California, USA
| | - Jeff L Fidler
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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7
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Omori J, Kaise M, Nagata N, Aoki T, Kobayashi K, Yamauchi A, Yamada A, Ikeya T, Aoyama T, Tominaga N, Sato Y, Kishino T, Ishii N, Sawada T, Murata M, Takao A, Mizukami K, Kinjo K, Fujimori S, Uotani T, Fujita M, Sato H, Suzuki S, Narasaka T, Hayasaka J, Funabiki T, Kinjo Y, Mizuki A, Kiyotoki S, Mikami T, Gushima R, Fujii H, Fuyuno Y, Hikichi T, Toya Y, Narimatsu K, Manabe N, Nagaike K, Kinjo T, Sumida Y, Funakoshi S, Kobayashi K, Matsuhashi T, Komaki Y, Miki K, Watanabe K, Iwakiri K. Characteristics, outcomes, and risk factors of surgery for acute lower gastrointestinal bleeding: nationwide cohort study of 10,342 hematochezia cases. J Gastroenterol 2024; 59:24-33. [PMID: 38006444 DOI: 10.1007/s00535-023-02057-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/23/2023] [Indexed: 11/27/2023]
Abstract
BACKGROUND Current evidence on the surgical rate, indication, procedure, risk factors, mortality, and postoperative rebleeding for acute lower gastrointestinal bleeding (ALGIB) is limited. METHODS We constructed a retrospective cohort of 10,342 patients admitted for acute hematochezia at 49 hospitals (CODE BLUE J-Study) and evaluated clinical data on the surgeries performed. RESULTS Surgery was performed in 1.3% (136/10342) of the cohort with high rates of colonoscopy (87.7%) and endoscopic hemostasis (26.7%). Indications for surgery included colonic diverticular bleeding (24%), colorectal cancer (22%), and small bowel bleeding (16%). Sixty-four percent of surgeries were for hemostasis for severe refractory bleeding. Postoperative rebleeding rates were 22% in patients with presumptive or obscure preoperative identification of the bleeding source and 12% in those with definitive identification. Thirty-day mortality rates were 1.5% and 0.8% in patients with and without surgery, respectively. Multivariate analysis showed that surgery-related risk factors were transfusion need ≥ 6 units (P < 0.001), in-hospital rebleeding (P < 0.001), small bowel bleeding (P < 0.001), colorectal cancer (P < 0.001), and hemorrhoids (P < 0.001). Endoscopic hemostasis was negatively associated with surgery (P = 0.003). For small bowel bleeding, the surgery rate was significantly lower in patients with endoscopic hemostasis as 2% compared to 12% without endoscopic hemostasis. CONCLUSIONS Our cohort study elucidated the outcomes and risks of the surgery. Extensive exploration including the small bowel to identify the source of bleeding and endoscopic hemostasis may reduce unnecessary surgery and improve the management of ALGIB.
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Affiliation(s)
- Jun Omori
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Mitsuru Kaise
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan.
| | - Naoyoshi Nagata
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan.
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan.
| | - Tomonori Aoki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Katsumasa Kobayashi
- Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Atsushi Yamauchi
- Department of Gastroenterology and Hepatology, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takashi Ikeya
- Department of Gastroenterology, St. Luke's International University, Tokyo, Japan
| | - Taiki Aoyama
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Naoyuki Tominaga
- Department of Gastroenterology, Saga-Ken Medical Centre Koseikan, Saga, Japan
| | - Yoshinori Sato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Takaaki Kishino
- Department of Gastroenterology and Hepatology, Center for Digestive and Liver Diseases, Nara City Hospital, Nara, Japan
| | - Naoki Ishii
- Department of Gastroenterology, Tokyo Shinagawa Hospital, Tokyo, Japan
| | - Tsunaki Sawada
- Department of Endoscopy, Nagoya University Hospital, Aichi, Japan
| | - Masaki Murata
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Akinari Takao
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | | | - Ken Kinjo
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Shunji Fujimori
- Department of Gastroenterology, Chiba Hokusoh Hospital, Nippon Medical School, Chiba, Japan
| | - Takahiro Uotani
- Department of Gastroenterology, Japanese Red Cross Shizuoka Hospital, Shizuoka, Japan
| | - Minoru Fujita
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Hiroki Sato
- Division of Gastroenterology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Sho Suzuki
- Department of Gastroenterology and Hepatology, Center for Digestive Disease and Division of Endoscopy, University of Miyazaki Hospital, Miyazaki, Japan
| | - Toshiaki Narasaka
- Department of Gastroenterology, University of Tsukuba, Ibaraki, Japan
- Division of Endoscopic Center, University of Tsukuba Hospital, Ibaraki, Japan
| | | | - Tomohiro Funabiki
- Emergency and Critical Care Center, Saiseikai Yokohamashi Tobu Hospital, Kanagawa, Japan
- Department of Emergency Medicine, Fujita Health University Hospital, Aichi, Japan
| | - Yuzuru Kinjo
- Department of Gastroenterology, Naha City Hospital, Okinawa, Japan
| | - Akira Mizuki
- Department of Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Shu Kiyotoki
- Department of Gastroenterology, Shuto General Hospital, Yamaguchi, Japan
| | - Tatsuya Mikami
- Division of Endoscopy, Hirosaki University Hospital, Aomori, Japan
| | - Ryosuke Gushima
- Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroyuki Fujii
- Department of Gastroenterology and Hepatology, National Hospital Organization Fukuokahigashi Medical Center, Fukuoka, Japan
| | - Yuta Fuyuno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takuto Hikichi
- Department of Gastroenterology, Fukushima Medical University, Fukushima, Japan
| | - Yosuke Toya
- Division of Gastroenterology, Department of Internal Medicine, Iwate Medical University, Iwate, Japan
| | - Kazuyuki Narimatsu
- Department of Internal Medicine, National Defense Medical College, Saitama, Japan
| | - Noriaki Manabe
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Okayama, Japan
| | - Koji Nagaike
- Department of Gastroenterology and Hepatology, Suita Municipal Hospital, Osaka, Japan
| | - Tetsu Kinjo
- Department of Endoscopy, University of the Ryukyus Hospital, Okinawa, Japan
| | - Yorinobu Sumida
- Department of Gastroenterology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Sadahiro Funakoshi
- Department of Gastroenterological Endoscopy, Fukuoka University Hospital, Fukuoka, Japan
| | - Kiyonori Kobayashi
- Department of Gastroenterology, School of Medicine, Kitasato University, Kanagawa, Japan
| | - Tamotsu Matsuhashi
- Department of Gastroenterology and Neurology, Akita University Graduate School of Medicine, Akita, Japan
| | - Yuga Komaki
- Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
- Hygiene and Health Promotion Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Kuniko Miki
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan
| | - Kazuhiro Watanabe
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Katsuhiko Iwakiri
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
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8
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Sano T, Ishikawa T, Azumi M, Sato R, Jimbo R, Kobayashi Y, Sato T, Iwanaga A, Yokoyama J, Honma T. Risk factors for difficult endoscopic hemostasis for colonic diverticular bleeding and efficacy and safety of transcatheter arterial embolization. Medicine (Baltimore) 2023; 102:e35092. [PMID: 37713820 PMCID: PMC10508449 DOI: 10.1097/md.0000000000035092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/15/2023] [Indexed: 09/17/2023] Open
Abstract
This study aimed to investigate the risk factors for difficult endoscopic hemostasis in patients with colonic diverticular bleeding and to evaluate the efficacy and safety of transcatheter arterial embolization (TAE) for colonic diverticular bleeding. This study included 208 patients with colorectal diverticular hemorrhage. The non-interventional radiotherapy group consisted of patients who underwent successful spontaneous hemostasis (n = 131) or endoscopic hemostasis (n = 56), whereas the interventional radiotherapy group consisted of patients who underwent TAE (n = 21). Patient clinical characteristics were compared to identify independent risk factors for the interventional radiotherapy group. Furthermore, the hemostasis success rate, rebleeding rate, complications, and recurrence-free survival were compared between patients who underwent endoscopic hemostasis and those who underwent TAE. Bleeding from the right colon (odds ratio [OR]: 7.86; 95% confidence interval [CI]: 1.6-38.8; P = .0113) and systolic blood pressure <80 mm Hg (OR: 0.108; 95% CI: 0.0189-0.62; P = .0126) were identified as independent risk factors for the interventional radiology group. The hemostasis success rate (P = 1.00), early rebleeding rate (within 30 days) (P = .736), late rebleeding rate (P = 1.00), and recurrence-free survival rate (P = .717) were not significantly different between the patients who underwent TAE and those who underwent endoscopic hemostasis. Patients in the TAE group experienced more complications than those in the endoscopic hemostasis group (P < .001). Complications included mild intestinal ischemia (19.0%) and perforation requiring surgery (4.8%). Patients who required interventional radiotherapy were more likely to bleed from the right colon and presented with a systolic blood pressure of <80 mm Hg. TAE is an effective treatment for patients with colonic diverticular hemorrhage that is refractory to endoscopic hemostasis. However, complications must be monitored carefully.
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Affiliation(s)
- Tomoe Sano
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Toru Ishikawa
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Motoi Azumi
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Ryo Sato
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Ryo Jimbo
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Yuji Kobayashi
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Toshifumi Sato
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Akito Iwanaga
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Junji Yokoyama
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Terasu Honma
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
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9
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Uehara T, Matsumoto S, Tamura H, Kashiura M, Moriya T, Yamanaka K, Shinhata H, Sekine M, Miyatani H, Mashima H. Evaluation of the Jichi Medical University diverticular hemorrhage score in the clinical management of acute diverticular bleeding with emergency or elective endoscopy: A pilot study. PLoS One 2023; 18:e0289698. [PMID: 37611042 PMCID: PMC10446219 DOI: 10.1371/journal.pone.0289698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 07/18/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND AND AIMS Emergency endoscopic hemostasis for colonic diverticular bleeding is effective in preventing serious consequences. However, the low identification rate of the bleeding source makes the procedure burdensome for both patients and providers. We aimed to establish an efficient and safe emergency endoscopy system. METHODS We prospectively evaluated the usefulness of a scoring system (Jichi Medical University diverticular hemorrhage score: JD score) based on our experiences with past cases. The JD score was determined using four criteria: CT evidence of contrast agent extravasation, 3 points; oral anticoagulant (any type) use, 2 points; C-reactive protein ≥1 mg/dL, 1 point; and comorbidity index ≥3, 1 point. Based on the JD score, patients with acute diverticular bleeding who underwent emergency or elective endoscopy were grouped into JD ≥3 or JD <3 groups, respectively. The primary and secondary endpoints were the bleeding source identification rate and clinical outcomes. RESULTS The JD ≥3 and JD <3 groups included 35 and 47 patients, respectively. The rate of bleeding source identification, followed by the hemostatic procedure, was significantly higher in the JD ≥3 group than in the JD <3 group (77% vs. 23%, p <0.001), with a higher JD score associated with a higher bleeding source identification rate. No significant difference was observed between the groups in terms of clinical outcomes, except for a higher incidence of rebleeding at one-month post-discharge and a higher number of patients requiring interventional radiology in the JD ≥3 group than in the JD <3 group. Subgroup analysis showed that successful identification of the bleeding source and hemostasis contributed to a shorter hospital stay. CONCLUSION We established a safe and efficient endoscopic scoring system for treating colonic diverticular bleeding. The higher the JD score, the higher the bleeding source identification, leading to a successful hemostatic procedure. Elective endoscopy was possible in the JD <3 group when vital signs were stable.
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Affiliation(s)
- Takeshi Uehara
- Department of Gastroenterology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Satohiro Matsumoto
- Department of Gastroenterology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Hiroyuki Tamura
- Department of Emergency Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masahiro Kashiura
- Department of Emergency Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Takashi Moriya
- Department of Emergency Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Kenichi Yamanaka
- Department of Gastroenterology, Saitama Citizens Medical Center, Saitama, Japan
| | - Hakuei Shinhata
- Department of Gastroenterology, Saitama Citizens Medical Center, Saitama, Japan
| | - Masanari Sekine
- Department of Gastroenterology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Hiroyuki Miyatani
- Department of Gastroenterology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Hirosato Mashima
- Department of Gastroenterology, Jichi Medical University Saitama Medical Center, Saitama, Japan
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10
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Minici R, Fontana F, Venturini M, Guzzardi G, Piacentino F, Spinetta M, Bertucci B, Serra R, Costa D, Ielapi N, Coppola A, Guerriero P, Apollonio B, Santoro R, Mgjr Research Team, Brunese L, Laganà D. A Multicenter Retrospective Cohort Study Evaluating the Clinical Outcomes of Patients with Coagulopathy Undergoing Transcatheter Arterial Embolization (TAE) for Acute Non-Neurovascular Bleeding. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1333. [PMID: 37512144 PMCID: PMC10383976 DOI: 10.3390/medicina59071333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/04/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023]
Abstract
Background and Objectives: Transcatheter arterial embolization (TAE) is the mainstay of treatment for acute major hemorrhage, even in patients with coagulopathy and spontaneous bleeding. Coagulopathy is associated with worsening bleeding severity and higher mortality and clinical failure rates. Furthermore, some unanswered questions remain, such as the definition of coagulopathy, the indication for TAE or conservative treatment, and the choice of embolic agent. This study aims to assess the efficacy and safety of TAE for spontaneous non-neurovascular acute bleeding in patients with coagulopathy. Materials and Methods: This study is a multicenter analysis of retrospectively collected data of consecutive patients with coagulopathy who had undergone, from January 2018 to May 2023, transcatheter arterial embolization for the management of spontaneous hemorrhages. Results: During the study interval (January 2018-May 2023), 120 patients with coagulopathy underwent TAE for spontaneous non-neurovascular acute bleeding. The abdominal wall was the most common bleeding site (72.5%). The most commonly used embolic agent was polyvinyl alcohol (PVA) particles or microspheres (25.0%), whereas coils and gelatin sponge together accounted for 32.5% of the embolic agents used. Technical success was achieved in all cases, with a 92.5% clinical success rate related to 9 cases of rebleeding. Complications were recorded in 12 (10%) patients. Clinical success was significantly better in the group of patients who underwent correction of the coagulopathy within 24 h of TAE. Conclusions: Transcatheter arterial embolization (TAE) is effective and safe for the management of acute non-neurovascular bleeding in patients with coagulopathy. Correction of coagulopathy should not delay TAE and vice versa, as better clinical outcomes were noted in the subgroup of patients undergoing correction of coagulopathy within 24 h of TAE.
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Affiliation(s)
- Roberto Minici
- Radiology Unit, Dulbecco University Hospital, 88100 Catanzaro, Italy
| | - Federico Fontana
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy
- School of Medicine and Surgery, Insubria University, 21100 Varese, Italy
| | - Massimo Venturini
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy
- School of Medicine and Surgery, Insubria University, 21100 Varese, Italy
| | - Giuseppe Guzzardi
- Radiology Unit, Maggiore della Carità University Hospital, 28100 Novara, Italy
| | - Filippo Piacentino
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy
| | - Marco Spinetta
- Radiology Unit, Maggiore della Carità University Hospital, 28100 Novara, Italy
| | - Bernardo Bertucci
- Radiology Unit, Dulbecco University Hospital, 88100 Catanzaro, Italy
| | - Raffaele Serra
- Vascular Surgery Unit, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Dulbecco University Hospital, 88100 Catanzaro, Italy
| | - Davide Costa
- Department of Law, Economics and Sociology, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy
| | - Nicola Ielapi
- Department of Public Health and Infectious Disease, Sapienza University of Rome, 00185 Rome, Italy
| | - Andrea Coppola
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy
| | - Pasquale Guerriero
- Radiology Unit, Santobono-Pausilipon Hospital, 80129 Naples, Italy
- Department of Medicine and Health Sciences, University of Molise, 86100 Campobasso, Italy
| | | | - Rita Santoro
- Haemophilia and Thrombosis Center, Dulbecco University Hospital, 88100 Catanzaro, Italy
| | | | - Luca Brunese
- Department of Medicine and Health Sciences, University of Molise, 86100 Campobasso, Italy
- Scientific Committee of the Italian National Institute of Health (Istituto Superiore di Sanità, ISS), 00161 Rome, Italy
| | - Domenico Laganà
- Radiology Unit, Dulbecco University Hospital, 88100 Catanzaro, Italy
- Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy
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11
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Choi TW, Kwon Y, Kim J, Won JH. [Endovascular Treatment for Vascular Injuries of the Extremities]. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2023; 84:846-854. [PMID: 37559804 PMCID: PMC10407075 DOI: 10.3348/jksr.2023.0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/16/2023] [Accepted: 07/08/2023] [Indexed: 08/11/2023]
Abstract
Vascular injuries of the extremities are associated with a high mortality rate. Conventionally, open surgery is the treatment of choice for peripheral vascular injuries. However, rapid development of devices and techniques in recent years has significantly increased the utilization and clinical application of endovascular treatment. Endovascular options for peripheral vascular injuries include stent-graft placement and embolization. The surgical approach is difficult in cases of axillo-subclavian or iliac artery injuries, and stent-graft placement is a widely accepted alternative to open surgery. Embolization can be considered for arterial injuries associated with active bleeding, pseudoaneurysms, and arteriovenous fistula and in patients in whom embolization can be safely performed without a risk of ischemic complications in the extremities. Endovascular treatment is a minimally invasive procedure and is useful as a simultaneous diagnostic and therapeutic approach, which serve as advantages of this technique that is widely utilized for vascular injuries of the extremities.
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12
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Gong T, Tsauo J, Ding M, Jin L, Duan F, Yu Y, Li X. Transcatheter arterial embolization for cancer-related non-variceal upper gastrointestinal bleeding: A multicenter retrospective study of 107 patients. Diagn Interv Imaging 2023; 104:60-66. [PMID: 36114135 DOI: 10.1016/j.diii.2022.07.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to retrospectively evaluate the outcome of transcatheter arterial embolization (TAE) in the treatment of cancer-related non-variceal upper gastrointestinal bleeding (UGIB). MATERIALS AND METHODS One-hundred and seven patients who underwent TAE for the treatment of cancer-related non-variceal UGIB at five institutions between June 2016 and May 2019 were retrospectively included. There were 78 men and 29 women, with a mean age of 60.6 ± 13.2 (SD) (age range: 31-87 years). Clinical success was defined as no rebleeding within 30 days after TAE. Rebleeding was defined as non-variceal UGIB resulting in a decrease in hemoglobin > 2 g/dL within 24 h. The Kaplan-Meier method was used to estimate actuarial probabilities of rebleeding and survival within 30 days after TAE. Univariable and multivariable analyses were performed to identify variables associated with clinical success and 30-day mortality. RESULTS Technical success was achieved in 106 out of 107 patients (99.1%). Positive angiographic findings (contrast extravasation and pseudoaneurysm) were observed in 30/107 patients (28.0%). Empiric embolization was performed in 77/107 patients (72.0%). Clinical success was achieved in 60/107 patients (56.1%). The 3-day, 7-day, and 30-day actuarial probabilities of rebleeding were 21.5%, 31.0%, and 44.6%, respectively. No variables were identified as predictors of clinical success. Nineteen patients (19/107; 17.8%) died within 30 days after TAE; of them, 14 (14/107; 13.1%) died due to bleeding-related causes. The 3-day, 7-day, and 30-day actuarial probabilities of survival were 91.6%, 88.8%, and 77.4%, respectively. A baseline hemoglobin level of ≤ 60 g/L (Odds ratio [OR]: 3.376; 95% confidence interval [CI]: 1.223-9.318; P = 0.019) and clinical failure (OR: 6.149; 95% CI: 2.113-17.893; P = 0.001) were identified as predictors of 30-day mortality. Major complications (gastrointestinal perforation) occurred in one patient (1/107; 0.9%). Minor complications (abdominal pain, fever, and vomiting) occurred in 19 patients (19/107; 17.8%). CONCLUSION TAE is a safe treatment option for patients with cancer-related non-variceal UGIB, and seems to be effective in more than half of these patients.
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Affiliation(s)
- Tao Gong
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Jiaywei Tsauo
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Mingchao Ding
- Department of Peripheral Vascular Intervention, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing 100049, China
| | - Long Jin
- Department of Interventional Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Feng Duan
- Department of Interventional Radiology, The First Medical Center of PLA General Hospital, Beijing 100853, China
| | - Youtao Yu
- Department of Interventional Radiology, The Fourth Medical Center of PLA General Hospital, Beijing 100048, China
| | - Xiao Li
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China.
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13
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Rabuffi P, Bruni A, Antonuccio EMG, Saraceni A, Vagnarelli S. Transarterial embolization of acute non-neurologic bleeding using Ethylene Vynil Alcohol Copolymer: a single-Centre retrospective study. CVIR Endovasc 2023; 6:2. [PMID: 36697892 PMCID: PMC9877256 DOI: 10.1186/s42155-023-00347-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 01/04/2023] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND To evaluate feasibility, safety and effectiveness of transarterial embolization of acute non-neurologic hemorrhage with Ethylene Vynil Alcohol Copolymer (EVOH). METHODS Between January 2018 and June 2021, 211 patients (male 123, mean age 69.7 y + 17.9) who underwent transarterial embolization with Onyx™ for acute non-neurologic arterial bleeding were retrospectively reviewed. Most frequent etiology of bleeding was post-operative (89/211, 42.2%), trauma (62/211, 29.4%) and tumor (18/211, 8.5%). Technical success was defined as the angiographic evidence of target vessel complete occlusion. Clinical success was defined as resolution of bleeding. Any rebleeding within the primitive site, requiring a new intervention during the first 30-days following embolization, was considered a clinical failure. Occurrence of procedure-related complication and mortality within 30 days of the embolization were examined. RESULTS A total of 229 embolization procedures was performed in 211 pts.; technical success rate was 99.5% (210/211 pts). Clinical success rate was 94.3% (199/211 pts). In 11 patients (5.2%) a reintervention was needed because of a rebleeding occurring within the primitive site, whereas in five patients (2.4%) rebleeding occurred within a site different from the primitive. Factors more often associated with clinical failure were coagulopathy/ongoing anticoagulant therapy (5/11, 45.4%), and post-operative etiology (3/11, 27.3%). EVOH was used as the sole embolic agent in 214/229 procedures (93.4%), in association with coils in 11 cases (4.8%), and with microparticles in 4 cases (1.7%). In the present series, major complications occurred in 6 cases (2.8%): respectively, four cases (1.9%) of colonic ischemia and two groin hematomas (0.9%) with active extravasation were observed. 26 (12.3%) patients died during the follow-up. CONCLUSION Embolization of acute arterial bleeding with EVOH as a first-line embolic agent is feasible, safe and effective.
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Affiliation(s)
- Paolo Rabuffi
- grid.415032.10000 0004 1756 8479Unit of Interventional Radiology, Azienda Ospedaliera San Giovanni Addolorata, Via dell’Amba Aradam 9, 00184 Rome, Italy
| | - Antonio Bruni
- grid.415032.10000 0004 1756 8479Unit of Interventional Radiology, Azienda Ospedaliera San Giovanni Addolorata, Via dell’Amba Aradam 9, 00184 Rome, Italy
| | - Enzo Maria Gabriele Antonuccio
- grid.415032.10000 0004 1756 8479Unit of Interventional Radiology, Azienda Ospedaliera San Giovanni Addolorata, Via dell’Amba Aradam 9, 00184 Rome, Italy
| | - Andrea Saraceni
- grid.415032.10000 0004 1756 8479Unit of Interventional Radiology, Azienda Ospedaliera San Giovanni Addolorata, Via dell’Amba Aradam 9, 00184 Rome, Italy
| | - Simone Vagnarelli
- grid.415032.10000 0004 1756 8479Unit of Interventional Radiology, Azienda Ospedaliera San Giovanni Addolorata, Via dell’Amba Aradam 9, 00184 Rome, Italy
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Kim HC, Jeong YS, Han K, Kim GM. Transcatheter arterial embolization of cystic artery bleeding. Front Surg 2023; 10:1160149. [PMID: 37114149 PMCID: PMC10126234 DOI: 10.3389/fsurg.2023.1160149] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 03/23/2023] [Indexed: 04/29/2023] Open
Abstract
Purpose The purpose of this study is to assess the safety and clinical outcomes of transcatheter arterial embolization (TAE) via the cystic artery for treating patients with bleeding from the cystic artery. Materials and Methods This retrospective study included 20 patients who underwent TAE via the cystic artery between January 2010 and May 2022. Radiological images and clinical data were reviewed to evaluate causes of bleeding, procedure-related complications, and clinical outcomes. Technical success was defined as the disappearance of contrast media extravasation or pseudoaneurysm, as demonstrated on completion angiography. Clinical success was defined as discharge from the hospital without any bleeding-related issues. Results Hemorrhagic cholecystitis (n = 10) was the most common cause of bleeding, followed by iatrogenic (n = 4), duodenal ulcer (n = 3), tumor (n = 2), and trauma (n = 1). Technical success was achieved in all cases, and clinical success was achieved in 70% (n = 14) of patients. Three patients developed ischemic cholecystitis as a complication. Six patients with clinical failure died within 45 days after embolization. Conclusion TAE through the cystic artery has a high technical success rate in treating cystic artery bleeding, but clinical failure remains a common occurrence due to concurrent medical conditions and the development of ischemic cholecystitis.
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Affiliation(s)
- Hyo-Cheol Kim
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yun Soo Jeong
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kichang Han
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Gyoung Min Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- Correspondence: Gyoung Min Kim
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15
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Lee S, Kim T, Han SC, Pak H, Jeon HH. Transcatheter arterial embolization for gastrointestinal bleeding: Clinical outcomes and prognostic factors predicting mortality. Medicine (Baltimore) 2022; 101:e29342. [PMID: 35945735 PMCID: PMC9351940 DOI: 10.1097/md.0000000000029342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
We evaluated clinical outcome and prognostic factors predicting mortality of transcatheter arterial embolization (TAE) for acute gastrointestinal (GI) bleeding. Fifty-nine patients (42 men, 17 women; mean age 66.1 ± 17.0) who underwent 59 TAE procedures for GI bleeding during 2013-2018 were retrospectively evaluated. Clinical outcomes included technical success, adverse events, and rebleeding and mortality rate within 30 days. The technical success rate was 100%. Angiography showed contrast extravasation in 41 (69.5%) patients and indirect signs of bleeding in 16 (27.1%) patients. Two (3.4%) patients underwent prophylactic embolization. TAE-related adverse events occurred in 7 (11.9%) patients; adverse events were more common for mid GI or lower GI bleeding than for upper GI bleeding (22.6% vs 0%, P = 0.007). Rebleeding within 30 days was observed in 22 (37.3%) patients after TAE. Coagulopathy was a prognostic factor for rebleeding (odds ratio [OR] = 3.53, 95% confidence interval 1.07-11.67, P = .038). Mortality within 30 days occurred in 11 (18.6%) patients. Coagulopathy (OR = 24, 95% confidence interval 2.56-225.32, P = .005) was an independent prognostic factor for mortality within 30 days. TAE is an effective, safe, and potentially lifesaving procedure for GI bleeding. If possible, coagulopathy should be corrected before TAE as it may reduce rebleeding and mortality.
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Affiliation(s)
- Shinhaeng Lee
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Taehwan Kim
- Department of Radiology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Seung Chul Han
- Department of Radiology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Haeyong Pak
- Institute of Health Insurance & Clinical Research, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Han Ho Jeon
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
- *Correspondence: Han Ho Jeon, Division of Gastroenterology, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea, 100 Ilsan-ro, Ilsan-donggu, Goyang 10444, Korea (e-mail: )
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16
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Minimally Invasive Interventional Procedures for Metastatic Bone Disease: A Comprehensive Review. Curr Oncol 2022; 29:4155-4177. [PMID: 35735441 PMCID: PMC9221897 DOI: 10.3390/curroncol29060332] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/03/2022] [Accepted: 06/06/2022] [Indexed: 11/16/2022] Open
Abstract
Metastases are the main type of malignancy involving bone, which is the third most frequent site of metastatic carcinoma, after lung and liver. Skeletal-related events such as intractable pain, spinal cord compression, and pathologic fractures pose a serious burden on patients’ quality of life. For this reason, mini-invasive treatments for the management of bone metastases were developed with the goal of pain relief and functional status improvement. These techniques include embolization, thermal ablation, electrochemotherapy, cementoplasty, and MRI-guided high-intensity focused ultrasound. In order to achieve durable pain palliation and disease control, mini-invasive procedures are combined with chemotherapy, radiation therapy, surgery, or analgesics. The purpose of this review is to summarize the recently published literature regarding interventional radiology procedures in the treatment of cancer patients with bone metastases, focusing on the efficacy, complications, local disease control and recurrence rate.
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17
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McCaughey C, Healy GM, Al Balushi H, Maher P, McCavana J, Lucey J, Cantwell CP. Patient radiation dose during angiography and embolization for abdominal hemorrhage: the influence of CT angiography, fluoroscopy system, patient and procedural variables. CVIR Endovasc 2022; 5:12. [PMID: 35171363 PMCID: PMC8850522 DOI: 10.1186/s42155-022-00284-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 01/06/2022] [Indexed: 11/19/2022] Open
Abstract
Background Angiography and embolization (AE) is a lifesaving, high radiation dose procedure for treatment of abdominal arterial hemorrhage (AAH). Interventional radiologists have utilized pre-procedure CT angiography (CTA) and newer fluoroscopic systems in an attempt to reduce radiation dose and procedure time. Purpose To study the factors contributing to the radiation dose of AE for AAH and to compare to the reference standard. Materials and methods This retrospective single-centre observational cohort study identified 154 consecutive AE procedures in 138 patients (median age 65 years; interquartile range 54–77; 103 men) performed with a C-arm fluoroscopic system (Axiom Artis DTA or Axiom Artis Q (Siemens Healthineers)), between January 2010 and December 2017. Parameters analysed included: demographics, fluoroscopy system, bleeding location, body mass index (BMI), preprocedural CT, air kerma-area product (PKA), reference air kerma (Ka,r), fluoroscopy time (FT) and the number of digital subtraction angiography (DSA) runs. Factors affecting dose were assessed using Mann–Whitney U, Kruskal–Wallis one-way ANOVA and linear regression. Results Patients treated with the new angiographic system (NS) had a median PKA, median Ka,r, Q3 PKA and Q3 Ka,r that were 74% (p < 0.0005), 66%(p < 0.0005), 55% and 52% lower respectively than those treated with the old system (OS). This dose reduction was consistent for each bleeding location (upper GI, Lower GI and extraluminal). There was no difference in PKA (p = 0.452), Ka,r (p = 0.974) or FT (p = 0.179), between those who did (n = 137) or did not (n = 17) undergo pre-procedure CTA. Other factors significantly influencing radiation dose were: patient BMI and number of DSA runs. A multivariate model containing these variables accounts for 15.2% of the variance in Ka,r (p < 0.005) and 45.9% of the variance of PKA (p < 0.005). Conclusion Radiation dose for AE in AAH is significantly reduced by new fluoroscopic technology. Higher patient body mass index is an independent key parameter affecting patient dose. Radiation dose was not influenced by haemorrhage site or performance of pre-procedure CTA.
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Affiliation(s)
| | - Gerard M Healy
- Department of Radiology, St Vincent's University Hospital, Dublin, Ireland
| | | | - Patrice Maher
- Department of Radiology, St Vincent's University Hospital, Dublin, Ireland
| | - Jackie McCavana
- Department of Medical Physics and Clinical Engineering, St Vincent's University Hospital, Dublin, Ireland
| | - Julie Lucey
- Department of Medical Physics and Clinical Engineering, St Vincent's University Hospital, Dublin, Ireland
| | - Colin P Cantwell
- Department of Radiology, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
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18
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Li MF, Liang HL, Chiang CL, Lin YH. Management of acute lower gastrointestinal bleeding by pharmaco-induced vasospasm embolization therapy. J Chin Med Assoc 2022; 85:233-239. [PMID: 35175244 DOI: 10.1097/jcma.0000000000000649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND To report the clinical outcomes of vasospasm embolization technique in treating lower gastrointestinal bleeding (LGIB). METHODS Fifty LGIB patients (32 men and 18 women; mean age, 70.4 years) with positive contrast extravasation on multidetector computed tomography were treated with pharmaco-induced vasospasm embolization by semiselective catheterization technique. Distal rectal bleeding was excluded. The bleedings in three patients were considered to be tumor related. Eighteen underwent regular hemodialysis, and 22 showed unstable hemodynamic at intervention. RESULTS Forty-two bleeders were found in superior mesenteric territory and eight in the inferior mesenteric territory. Successful, immediate hemostasis was achieved in 49 (98%) patients. Early recurrent bleeding (<30 days) was found in 13 (26.5%) patients with 6 local rebleeding (12.2%), 5 new-foci bleeding (10.2%), and 2 uncertain foci bleeding (4.1%). Repeated vasospasm embolization therapy was given to five patients, with successful hemostasis in four. All the three tumor-related bleeding patients undergoing vasospasm embolization had ceased bleeding and discharged. Patient-based primary and overall clinical successes were achieved in 73.5% and 83.7%, and lesion-based primary and overall clinical successes were 83.0% and 86.7%, respectively. The 30-day mortality rate was 21.3%, and the 1- and 2-year survival rates were 51.5% and 43.8%. No major procedure-related complications (eg, bowel ischemia) were encountered. CONCLUSION This study confirmed our prior preliminary conclusion that pharmaco-induced vasospasm embolization is easy, safe, and effective for LGIB. This treatment may be considered the first-line alternative approach for LGIB, especially for patients of advanced age with complex medical problems and/or when vasa rectal embolization isn't feasible.
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Affiliation(s)
- Ming-Feng Li
- Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- Department of Medical Imaging and Radiology, Shu-Zen Junior College of Medicine and Management, Kaohsiung, Taiwan, ROC
| | - Huei-Lung Liang
- Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- Department of Medical Imaging and Radiology, Shu-Zen Junior College of Medicine and Management, Kaohsiung, Taiwan, ROC
| | - Chia-Ling Chiang
- Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Yih-Huie Lin
- Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
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19
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Ueda T, Mori H, Sekiguchi T, Mishima Y, Sano M, Teramura E, Fujimoto R, Kaneko M, Nakae H, Fujisawa M, Matsushima M, Suzuki H. Successful endoscopic hemostasis compared to transarterial embolization in patients with colonic diverticular bleeding. J Clin Biochem Nutr 2022; 70:283-289. [PMID: 35692675 PMCID: PMC9130068 DOI: 10.3164/jcbn.21-123] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 09/13/2021] [Indexed: 11/22/2022] Open
Affiliation(s)
- Takashi Ueda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine
| | - Hideki Mori
- Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven
| | - Tatsuya Sekiguchi
- Department of Diagnostic Radiology, Tokai University School of Medicine
| | - Yusuke Mishima
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine
| | - Masaya Sano
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine
| | - Erika Teramura
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine
| | - Ryutaro Fujimoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine
| | - Motoki Kaneko
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine
| | - Hirohiko Nakae
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine
| | - Mia Fujisawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine
| | - Masashi Matsushima
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine
| | - Hidekazu Suzuki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine
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20
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Seyferth E, Dai R, Ronald J, Martin JG, Sag AA, Befera N, Pabon-Ramos WM, Suhocki PV, Smith TP, Kim CY. Safety Profile of Particle Embolization for Treatment of Acute Lower Gastrointestinal Bleeding. J Vasc Interv Radiol 2021; 33:286-294. [PMID: 34798292 DOI: 10.1016/j.jvir.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 10/21/2021] [Accepted: 11/07/2021] [Indexed: 10/19/2022] Open
Abstract
PURPOSE To assess ischemic adverse events following particle embolization when used as a second-line embolic to coil embolization for treatment of acute lower gastrointestinal bleeding(LGIB). MATERIALS AND METHODS This single-institution retrospective study examined 154 procedures where embolization was attempted for LGIB. In 122 patients (64 males, mean age 69.9 years), embolization was successfully performed using microcoils in 73 procedures, particles in 34 procedures, and both microcoils and particles in 27 procedures. Particles were used as second-line only when coil embolization was infeasible or inadequate. Technical success was defined as angiographic cessation of active extravasation after embolization. Clinical success was defined as absence of recurrent bleeding within 30 days of embolization. RESULTS Technical success for embolization of LGIB was achieved in 87.0% of cases (134/154), and clinical success was 76.1%(102/134) among technically successful cases. Clinical success was 82.2%(60/73) for coils alone and 68.9%(42/61) for particles +/- coils. Severe adverse events involving embolization-induced bowel ischemia occurred in 3 of 56 patients who underwent particle embolization +/- coils (5.3%) versus zero out of 66 patients when coils alone were used (P=0.09). In patients who had colonoscopy or bowel resection within 2 weeks of embolization, ischemic findings attributable to the embolization were found in 3 of 15 who underwent embolization with coils alone, versus 8 of 18 who underwent embolization with particles +/- coils (p=0.27). CONCLUSION Particle embolization for treatment of LGIB as second line to coil embolization was associated with a 68.9% clinical success rate and a 5.3% rate of ischemia-related adverse events.
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Affiliation(s)
- Elisabeth Seyferth
- Division of Interventional Radiology, Duke University Medical Center, Durham, NC 27710
| | - Rui Dai
- Division of Interventional Radiology, Duke University Medical Center, Durham, NC 27710
| | - James Ronald
- Division of Interventional Radiology, Duke University Medical Center, Durham, NC 27710
| | - Jonathan G Martin
- Division of Interventional Radiology, Duke University Medical Center, Durham, NC 27710
| | - Alan A Sag
- Division of Interventional Radiology, Duke University Medical Center, Durham, NC 27710
| | - Nicholas Befera
- Division of Interventional Radiology, Duke University Medical Center, Durham, NC 27710
| | - Waleska M Pabon-Ramos
- Division of Interventional Radiology, Duke University Medical Center, Durham, NC 27710
| | - Paul V Suhocki
- Division of Interventional Radiology, Duke University Medical Center, Durham, NC 27710
| | - Tony P Smith
- Division of Interventional Radiology, Duke University Medical Center, Durham, NC 27710
| | - Charles Y Kim
- Division of Interventional Radiology, Duke University Medical Center, Durham, NC 27710
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21
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Reitano E, de'Angelis N, Bianchi G, Laera L, Spiliopoulos S, Calbi R, Memeo R, Inchingolo R. Current trends and perspectives in interventional radiology for gastrointestinal cancers. World J Radiol 2021; 13:314-326. [PMID: 34786187 PMCID: PMC8567440 DOI: 10.4329/wjr.v13.i10.314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 06/12/2021] [Accepted: 10/15/2021] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal (GI) cancers often require a multidisciplinary approach involving surgeons, endoscopists, oncologists, and interventional radiologists to diagnose and treat primitive cancers, metastases, and related complications. In this context, interventional radiology (IR) represents a useful minimally-invasive tool allowing to reach lesions that are not easily approachable with other techniques. In the last years, through the development of new devices, IR has become increasingly relevant in the context of a more comprehensive management of the oncologic patient. Arterial embolization, ablative techniques, and gene therapy represent useful and innovative IR tools in GI cancer treatment. Moreover, IR can be useful for the management of GI cancer-related complications, such as bleeding, abscesses, GI obstructions, and neurological pain. The aim of this study is to show the principal IR techniques for the diagnosis and treatment of GI cancers and related complications, as well as to describe the future perspectives of IR in this oncologic field.
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Affiliation(s)
- Elisa Reitano
- Division of General Surgery, Department of Translational Medicine, University of Eastern Piedmont, Novara 28100, Italy
| | - Nicola de'Angelis
- Unit of Minimally Invasive and Robotic Digestive Surgery, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti 70021, Italy
| | - Giorgio Bianchi
- Unit of Minimally Invasive and Robotic Digestive Surgery, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti 70021, Italy
| | - Letizia Laera
- Department of Oncology, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti 70021, Italy
| | - Stavros Spiliopoulos
- 2nd Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Athens 12461, Greece
| | - Roberto Calbi
- Department of Radiology, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti 70124, Italy
| | - Riccardo Memeo
- Unit of Hepato-Pancreatic-Biliary Surgery, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti 70021, Italy
| | - Riccardo Inchingolo
- Interventional Radiology Unit, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti 70021, Italy
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22
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Fontana F, Piacentino F, Ossola C, Coppola A, Curti M, Macchi E, De Marchi G, Floridi C, Ierardi AM, Carrafiello G, Segato S, Carcano G, Venturini M. Transcatheter Arterial Embolization in Acute Non-Variceal Gastrointestinal Bleedings: A Ten-Year Single-Center Experience in 91 Patients and Review of the Literature. J Clin Med 2021; 10:jcm10214979. [PMID: 34768505 PMCID: PMC8584454 DOI: 10.3390/jcm10214979] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/12/2021] [Accepted: 10/21/2021] [Indexed: 12/13/2022] Open
Abstract
Objective: To report the safety and efficacy of trans-arterial embolization (TAE) for upper gastrointestinal bleeding (UGIB) and lower gastrointestinal bleeding (LGIB) due to different etiologies in 91 patients for ten years. Methods: A retrospective analysis of GIB treated between January 2010 and December 2020 was performed. TAE was performed using different embolic agents (coils, particles, glue, gelatin sponge, and EVOH-based agents). Technical success, secondary technical success, clinical success, and complications were evaluated. Results: Technical success was achieved in 74/91 (81.32%) patients. Seventeen patients (18.68%) required re-intervention. Secondary technical success was achieved in all cases (100.0%). Clinical success was achieved in 81/91 patients (89.01%). No major complications were recorded; overall, minor complications occurred in 20/91 patients. Conclusions: TAE is a technically feasible and safe therapeutic option for patients with GIB from a known or blind anatomic source where endoscopic therapy has failed or is deemed unfeasible.
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Affiliation(s)
- Federico Fontana
- Diagnostic and Interventional Radiology Department, Ospedale di Circolo, ASST dei Sette Laghi, 21100 Varese, Italy; (F.F.); (F.P.); (A.C.); (E.M.); (G.D.M.); (M.V.)
- School of Medicine and Surgery, Università degli Studi dell’Insubria, 21100 Varese, Italy; (M.C.); (G.C.)
| | - Filippo Piacentino
- Diagnostic and Interventional Radiology Department, Ospedale di Circolo, ASST dei Sette Laghi, 21100 Varese, Italy; (F.F.); (F.P.); (A.C.); (E.M.); (G.D.M.); (M.V.)
- School of Medicine and Surgery, Università degli Studi dell’Insubria, 21100 Varese, Italy; (M.C.); (G.C.)
| | - Christian Ossola
- School of Medicine and Surgery, Università degli Studi dell’Insubria, 21100 Varese, Italy; (M.C.); (G.C.)
- Correspondence: ; Tel.: +39-0332-393609
| | - Andrea Coppola
- Diagnostic and Interventional Radiology Department, Ospedale di Circolo, ASST dei Sette Laghi, 21100 Varese, Italy; (F.F.); (F.P.); (A.C.); (E.M.); (G.D.M.); (M.V.)
| | - Marco Curti
- School of Medicine and Surgery, Università degli Studi dell’Insubria, 21100 Varese, Italy; (M.C.); (G.C.)
| | - Edoardo Macchi
- Diagnostic and Interventional Radiology Department, Ospedale di Circolo, ASST dei Sette Laghi, 21100 Varese, Italy; (F.F.); (F.P.); (A.C.); (E.M.); (G.D.M.); (M.V.)
| | - Giuseppe De Marchi
- Diagnostic and Interventional Radiology Department, Ospedale di Circolo, ASST dei Sette Laghi, 21100 Varese, Italy; (F.F.); (F.P.); (A.C.); (E.M.); (G.D.M.); (M.V.)
| | - Chiara Floridi
- Department of Radiology, University Hospital “Umberto I—Lancisi—Salesi”, 60100 Ancona, Italy;
| | - Anna Maria Ierardi
- Department of Radiology, Foundation IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, University of Milan, 20122 Milan, Italy; (A.M.I.); (G.C.)
| | - Gianpaolo Carrafiello
- Department of Radiology, Foundation IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, University of Milan, 20122 Milan, Italy; (A.M.I.); (G.C.)
| | - Sergio Segato
- Gastroenterology Department, Ospedale di Circolo, ASST dei Sette Laghi, 21100 Varese, Italy;
| | - Giulio Carcano
- School of Medicine and Surgery, Università degli Studi dell’Insubria, 21100 Varese, Italy; (M.C.); (G.C.)
- Surgery Department, Ospedale di Circolo, ASST dei Sette Laghi, 21100 Varese, Italy
| | - Massimo Venturini
- Diagnostic and Interventional Radiology Department, Ospedale di Circolo, ASST dei Sette Laghi, 21100 Varese, Italy; (F.F.); (F.P.); (A.C.); (E.M.); (G.D.M.); (M.V.)
- School of Medicine and Surgery, Università degli Studi dell’Insubria, 21100 Varese, Italy; (M.C.); (G.C.)
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Karuppasamy K, Kapoor BS, Fidelman N, Abujudeh H, Bartel TB, Caplin DM, Cash BD, Citron SJ, Farsad K, Gajjar AH, Guimaraes MS, Gupta A, Higgins M, Marin D, Patel PJ, Pietryga JA, Rochon PJ, Stadtlander KS, Suranyi PS, Lorenz JM. ACR Appropriateness Criteria® Radiologic Management of Lower Gastrointestinal Tract Bleeding: 2021 Update. J Am Coll Radiol 2021; 18:S139-S152. [PMID: 33958109 DOI: 10.1016/j.jacr.2021.02.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 02/17/2021] [Indexed: 02/07/2023]
Abstract
Diverticulosis remains the commonest cause for acute lower gastrointestinal tract bleeding (GIB). Conservative management is initially sufficient for most patients, followed by elective diagnostic tests. However, if acute lower GIB persists, it can be investigated with colonoscopy, CT angiography (CTA), or red blood cell (RBC) scan. Colonoscopy can identify the site and cause of bleeding and provide effective treatment. CTA is a noninvasive diagnostic tool that is better tolerated by patients, can identify actively bleeding site or a potential bleeding lesion in vast majority of patients. RBC scan can identify intermittent bleeding, and with single-photon emission computed tomography, can more accurately localize it to a small segment of bowel. If patients are hemodynamically unstable, CTA and transcatheter arteriography/embolization can be performed. Colonoscopy can also be considered in these patients if rapid bowel preparation is feasible. Transcatheter arteriography has a low rate of major complications; however, targeted transcatheter embolization is only feasible if extravasation is seen, which is more likely in hemodynamically unstable patients. If bleeding site has been previously localized but the intervention by colonoscopy and transcatheter embolization have failed to achieve hemostasis, surgery may be required. Among patients with obscure (nonlocalized) recurrent bleeding, capsule endoscopy and CT enterography can be considered to identify culprit mucosal lesion(s). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | - Nicholas Fidelman
- Panel Vice-Chair, University of California San Francisco, San Francisco, California
| | - Hani Abujudeh
- Detroit Medical Center, Tenet Healthcare and Envision Radiology Physician Services, Detroit, Michigan
| | | | - Drew M Caplin
- Zucker School of Medicine at Hofstra Northwell, Hempstead, New York, Chair, Committee on Practice Parameters Interventional Radiology, American College of Radiology, Program Director, Interventional Radiology Residency, Zucker School of Medicine NSLIJ
| | - Brooks D Cash
- University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas, American Gastroenterological Association
| | | | - Khashayar Farsad
- Oregon Health and Science University, Portland, Oregon, Vice Chair, Department of Interventional Radiology, Oregon Health & Science University
| | - Aakash H Gajjar
- PRiSMA Proctology Surgical Medicine & Associates, Houston, Texas, American College of Surgeons
| | | | - Amit Gupta
- Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | | | - Daniele Marin
- Duke University Medical Center, Durham, North Carolina
| | - Parag J Patel
- Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Paul J Rochon
- University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | | | - Pal S Suranyi
- Medical University of South Carolina, Charleston, South Carolina
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Kim YS, Kwon JH, Han K, Kim MD, Lee J, Kim GM, Won JY. Superselective transcatheter arterial embolization for acute small bowel bleeding: clinical outcomes and prognostic factors for ischemic complications. Acta Radiol 2021; 62:574-583. [PMID: 32586121 DOI: 10.1177/0284185120936258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Small bowel bleeding (SBB) accounts for 5%-10% of all cases of acute gastrointestinal bleeding. Transcatheter arterial embolization (TAE) plays an important role in the treatment of SBB. PURPOSE To evaluate the safety and efficacy of superselective TAE exclusively for SBB and to assess factors associated with clinical outcomes. MATERIAL AND METHODS From January 2006 to April 2017, 919 patients were admitted with signs and symptoms of gastrointestinal bleeding; 74 patients (mean age = 57.5 years; age range = 14-82 years) with positive angiographic findings for SBB were retrospectively analyzed. The technical success of TAE and clinical outcomes, including recurrent bleeding, major complications, and in-hospital mortality were evaluated. The associations of various clinical and technical factors with clinical outcomes were analyzed. RESULTS The bleeding foci were in the ileum in 48 (65%) patients and the jejunum in 26 (35%). Technical success was achieved in 72 (97%) patients. The rates of recurrent bleeding, major complications, and in-hospital mortality were 12% (7/57), 21% (15/71), and 25% (18/72), respectively. Superselective embolization was a significant prognostic factor associated with fewer major complications (OR = 0.069; P = 0.003). The increased number of embolized vasa recta was significantly associated with a higher probability of major complications (OR = 2.64; P < 0.001). The use of N-butyl cyanoacrylate was associated with lower rates of major complication (OR = 0.257; P = 0.027). CONCLUSION TAE is a safe and effective treatment modality for SBB. In addition, whenever possible, TAE should be performed in a superselective manner to minimize ischemic complications.
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Affiliation(s)
- Yong Seek Kim
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Radiology, Mediplex Sejong Hospital, 20, Gyeyangmunhwa-ro, Gyeyang-gu, Incheon, Republic of Korea
| | - Joon Ho Kwon
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kichang Han
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Man-Deuk Kim
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Junhyung Lee
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Gyoung Min Kim
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Yun Won
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea
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Chevallier O, Comby PO, Guillen K, Pellegrinelli J, Mouillot T, Falvo N, Bardou M, Midulla M, Aho-Glélé S, Loffroy R. Efficacy, safety and outcomes of transcatheter arterial embolization with N-butyl cyanoacrylate glue for non-variceal gastrointestinal bleeding: A systematic review and meta-analysis. Diagn Interv Imaging 2021; 102:479-487. [PMID: 33893060 DOI: 10.1016/j.diii.2021.03.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/20/2021] [Accepted: 03/25/2021] [Indexed: 12/30/2022]
Abstract
PURPOSE To perform a systematic review and meta-analysis to determine the safety, efficacy, and outcomes of transcatheter arterial embolization (TAE) with N-butyl cyanoacrylate (NBCA) as the single embolic agent for the management of non-variceal upper and lower gastrointestinal bleeding (GIB). MATERIALS AND METHODS A literature search using MEDLINE/PubMed, EMBASE, and SCOPUS databases was performed for studies published from January 1980 to December 2019. Data from eligible studies were extracted and evaluated by two independent reviewers. Exclusion criteria were sample size <5, article reporting the use of NBCA with other embolic agents, no extractable data, and duplicate reports. Technical success, clinical success, 30-day rebleeding, 30-day overall and major complications, and 30-day mortality were evaluated. The estimated overall rates were calculated with their 95% confidence intervals, based on each study rate, weighted by the number of patients involved in each study. Heterogeneity across studies was assessed using the Q test and I2 statistic. RESULTS Fifteen studies with 574 patients were included. For upper GIB (331 patients), the technical and clinical success rates, and 30-day rebleeding and mortality rates, were 98.8% (328 of 331 patients) and 88.0% (237 of 300 patients), and 12.5% (69 of 314 patients) and 15.9% (68 of 331 patients), respectively. Thirty-day overall and major complications occurred in 14.3% (28 of 331 patients) and 2.7% (7 of 331 patients) of patients, respectively. For lower GIB (243 patients), the technical and clinical success rates, and 30-day rebleeding and mortality rates, were 98.8% (78 of 78 patients) and 78.0% (145 of 189 patients), and 15.7% (33 of 218 patients) and 12.7% (14 of 78 patients), respectively. Thirty-day overall and major complications occurred in 13.0% (25 of 228 patients) and 8.6% (19 of 228 patients) of patients, respectively. CONCLUSION TAE with NBCA is safe and effective for treating non-variceal GIB, with high clinical success and very low major complication rates.
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Affiliation(s)
- Olivier Chevallier
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 21079 Dijon, France
| | - Pierre-Olivier Comby
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 21079 Dijon, France
| | - Kevin Guillen
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 21079 Dijon, France
| | - Julie Pellegrinelli
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 21079 Dijon, France
| | - Thomas Mouillot
- Department of Gastroenterology and Hepatology, François-Mitterrand University Hospital, 21079 Dijon, France
| | - Nicolas Falvo
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 21079 Dijon, France
| | - Marc Bardou
- Department of Gastroenterology and Hepatology, François-Mitterrand University Hospital, 21079 Dijon, France
| | - Marco Midulla
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 21079 Dijon, France
| | - Serge Aho-Glélé
- Department of Epidemiology and Biostatistics, François-Mitterrand University Hospital, 21079 Dijon, France
| | - Romaric Loffroy
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 21079 Dijon, France.
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Razavilar N, Taleshi JM. Cost-Effectiveness Analysis of Transcatheter Arterial Embolization Techniques for the Treatment of Gastrointestinal Bleeding in the United States. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:477-485. [PMID: 33840425 DOI: 10.1016/j.jval.2020.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 09/04/2020] [Accepted: 10/30/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Gastrointestinal (GI) bleeding is a common medical emergency associated with significant mortality. Transcatheter arterial embolization first was introduced by Rosch et al as an alternative to surgery for upper GI bleeding. The clinical success in patients with GI bleeding treated with transcatheter arterial embolization previously has been reported. However, there are no cost-effectiveness analyses reported to date. Here we report cost-effectiveness analysis of N-butyl 2-cyanoacrylate glue (NBCA) and ethylene-vinyl alcohol copolymer (Onyx) versus coil (gold standard) for treatment of GI bleeding from a healthcare payer perspective. METHODS Fixed-effects modeling with a generalized linear mixed method was used in NBCA and coil intervention arms to determine the pooled probabilities of clinical success and mortality with complications with their confidence intervals, while the Clopper-Pearson model was used for Onyx to determine the same parameters. Models were provided by the "Meta-Analysis with R" software package. A decision tree was built for cost-effectiveness analysis, and Microsoft Excel was used for probabilistic sensitivity analysis. The cost-effective option was determined based on the incremental cost-effectiveness ratio and scatter plots of incremental cost versus incremental quality-adjusted life-years. RESULTS Comparing scatter plots and incremental cost-effectiveness ratio results, -$1024 and -$1349 per quality-adjusted life-year for Onyx and N-butyl 2-cyanoacrylate glue, respectively, Onyx was the least expensive and most effective intervention. CONCLUSION Onyx was the dominant strategy regardless of threshold values. Our analyses provide a framework for researchers to predict the target clinical effectiveness for early-stage TAE interventions and guide resource allocation decisions.
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Affiliation(s)
- Negin Razavilar
- RAZN Health Decision Modelling LTD, University of Alberta Health Accelerator, Edmonton, Canada; Faculty of Sciences, University of Alberta, Edmonton, Canada.
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Kinoshita M, Kondo H, Hitomi S, Hara T, Zako R, Yamamoto M, Hiraoka J, Takaoka Y, Enomoto H, Matsunaga N, Takechi K, Shirono R, Akagawa Y, Osaki K, Ohnishi N, Tani H. Ultraselective transcatheter arterial embolization with small-sized microcoils for acute lower gastrointestinal bleeding. CVIR Endovasc 2021; 4:28. [PMID: 33687589 PMCID: PMC7943668 DOI: 10.1186/s42155-021-00215-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 02/23/2021] [Indexed: 02/03/2023] Open
Abstract
Purpose To evaluate the clinical outcome of ultraselective transcatheter arterial embolization (TAE) with small-sized microcoils for acute lower gastrointestinal bleeding (LGIB). Materials and methods The subjects were 17 consecutive patients (mean age, 69 years) with LGIB who were treated with ultraselective TAE using small-sized microcoils between December 2013 and December 2019. Ultraselective TAE was defined as embolization of one or both of the long or short branches of the vasa recta. The etiologies of bleeding were colonic diverticulosis in 16 patients (94%) and malignancy in one patient (6%). The bleeding foci were in the ascending colon in 11 patients (65%), transverse colon in 2 patients (12%), and sigmoid colon in 4 patients (23%). A total of 18 branches (diameter: range 0.5–1.5 mm, mean 1.1 mm) of the vasa recta in 17 patients were embolized with small-sized microcoils (size range 1–3 mm, mean combined lengths of all microcoils 7.6 cm). The mean follow-up period was 19 months (range 1–80 months). The technical and clinical success rate, recurrent bleeding rate, major complications and long-term clinical outcomes were retrospectively evaluated. Results Technical and clinical success was achieved in all patients (17/17). The rates of early recurrent bleeding (within 30 days of TAE) and major complications were 0% (0/17). Recurrent bleeding occurred in one patient at 2 months after TAE, but was stopped with conservative treatment. There were no other bleeding episodes or complications in the follow-up period. Conclusion Ultraselective TAE with small-sized microcoils is a highly effective and safe treatment modality for LGIB.
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Affiliation(s)
- Mitsuhiro Kinoshita
- Department of Radiology, Tokushima Red Cross Hospital, 103 Irinokuchi Komatsushima-cho, Komatsushima City, Tokushima, 773-8502, Japan
| | - Hiroshi Kondo
- Department of Radiology, Teikyo University School of Medicine, 2-11-1 Kaga Itabashi-ku, Tokyo, 173-8606, Japan.
| | - Suguru Hitomi
- Department of Radiology, Teikyo University School of Medicine, 2-11-1 Kaga Itabashi-ku, Tokyo, 173-8606, Japan
| | - Takuya Hara
- Department of Radiology, Teikyo University School of Medicine, 2-11-1 Kaga Itabashi-ku, Tokyo, 173-8606, Japan
| | - Ryusei Zako
- Department of Radiology, Teikyo University School of Medicine, 2-11-1 Kaga Itabashi-ku, Tokyo, 173-8606, Japan
| | - Masayoshi Yamamoto
- Department of Radiology, Teikyo University School of Medicine, 2-11-1 Kaga Itabashi-ku, Tokyo, 173-8606, Japan
| | - Junichiro Hiraoka
- Department of Radiology, Tokushima Red Cross Hospital, 103 Irinokuchi Komatsushima-cho, Komatsushima City, Tokushima, 773-8502, Japan
| | - Yukiko Takaoka
- Department of Radiology (Diagnostic Radiology), Tokushima University Hospital, 2-50-1, Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan
| | - Hideaki Enomoto
- Department of Radiology (Diagnostic Radiology), Tokushima University Hospital, 2-50-1, Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan
| | - Naoki Matsunaga
- Department of Emergency & Clinical Care Medicine, Tokushima Red Cross Hospital, 103 Irinokuchi Komatsushima-cho, Komatsushima City, Tokushima, 773-8502, Japan
| | - Katsuya Takechi
- Department of Radiology, Tokushima Red Cross Hospital, 103 Irinokuchi Komatsushima-cho, Komatsushima City, Tokushima, 773-8502, Japan
| | - Ryozo Shirono
- Department of Radiology, Kawashima-kai Kawashima Hospital, 1-39, Kitasakoichiban-cho, Tokushima City, Tokushima, 770-0011, Japan
| | - Yoko Akagawa
- Department of Radiology, Tokushima Red Cross Hospital, 103 Irinokuchi Komatsushima-cho, Komatsushima City, Tokushima, 773-8502, Japan
| | - Kyosuke Osaki
- Department of Radiology, Tokushima Red Cross Hospital, 103 Irinokuchi Komatsushima-cho, Komatsushima City, Tokushima, 773-8502, Japan
| | - Norio Ohnishi
- Department of Radiology, Tokushima Red Cross Hospital, 103 Irinokuchi Komatsushima-cho, Komatsushima City, Tokushima, 773-8502, Japan
| | - Hayato Tani
- Department of Radiology, Tokushima Red Cross Hospital, 103 Irinokuchi Komatsushima-cho, Komatsushima City, Tokushima, 773-8502, Japan
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Morgan TG, Carlsson T, Loveday E, Collin N, Collin G, Mezes P, Pullyblank AM. Needle or knife? The role of interventional radiology in managing uncontrolled gastrointestinal bleeding. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2021. [DOI: 10.18528/ijgii200018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Thomas G. Morgan
- Dpeartment of Surgery, University of Auckland, Auckland, New Zealand
| | | | - Eric Loveday
- Departments of Radiology, Southmead Hospital, Bristol, UK
| | - Neil Collin
- Departments of Radiology, Southmead Hospital, Bristol, UK
| | - Graham Collin
- Departments of Radiology, Southmead Hospital, Bristol, UK
| | - Peter Mezes
- Departments of Radiology, Southmead Hospital, Bristol, UK
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Haraguchi T, Hamaguchi S. Nonselective Bilateral Embolization of Internal Iliac Arteries with N-Butyl-2-Cyanoacrylate in Hemodynamically Unstable Patients with Pelvic Fracture. INTERVENTIONAL RADIOLOGY 2021; 6:37-43. [PMID: 35909907 PMCID: PMC9327384 DOI: 10.22575/interventionalradiology.2019-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 04/08/2021] [Indexed: 11/17/2022]
Abstract
Purpose: This study was designed to evaluate the efficacy and safety of nonselective bilateral embolization of the internal iliac arteries (IIAs) with n-butyl-2-cyanoacrylate (NBCA) in hemodynamically unstable patients with pelvic fractures. Material and Methods: Twelve patients underwent nonselective bilateral embolization of the IIAs using NBCA diluted with lipiodol at our institution between January 2004 and March 2014. We analyzed the time of bilateral occlusion of the IIAs, the time from admission to entrance into the interventional radiology room, the need for repeat embolization, outcomes, cause of death, follow-up period, and complications. Results: The mean duration of bilateral occlusion of the IIAs was 17 min (range, 4-34 min), and the mean time from admission to entrance into the interventional radiology room was 89 min (range, 28-168 min). All patients underwent technically successful embolization. Repeat embolization was required after treatment in three patients. The mortality rate was 33.3%. Complications after embolization were suspected in one patient. Conclusions: Nonselective bilateral embolization of IIAs with NBCA could be a choice of treatment for hemodynamically unstable patients with severe pelvic fracture hemorrhage.
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Affiliation(s)
| | - Shingo Hamaguchi
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine
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Spiliopoulos S, Katsanos K, Paraskevopoulos I, Mariappan M, Festas G, Kitrou P, Papageorgiou C, Reppas L, Palialexis K, Karnabatidis D, Brountzos E. Multicenter retrospective study of transcatheter arterial embolisation for life-threatening haemorrhage in patients with uncorrected bleeding diathesis. CVIR Endovasc 2020; 3:95. [PMID: 33301058 PMCID: PMC7728894 DOI: 10.1186/s42155-020-00186-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/29/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND We retrospectively investigated outcomes of emergency TAE for the management of life-threatening haemorrhage in patients with uncorrected bleeding diathesis. MATERIALS AND METHODS This multicenter, retrospective, study, was designed to investigate the safety and efficacy of percutaneous TAE for the management of life-threatening haemorrhage in patients with uncorrected bleeding disorder at the time of embolization. All consecutive patients with uncorrected coagulation who underwent TAE for the treatment of haemorrhage, between January 1st and December 31th 2019 in three European centers were included. Inclusion criteria were thrombocytopenia (platelet count < 50,000/mL) and/or International Normalized Ratio (INR) ≥2.0, and/or activated partial thromboplastin time (aPTT) > 45 s, and/or a pre-existing underlying blood-clotting disorder such as factor VIII, Von Willebrand disease, hepatic cirrhosis with abnormal liver function tests. Primary outcome measures were technical success, rebleeding rate and clinical success. Secondary outcome measures included patients' 30-day survival rate, and procedure-related complications. RESULTS In total, 134 patients underwent TAE for bleeding control. A subgroup of 17 patients with 18 procedures [11 female, mean age 70.5 ± 15 years] which represent 12.7% of the total number of patients, presented with pathological coagulation parameters at the time of TAE (haemophilia n = 3, thrombocytopenia n = 1, cirrhosis n = 5, anticoagulants n = 7, secondary to bleeding n = 1) and were analyzed. Technical success was 100%, as in all procedures the bleeding site was detected and successfully embolised. Clinical success was 100%, as none of the patients died of bleeding during hospitalization, nor was surgically treated for bleeding relapse. Only one rebleeding case was noted (5.9%) that was successfully treated with a second TAE. No procedure-related complications were noted. According to Kaplan-Meier analysis the estimated 30-day survival rate was 84.2%. CONCLUSION TAE in selected patients with uncorrected bleeding diathesis should be considered as a suitable individualized management approach. Emergency TAE for life threatening haemorrhage in patients with coagulation cascade disorders should be used as an aid in realistic clinical decision making.
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Affiliation(s)
- Stavros Spiliopoulos
- grid.5216.00000 0001 2155 08002nd Department of Radiology, Interventional Radiology Unit, Medical School, National and Kapodistrian University of Athens, “Attikon” University Hospital, Athens, Greece
- grid.417581.e0000 0000 8678 4766Department of Clinical Radiology, Interventional Radiology Unit, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, AB25 2ZN UK
| | - Konstantinos Katsanos
- grid.412458.eDepartment of Interventional Radiology, School of Medicine, Patras University Hospital, Rion, Greece
| | - Ioannis Paraskevopoulos
- grid.417581.e0000 0000 8678 4766Department of Clinical Radiology, Interventional Radiology Unit, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, AB25 2ZN UK
| | - Martin Mariappan
- grid.417581.e0000 0000 8678 4766Department of Clinical Radiology, Interventional Radiology Unit, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, AB25 2ZN UK
| | - Georgios Festas
- grid.5216.00000 0001 2155 08002nd Department of Radiology, Interventional Radiology Unit, Medical School, National and Kapodistrian University of Athens, “Attikon” University Hospital, Athens, Greece
| | - Panagiotis Kitrou
- grid.412458.eDepartment of Interventional Radiology, School of Medicine, Patras University Hospital, Rion, Greece
| | - Christos Papageorgiou
- grid.412458.eDepartment of Interventional Radiology, School of Medicine, Patras University Hospital, Rion, Greece
| | - Lazaros Reppas
- grid.5216.00000 0001 2155 08002nd Department of Radiology, Interventional Radiology Unit, Medical School, National and Kapodistrian University of Athens, “Attikon” University Hospital, Athens, Greece
| | - Konstantinos Palialexis
- grid.5216.00000 0001 2155 08002nd Department of Radiology, Interventional Radiology Unit, Medical School, National and Kapodistrian University of Athens, “Attikon” University Hospital, Athens, Greece
| | - Dimitrios Karnabatidis
- grid.412458.eDepartment of Interventional Radiology, School of Medicine, Patras University Hospital, Rion, Greece
| | - Elias Brountzos
- grid.5216.00000 0001 2155 08002nd Department of Radiology, Interventional Radiology Unit, Medical School, National and Kapodistrian University of Athens, “Attikon” University Hospital, Athens, Greece
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Loffroy R, Mouillot T, Bardou M, Chevallier O. Current role of cyanoacrylate glue transcatheter embolization in the treatment of acute nonvariceal gastrointestinal bleeding. Expert Rev Gastroenterol Hepatol 2020; 14:975-984. [PMID: 32602758 DOI: 10.1080/17474124.2020.1790355] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Over the past three decades, transcatheter arterial embolization (TAE) has become the first-line therapy for the management of acute nonvariceal gastrointestinal bleeding (NVGIB) that is refractory to endoscopic hemostasis. Advances in catheter-based techniques and newer liquid embolic agents, as well as recognition of the effectiveness of minimally invasive treatment options, have expanded the role of interventional radiology in the treatment of acute NVGIB. Many embolic agents have been used successfully. However, no guidelines exist about the choice of the best embolic agent which is still controversial. Cyanoacrylate glue has gained acceptance over time. This article aims to address the current role of TAE using cyanoacrylate glue for the treatment of acute NVGIB. AREAS COVERED The authors undertook a literature review of the current evidence on the use of cyanoacrylate glue in treating patients with acute NVGIB. EXPERT OPINION The evidence shows that cyanoacrylate glue is the most clinically useful embolic agent in treating patients with acute NVGIB, despite the need for learning curve, especially in case of coagulopathy. At present, research is ongoing to assess liquid embolic agents in the treatment of patients presenting with acute NVGIB. More research is needed but cyanoacrylate glue show promise for the future.
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Affiliation(s)
- Romaric Loffroy
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital , Dijon, France
| | - Thomas Mouillot
- Department of Gastroenterology and Hepatology, Clinical Investigation Center, François-Mitterrand University Hospital , Dijon, France
| | - Marc Bardou
- Department of Gastroenterology and Hepatology, Clinical Investigation Center, François-Mitterrand University Hospital , Dijon, France
| | - Olivier Chevallier
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital , Dijon, France
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32
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Empiric cone-beam CT-guided embolization in acute lower gastrointestinal bleeding. Eur Radiol 2020; 31:2161-2172. [PMID: 32964336 DOI: 10.1007/s00330-020-07232-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 07/17/2020] [Accepted: 08/26/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To evaluate the clinical effect and safety of cone-beam CT (CBCT)-guided empirical embolization for acute lower gastrointestinal bleeding (LGIB) in patients with a positive CT angiography (CTA) but subsequent negative digital subtraction angiography (DSA). METHODS A retrospective study of consecutive LGIB patients with a positive CTA who received a DSA within 24 h from January 2008 to July 2019. Patients with a positive DSA were treated with targeted embolization (TE group). Patients with a negative DSA underwent an empiric CBCT-guided embolization of the assumed ruptured vas rectum (EE group) or no embolization (NE group). Recurrent bleeding, major ischemic complications, and in-hospital mortality were compared by means of Fisher's exact test. Further subgroup analysis was performed on hemodynamic instability. RESULTS Eighty-five patients (67.6 years ± 15.7, 52 men) were included (TE group, n = 47; EE group, n = 19; NE group, n = 19). If DSA was positive, technical success of targeted embolization was 100% (47/47). If DSA was negative and the intention to treat by empiric CBCT-guided embolization, technical success was 100% (19/19). Recurrent bleeding rates in the TE group, EE group, and NE group were 17.0% (8/47), 21.1% (4/19), and 52.6% (10/19) respectively. Empiric CBCT-guided embolization reduced rebleeding significantly in patients with a negative DSA and hemodynamic instability (EE group, 3/10 vs NE group, 10/12, p = .027). Major ischemic complications occurred in one patient (TE group). Overall, the in-hospital mortality rate was 7.1% (6/85). CONCLUSION Empiric cone-beam CT-guided embolization proved to be a feasible, effective, and safe treatment strategy to reduce rebleeding and improve clinical success in hemodynamically unstable patients with acute LGIB, positive CTA but negative DSA. KEY POINTS • A novel transarterial embolization technique guided by cone-beam CT could be developed extending the "empiric" embolization strategy to lower gastrointestinal bleeding. • By implementing the empiric treatment strategy, nearly all patients with an active lower gastrointestinal bleeding on CTA will be eligible for a superselective empiric embolization, even if subsequent catheter angiography is negative. • In patients with a negative catheter angiography, empiric embolization reduces the rebleeding rate and, particularly in hemodynamically unstable patients, improves clinical success compared with a conservative "wait-and-see" management.
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Kawachi J, Ogino H, Shimoyama R, Ichita C, Isogai N, Murata T, Miyake K, Nishida T, Fukai R, Kashiwagi H. Intraoperative angiography with indocyanine green injection for precise localization and resection of small bowel bleeding. Acute Med Surg 2020; 7:e549. [PMID: 32817800 PMCID: PMC7426192 DOI: 10.1002/ams2.549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 06/20/2020] [Accepted: 06/30/2020] [Indexed: 12/22/2022] Open
Abstract
Aim Bleeding in the small bowel rarely occurs, and its treatment is challenging. Surgery is sometimes required in unstable patients; however, intraoperative identification of the bleeding site is extremely difficult. Many methods have been reported, but no standard strategy has been established yet. Here, we aimed to assess the safety and feasibility of intraoperative angiography with indocyanine green staining to accurately identify small bowel bleeding sites. Methods This retrospective study analyzed contrast‐enhanced computed tomography images of patients (n = 8) with small bowel extravasation who underwent surgery. If extravasation or other vessel abnormalities that were potential bleeding sites were detected on intraoperative angiography, a microcatheter was placed as close as possible to the extravasation site. Laparotomy was carried out, and 3–5 mL indocyanine green was injected through the microcatheter. The green‐stained segment of the small bowel was resected. Results Seven of the eight patients had positive angiographic findings and underwent bowel resection. The eighth patient had no abnormalities and hence did not undergo laparotomy. The rate of hemostatic success among the resected cases was 85.7% (six of seven cases). The resected specimens showed pathologic features in six of the seven patients (85.7%), all of whom achieved hemostasis. One patient had pneumonia and congestive heart failure that required longer hospital stay, but no mortality occurred. Conclusions Intraoperative angiography with indocyanine green injection, followed by resection for massive small bowel bleeding is effective. This can be a therapeutic option for hemodynamically unstable patients.
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Affiliation(s)
- Jun Kawachi
- Department of Surgery Shonan Kamakura General Hospital Kamakura Japan
| | - Hidemitsu Ogino
- Department of Surgery Narita Tomisato Tokushukai Hospital Tomisato Japan
| | - Rai Shimoyama
- Department of Surgery Shonan Kamakura General Hospital Kamakura Japan
| | - Chikamasa Ichita
- Gastroenterology Center Shonan Kamakura General Hospital Kamakura Japan
| | - Naoko Isogai
- Department of Surgery Shonan Kamakura General Hospital Kamakura Japan
| | - Takaaki Murata
- Department of Surgery Shonan Kamakura General Hospital Kamakura Japan
| | - Katsunori Miyake
- Department of Surgery Shonan Kamakura General Hospital Kamakura Japan
| | - Tomoki Nishida
- Department of Surgery Shonan Kamakura General Hospital Kamakura Japan
| | - Ryuta Fukai
- Department of Surgery Shonan Kamakura General Hospital Kamakura Japan
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Wattanasatesiri T, Chung JW, Choi TW, Kim HC, Lee M, Hur S. Shaping the tip of microcatheters for superselective catheterization: steam vs. manual methods. Diagn Interv Radiol 2020; 26:456-463. [PMID: 32673203 DOI: 10.5152/dir.2020.19314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We aimed to evaluate and compare the shapeability and stability of five microcatheters commonly used in interventional radiology after steam shaping and manual shaping. METHODS Steam shaping was performed using three mandrels of different angles: L(S) shape (90°), U(S) shape (180°), and O(S) shape (360°). Three manual shapes-L(M), U(M), and O(M)-were made to have a similar angle to their steam-shaped counterparts. The stability of the microcatheters was evaluated by passing them through a 5 F catheter and inserting microguidewires. The tip angles of the microcatheters and the angle change rates were compared between groups. RESULTS The mean angle of the microcatheters after steam shaping was 42.4°-54.1° for L(S) shape, 80.2°-96.7° for U(S) shape, and 130.7°-150.8° for O(S) shape. Five microcatheters showed significantly different mean angle reductions after passing through the 5 F catheter (17.4%-30.3%) and inserting microguidewires (24.1%-61.2%). Different microguidewires also caused significantly different mean angle reductions (34.6%-50.8%). The reduced angle caused by the guidewire was almost completely recovered after withdrawing it (93.2%-101.6%). Although manual-shaped microcatheters showed a 4.2%-6.3% greater angle reduction than steam-shaped microcatheters after passing through the 5 F catheter, the final tip angle was not significantly different between the two groups and was within 10%. CONCLUSION The tip angle of the microcatheters after steam shaping using mandrels may differ depending on the shape of the mandrel and the type of microcatheter used, and the stability varies depending on the type of microcatheter. The manual shaping of microcatheters can be a good alternative to steam shaping.
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Affiliation(s)
| | - Jin Wook Chung
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea
| | - Tae Won Choi
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea
| | - Hyo-Cheol Kim
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea
| | - Myungsu Lee
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea
| | - Saebeom Hur
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea
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Oi M, Maruhashi T, Yamamoto D, Kurihara Y, Koizumi H, Asari Y. Intravascular treatment for ruptured facial artery aneurysm via percutaneous cardiopulmonary support device: A case report. Clin Case Rep 2020; 8:1202-1205. [PMID: 32695357 PMCID: PMC7364082 DOI: 10.1002/ccr3.2869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/11/2020] [Accepted: 03/20/2020] [Indexed: 11/15/2022] Open
Abstract
Even in cases of cardiac arrest caused by hemorrhagic shock, when reliable control of the bleeding source is possible, ECPR may be an effective treatment option if anticoagulant therapy is well-managed and is withdrawn early.
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Affiliation(s)
- Marina Oi
- Department of Emergency and Critical Care MedicineKitasato University School of MedicineSagamiharaJapan
| | - Takaaki Maruhashi
- Department of Emergency and Critical Care MedicineKitasato University School of MedicineSagamiharaJapan
| | - Daisuke Yamamoto
- Department of NeurosurgeryKitasato University School of MedicineSagamiharaJapan
| | - Yutaro Kurihara
- Department of Emergency and Critical Care MedicineKitasato University School of MedicineSagamiharaJapan
| | - Hiroyuki Koizumi
- Department of NeurosurgeryKitasato University School of MedicineSagamiharaJapan
| | - Yasushi Asari
- Department of Emergency and Critical Care MedicineKitasato University School of MedicineSagamiharaJapan
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Outcome of Rectal Arterial Embolization for Rectal Bleeding in 34 Patients: A Single-Center Retrospective Study over 20 Years. J Vasc Interv Radiol 2020; 31:576-583. [DOI: 10.1016/j.jvir.2019.05.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 05/08/2019] [Accepted: 05/12/2019] [Indexed: 12/27/2022] Open
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Lv LS, Gu JT. Super-selective arterial embolization in the control of acute lower gastrointestinal hemorrhage. World J Clin Cases 2019; 7:3728-3733. [PMID: 31799297 PMCID: PMC6887619 DOI: 10.12998/wjcc.v7.i22.3728] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 11/14/2019] [Accepted: 11/15/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Acute gastrointestinal bleeding is an emergency condition that can lead to significant morbidity and mortality. Embolization is considered the preferred therapy in the treatment of lower gastrointestinal bleeding when it is unrealistic to perform the surgery or vasopressin infusion in this population. Treatment of acute lower gastrointestinal (GI) bleeding (any site below the ligament of Treitz) using this technique has not reached a consensus, because of the belief that the risk of intestinal infarction in this condition is extremely high. The purpose of the study is to evaluate the effectiveness and safety of this technique in a retrospective group of patients who underwent embolization for acute lower GI bleeding.
AIM To evaluate the efficacy and safety of super-selective arterial embolization in the management of acute lower GI bleeding.
METHODS A series of 31 consecutive patients with angiographically demonstrated small intestinal or colonic bleeding was retrospectively reviewed. The success rate and complication rate of super-selective embolization were recorded.
RESULTS Five out of thirty-one patients (16.1%) could not achieve sufficiently selective catheterization to permit embolization. Initial control of bleeding was achieved in 26 patients (100%), and relapsed GI bleeding occurred in 1 of them at 1 wk after the operation. No clinically apparent bowel infarctions were observed in patients undergoing embolization.
CONCLUSION Super-selective embolization is a safe therapeutic method for acute lower GI bleeding, and it is suitable and effective for many patients suffering this disease. Importantly, careful technique and suitable embolic agent are essential to the successful operation.
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Affiliation(s)
- Liang-Shan Lv
- Department of Gastroenterology and Interventional Radiography, Xi’an Gaoxin Hospital, Xi’an Jiaotong University, Xi’an 710075, Shaanxi Province, China
| | - Jing-Tao Gu
- Department of Vascular Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
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Lee SY, Wang ML, Wong YC, Wu CH, Wang LJ. Prolonged international normalized ratio and vascular injury at divisional level predict embolization failures of patients with iatrogenic renal vascular injuries. Sci Rep 2019; 9:17108. [PMID: 31745170 PMCID: PMC6864247 DOI: 10.1038/s41598-019-53561-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 11/04/2019] [Indexed: 11/26/2022] Open
Abstract
Transcatheter arterial embolization (TAE), as an alternative to surgery for iatrogenic renal vascular injury (IRVI), may have unsatisfactory outcomes. Nonetheless, there is inadequate information regarding the predictors of TAE outcomes for IRVI in the literature. The aim of this retrospective study was to investigate the predictors of TAE outcomes for IRVI. Of 47 patients, none had major complications, 17 (36.2%) patients had minor complications, and none suffered significant renal function deterioration after TAE. Technical success and clinical success were 91.5% and 93.6%, respectively. Technical failure was associated with older age, thrombocytopenia, prolonged international normalized ratio (INR) and divisional IRVI. Clinical failure was associated with kidney failure, use of steroids, prolonged INR, and divisional IRVI. In addition, prolonged INR was a significant predictor of technical failure. This implies that aggressive measures to control the INR prior to TAE are warranted to facilitate technical success, and technical success could then be validated on post-TAE images. Furthermore, divisional IRVI was a predictor of clinical failure. Thus, divisional IRVI should undergo surgery first since TAE is prone to clinical failure. The avoidance of clinical failure is validated if divisional IRVI does not need further intervention.
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Affiliation(s)
- Shen-Yang Lee
- Department of Nephrology, Linkou Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Mei-Lin Wang
- Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yon-Cheong Wong
- Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Hsian Wu
- Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Li-Jen Wang
- Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Characteristics of patients treated for active lower gastrointestinal bleeding detected by CT angiography: Interventional radiology versus surgery. Eur J Radiol 2019; 120:108691. [PMID: 31589996 DOI: 10.1016/j.ejrad.2019.108691] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 08/07/2019] [Accepted: 09/22/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE To determine radiological or clinical criteria guiding treatment decisions in active lower gastrointestinal bleeding (LGIB). MATERIALS AND METHODS We consecutively and retrospectively included all patients admitted to our emergency department for acute LGIB proven by CT angiography (CTA) from 2004 to 2017. Patients were divided into two groups depending on whether they first underwent interventional radiological (IR) or surgical treatment. Two radiologists reviewed CTA and angiographic images. Patients' hemodynamic and clinical parameters, delay between imaging and treatment, procedure characteristics, and outcomes were investigated to detect differences between the two groups. RESULTS Initial management consisted of IR in 62 cases (70.5%) and surgery in 26 (29.5%). IR cases were older than surgical cases (74.3 vs 64.3y, p = 0.014). Baseline hemodynamic parameters were similar between the two groups. For colonic bleeding sources, the delay between CTA and IR was shorter than between CTA and surgery (p = 0.027), while there was a trend towards a shorter delay for all LGIB taken together (p = 0.061). In cases with hematochezia or melena, IR was more frequently performed than surgery (p = 0.001). Surgical cases showed higher base excesses (p = 0.039) and lactate levels (p = 0.042) after treatment compared with IR cases. Length of hospital stay was similar between the two groups (p = 0.728). During angiography, 41 (66%) cases were embolized. Complications occurred in three cases after IR (7%) and in five after surgery (19%). CONCLUSION Initial management of active LGIB revealed by CTA (i.e. IR versus surgery), may depend on age and clinical signs, rather than hemodynamic parameters.
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Miranda-Bautista J, Diéguez L, Rodríguez-Rosales G, Marín-Jiménez I, Menchén L. Cases report: severe colonic bleeding in ulcerative colitis is refractory to selective transcatheter arterial embolization. BMC Gastroenterol 2019; 19:55. [PMID: 30991964 PMCID: PMC6469077 DOI: 10.1186/s12876-019-0970-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 03/31/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Severe haemorrhage is an uncommon but life-threatening complication of ulcerative colitis (UC). Superselective transcatheter embolization has shown to be an effective and safe therapeutic modality in patients with lower gastrointestinal bleeding of various aetiologies; nevertheless, its role in UC-related acute bleeding is unknown. CASES PRESENTATION Efficacy and safety of selective transcatheter arterial embolization in three consecutive UC patients diagnosed with massive haemorrhage admitted in a tertiary institution are reported. In all patients computed tomography scan showed active arterial haemorrhage from ascendant or sigmoid colon; subsequent arteriography demonstrated active arterial bleeding from colic branches of the superior or inferior mesenteric arteries, and selective transcatheter embolization was performed with immediate technical success in all three cases. Nevertheless, rebleeding requiring subtotal colectomy occurred between 5 h and 6 days after the procedure. CONCLUSIONS Transcatheter arterial embolization is not an effective therapeutic approach in UC patients with severe, acute colonic haemorrhage. Colectomy should not be delayed in this setting.
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Affiliation(s)
- Jose Miranda-Bautista
- Servicio de Aparato Digestivo. Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, C/ Dr. Esquerdo 46, 28007, Madrid, Spain
| | - Lucía Diéguez
- Servicio de Aparato Digestivo. Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, C/ Dr. Esquerdo 46, 28007, Madrid, Spain
| | - Gracia Rodríguez-Rosales
- Servicio de Radiología. Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Ignacio Marín-Jiménez
- Servicio de Aparato Digestivo. Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, C/ Dr. Esquerdo 46, 28007, Madrid, Spain
| | - Luis Menchén
- Servicio de Aparato Digestivo. Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, C/ Dr. Esquerdo 46, 28007, Madrid, Spain. .,Departamento de Medicina, Universidad Complutense de Madrid, Madrid, Spain. .,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.
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Ye T, Yang L, Wang Q, Liu J, Zhou C, Zheng C, Xiong B. Analysis of negative DSA findings in patients with acute nonvariceal gastrointestinal bleeding: A retrospective study of 133 patients. J Interv Med 2019; 2:27-30. [PMID: 34805866 PMCID: PMC8562268 DOI: 10.1016/j.jimed.2019.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Purpose To analyze causes of acute nonvariceal gastrointestinal bleeding (GIB) with negative digital subtraction angiography (DSA) results. Materials and methods The clinical and follow-up data of 133 patients - recruited between February 2008 and November 2016 - with acute nonvariceal GIB and negative DSA results were included in this study. DSA results, diagnoses, and clinical outcomes were recorded. Results The DSA results were negative in all 133 patients. Of the total, 55 patients (41.4%) chose to undergo surgery and 78 (58.6%) opted for conservative treatment. Within 30 days, there was no significant difference in the rebleeding or mortality rates between the two groups (P < .05). Of all 133 patients, 76 (57.1%) had upper GIB and 57 (42.9%) had lower GIB; within 30 days, the rebleeding rate in the upper GIB group (44.7%, 34/76) was significantly higher than that in the lower GIB group (26.3%, 15/57). There was no significant statistical difference (P < .05) within 30 days in the mortality rates between the two groups. Among patients with upper GIB, 26 (34.2%, 26/76) opted to undergo surgery and 50 (65.8%, 50/76) chose conservative treatment; within 30 days, the rebleeding rate in the group that chose surgery (61.5%, 16/26) was higher than that in the conservative treatment group (36%, 18/50). There was no significant difference (P < .05) within 30 days in the mortality rate between the two groups. Among the patients with lower GIB, 29 (50.9%, 29/57) chose to undergo surgery and 28 (49.1%, 28/57) opted for conservative treatment. Within 30 days, the rebleeding rate in the surgery group (13.8%, 4/29) was lower than that in conservative treatment group (39.3%, 11/28). There was no significant difference (P < .05) within 30 days in the mortality rate between the two groups. Sixteen patients underwent prophylactic arterial embolization; in 6 of these, bleeding was stopped for 30 days. DSA was then repeated in these 16 patients after a median interval of 1 day, and a positive bleeding site was found in 9 of the 16. Causes of bleeding were found in 111 patients by surgery or endoscopy, whereas the causes remained unknown in 22 patients. Conclusions Upper GIB with negative DSA results was stopped by conservative treatment, whereas lower GIB required surgery to detect the culprit bleeding site. Rare causes of GIB should be considered and appropriate management selected in a timely manner in order to detect unusual causes.
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Noh SM, Shin JH, Kim HI, Lee SH, Chang K, Song EM, Hwang SW, Yang DH, Ye BD, Myung SJ, Yang SK, Byeon JS. [Clinical Outcomes of Angiography and Transcatheter Arterial Embolization for Acute Gastrointestinal Bleeding: Analyses according to Bleeding Sites and Embolization Types]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2018; 71:219-228. [PMID: 29684971 DOI: 10.4166/kjg.2018.71.4.219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background/Aims The clinical outcomes of angiography and transcatheter arterial embolization (TAE) for acute gastrointestinal bleeding (GIB) have not been completely assessed, especially according to bleeding sites. This study aimed to assess the efficacy of angiography and safety of TAE in acute GIB. Methods This was a retrospective study evaluating the records of 321 patients with acute GIB who underwent angiography with or without TAE. Targeted TAE was conducted in 134 patients, in whom angiography showed bleeding sources. Prophylactic TAE was performed in 29 patients when the bleeding source was not detected but a specific vessel was strongly suspected by other examinations. The rate of technical success, clinical success, and complications were analyzed. Results The detection rate of bleeding source via angiography was 50.8% (163/321), which was not different according to the bleeding sites. The detection rate was higher if the probable bleeding source had already been found by another investigation (59.7% vs. 35.8%, p<0.001). TAE sites were upper GIB in 67, mid GIB in 74, and lower GIB in 22. The technical success rate was 99.3% (133/134), and the clinical success rate was 63.0% (104/163). The prophylactic embolization group showed lower clinical success rate than the targeted embolization group (44.8% vs. 67.9%, p=0.06). The TAE-related complication rate was 12.9% (21/163). Ischemia and/or infarction was more common after TAE for mid and lower GIB than for upper GIB (15.6% vs. 3.0%, p=0.007). Conclusions Angiography with or without TAE was an effective method for acute GIB. Targeted embolization should be performed if possible given that it has a higher clinical success rate.
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Affiliation(s)
- Soo Min Noh
- Departments of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Hoon Shin
- Departments of Internal Medicine and Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ha Il Kim
- Departments of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sun Ho Lee
- Division of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kiju Chang
- Division of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Mi Song
- Division of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Wook Hwang
- Division of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Hoon Yang
- Division of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byong Duk Ye
- Division of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Jae Myung
- Division of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suk Kyun Yang
- Division of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Sik Byeon
- Division of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Kim CY. Provocative mesenteric angiography for diagnosis and treatment of occult gastrointestinal hemorrhage. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Charles Y. Kim
- Division of Interventional Radiology, Duke University Medical Center, Durham, NC, USA
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Lee IJ. Outcomes and complications of embolization for gastrointestinal bleeding. GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- In Joon Lee
- Department of Radiology, Center for Liver Cancer, National Cancer Center, Goyang, Korea
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Lee HH, Oh JS, Park JM, Chun HJ, Kim TH, Cheung DY, Lee BI, Cho YS, Choi MG. Transcatheter embolization effectively controls acute lower gastrointestinal bleeding without localizing bleeding site prior to angiography. Scand J Gastroenterol 2018; 53:1089-1096. [PMID: 30354855 DOI: 10.1080/00365521.2018.1501512] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Colonoscopy is preferred for treatment of lower gastrointestinal bleeding (LGIB). However, several conditions such as poor bowel preparation can cause endoscopic failure, leading to surgery or transcatheter therapy as alternative options. We aimed to assess the efficacy and safety of transcatheter arterial embolization (TAE) for LGIB in patients with endoscopic failure. METHODS Between January 2005 and June 2015, 93 consecutive patients with acute LGIB underwent visceral angiography at three academic hospitals. Among them, a total of 52 patients were treated with TAE for LGIB and analyzed. Technical success, complications and 30-day rebleeding and mortality after TAE were investigated retrospectively in patients with and without localization of LGIB. RESULTS Technical success of TAE was achieved in all patients. After TAE, 30-day rebleeding and mortality rate were 27% (14/52) and 29% (15/52), respectively. TAE was performed without localizing bleeding site in 32 of 52 patients (62%). Between patients with and without localized bleeding site, there were no significant differences in 30-day rebleeding rate (25% vs. 28%) and mortality rate (15% vs. 38%). Causes of death were mostly unrelated to bleeding. Only two cases of bowel infarction occurred after TAE in patients without bleeding site localization. Rebleeding could be predicted if the patient received more than six units of packed red blood cell transfusion before TAE in multivariate analysis. CONCLUSIONS TAE can be an effective treatment for LGIB even without localizing bleeding site.
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Affiliation(s)
- Han Hee Lee
- a Division of Gastroenterology, Department of Internal Medicine , College of Medicine, The Catholic University of Korea , Seoul , Korea.,b Catholic Photomedicine Research Institute , Seoul , Korea
| | - Jung Suk Oh
- c Department of Radiology , College of Medicine, The Catholic University of Korea , Seoul , Korea
| | - Jae Myung Park
- a Division of Gastroenterology, Department of Internal Medicine , College of Medicine, The Catholic University of Korea , Seoul , Korea.,b Catholic Photomedicine Research Institute , Seoul , Korea
| | - Ho Jong Chun
- c Department of Radiology , College of Medicine, The Catholic University of Korea , Seoul , Korea
| | - Tae Ho Kim
- a Division of Gastroenterology, Department of Internal Medicine , College of Medicine, The Catholic University of Korea , Seoul , Korea
| | - Dae Young Cheung
- a Division of Gastroenterology, Department of Internal Medicine , College of Medicine, The Catholic University of Korea , Seoul , Korea
| | - Bo-In Lee
- a Division of Gastroenterology, Department of Internal Medicine , College of Medicine, The Catholic University of Korea , Seoul , Korea.,b Catholic Photomedicine Research Institute , Seoul , Korea
| | - Young-Seok Cho
- a Division of Gastroenterology, Department of Internal Medicine , College of Medicine, The Catholic University of Korea , Seoul , Korea.,b Catholic Photomedicine Research Institute , Seoul , Korea
| | - Myung-Gyu Choi
- a Division of Gastroenterology, Department of Internal Medicine , College of Medicine, The Catholic University of Korea , Seoul , Korea.,b Catholic Photomedicine Research Institute , Seoul , Korea
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Powerski M, Meyer-Wilmes P, Omari J, Damm R, Seidensticker M, Friebe B, Fischbach F, Pech M. Transcatheter arterial embolization of acute bleeding as 24/7 service: predictors of outcome and mortality. Br J Radiol 2018; 91:20180516. [PMID: 30102552 DOI: 10.1259/bjr.20180516] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To analyze times of occurrence and identify risk factors (RFs) for technical and clinical failure and mortality of transcatheter arterial embolization (TAE) of acute bleeding in a major hospital. METHODS All TAEs performed at our hospital from 2006 to 2013 (n = 327) were retrospectively analyzed. RESULTS TAEs were performed during regular weekday hours in 165 (50%) and during off-hours in 162 (50%) cases. With 40 regular and 128 off-hours/week, 3.25 times more TAEs were performed during regular hours. There was an even distribution across weekdays (Mon-Fri:16.9 ± 1.5%), while fewer TAEs were performed on weekends (Sat: 8.3%, Sun: 7.3%). Technical success of TAEs was 93.9% with a clinical success of 79.2% and a 30-day mortality of 18.4%. Shock was an RF for technical failure (p = 0.022). RFs for clinical failure were low hemoglobin (Hb) (p = 0.021) and transfusion of ≥6 units packed cells (p = 0.009). Independent RFs for mortality were clinical failure (p < 0.001), coagulopathy (p = 0.005), and shock (p < 0.001). CONCLUSION Our results provide no evidence for a subjectively perceived increase in TAEs during off-hours but rather appear to show that most TAEs are performed during regular hours. Prompt TAE to control acute bleeding is crucial to prevent a drop in Hb with shock and the need for transfusion, which may promote coagulopathy and rebleeding, all of which are risk factors for a negative outcome. ADVANCES IN KNOWLEDGE The presented analysis provides insights of occurrences and risk factors for success of transcatheter arterial embolization in acute bleeding in a large study population.
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Affiliation(s)
- Maciej Powerski
- 1 Department of Radiology and Nuclear Medicine, Otto-von-Guericke University , Magdeburg , Germany
| | - Philipp Meyer-Wilmes
- 1 Department of Radiology and Nuclear Medicine, Otto-von-Guericke University , Magdeburg , Germany
| | - Jazan Omari
- 1 Department of Radiology and Nuclear Medicine, Otto-von-Guericke University , Magdeburg , Germany
| | - Robert Damm
- 1 Department of Radiology and Nuclear Medicine, Otto-von-Guericke University , Magdeburg , Germany
| | - Max Seidensticker
- 2 Klinik und Poliklinik für Radiologie, Klinikum der Universität München , München , Germany
| | - Björn Friebe
- 1 Department of Radiology and Nuclear Medicine, Otto-von-Guericke University , Magdeburg , Germany
| | - Frank Fischbach
- 1 Department of Radiology and Nuclear Medicine, Otto-von-Guericke University , Magdeburg , Germany
| | - Maciej Pech
- 1 Department of Radiology and Nuclear Medicine, Otto-von-Guericke University , Magdeburg , Germany.,3 Department of Radiology, Medical University of Gdansk , Gdańsk , Poland
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Nykänen T, Peltola E, Kylänpää L, Udd M. Transcatheter Arterial Embolization in Lower Gastrointestinal Bleeding: Ischemia Remains a Concern Even with a Superselective Approach. J Gastrointest Surg 2018; 22:1394-1403. [PMID: 29549618 DOI: 10.1007/s11605-018-3728-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 02/22/2018] [Indexed: 01/31/2023]
Abstract
PURPOSE To evaluate the safety, efficacy, and feasibility of transcatheter arterial embolization (TAE) in the treatment of lower gastrointestinal bleeding (LGIB). METHODS Study group comprised all patients receiving angiography for LGIB in the Helsinki University Hospital during the period of 2004-2016. Hospital medical records provided the study data. Rebleeding, complication, and mortality rates (≤ 30 days) were the primary outcomes. Secondary outcomes included need for blood transfusions, durations of intensive care unit and hospital admissions, incidence of delayed rebleeding, and long-term complications, as well as overall survival. RESULTS During the study period, angiography for LGIB was necessary on 123 patients. Out of 123, 55 (45%) underwent embolization attempts. TAE was technically successful in 53 (96%). Rebleeding occurred in 14 (26%). The complication rate was 36%, minor complications occurring in 10 (19%) and major in nine (17%). Major complications resulted in bowel resection in seven (13%). Post embolization ischemia was the most common single complication seen in nine (17%). The mortality rate was 6%. Survival estimates of 1 and 5 years were 79 and 49%. DISCUSSION LGIB is a severe physiological insult occurring in patients who are often elderly and moribund. Although major post embolization complications occur, transcatheter arterial embolization should be the first-line approach over surgery in profuse LGIB in patients with hemodynamic instability, when colonoscopy fails or is unavailable, or when computerized tomography angiography detects small intestinal bleeding.
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Affiliation(s)
- Taina Nykänen
- Helsinki University Hospital, Abdominal Center and University of Helsinki, Department of Surgery, P.O. BOX 340, FI-00029, HUS, Helsinki, Finland.
| | - Erno Peltola
- Helsinki University Hospital, Helsinki Medical Imaging Center, Helsinki, Finland
| | - Leena Kylänpää
- Helsinki University Hospital, Abdominal Center and University of Helsinki, Department of Surgery, P.O. BOX 340, FI-00029, HUS, Helsinki, Finland
| | - Marianne Udd
- Helsinki University Hospital, Abdominal Center and University of Helsinki, Department of Surgery, P.O. BOX 340, FI-00029, HUS, Helsinki, Finland
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Lee NJ, Shin JH, Lee SS, Park DH, Lee SK, Yoon HK. Transcatheter arterial embolization for iatrogenic bleeding after endoscopic ultrasound-guided pancreaticobiliary drainage. Diagn Interv Imaging 2018; 99:717-724. [PMID: 30033142 DOI: 10.1016/j.diii.2018.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 06/26/2018] [Accepted: 06/28/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE The purpose of this study was to report the incidence of massive bleeding after endoscopic ultrasound-guided transmural pancreaticobiliary drainage (EUS-TPBD) and the clinical outcomes in patients with this condition treated with transcatheter arterial embolization (TAE). PATIENTS AND METHODS We performed a 9-year retrospective analysis of 797 EUS-TPBD procedures (excluding gallbladder or pseudocysts) in 729 patients. Among them, twelve (12/729, 1.65%) patients were referred for TAE to manage active bleeding adjacent to the TPBD sites. There were 8 men and 4 women with a mean age of 66.1 years±13.4 (SD) (range: 45-89 years). The clinical and procedure data of these 12 patients were reviewed. RESULTS Thirteen TAE procedures in 12 patients were performed. The bleeding sites were the left hepatic artery (n=7), the right hepatic artery (n=3), the left gastric artery (n=1), the left accessory gastric artery (n=1) and gastroduodenal artery (n=1). TAE was performed with gelatin sponge particles (n=1), coil (n=1) and n-butyl-2 cyanoacrylate with/without coils (n=11), with technical and clinical success rates of 100% (13/13) and 85% (11/13), respectively. Re-bleeding following embolization with gelatin sponge particles occurred in one patient. Procedure-related ischemic hepatitis was observed in another patient with pancreatic cancer with portal vein involvement. CONCLUSION On the basis of our results, TAE using n-butyl-2 cyanoacrylate seems safe and effective for the treatment of bleeding after EUS-TPBD procedures. When the portal vein is compromised, TAE of the hepatic artery can cause ischemic liver damage.
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Affiliation(s)
- N J Lee
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - J H Shin
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea.
| | - S S Lee
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - D H Park
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - S K Lee
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - H-K Yoon
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
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Kwon JH, Kim MD, Han K, Choi W, Kim YS, Lee J, Kim GM, Won JY, Lee DY. Transcatheter arterial embolisation for acute lower gastrointestinal haemorrhage: a single-centre study. Eur Radiol 2018; 29:57-67. [PMID: 29926205 DOI: 10.1007/s00330-018-5587-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 05/25/2018] [Accepted: 06/04/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To investigate the safety and efficacy of transcatheter arterial embolisation (TAE) in the management of lower gastrointestinal bleeding (LGIB) and to identify predictors of clinical outcomes. METHODS Between December 2005 and April 2017, 274 patients underwent diagnostic angiography for signs and symptoms of LGIB; 134 patients with positive angiographic findings were retrospectively analysed. The technical success of TAE and clinical outcomes, including recurrent bleeding, major complications, and in-hospital mortality were evaluated. The associations of various clinical and technical factors with clinical outcomes were analysed. Predictors for clinical outcomes were evaluated using univariate and multivariate logistic regression analyses. RESULTS A total of 134 patients (mean age, 59.7 years; range, 14-82 years) underwent TAE for LGIB. The bleeding foci were in the small bowel in 74 patients (55.2%), colon in 35 (26.1%), and rectum in 25 (18.7%). Technical success was achieved in 127 patients (94.8%). The clinical success rate was 63% (80/127). The rates of recurrent bleeding, major complications, and in-hospital mortality were 27.9% (31/111), 18.5% (23/124), and 23.6% (33/127), respectively. Superselective embolisation and the use of N-butyl cyanoacrylate (NBCA) were significant prognostic factors associated with reduced recurrent bleeding (OR, 0.258; p = 0.004 for superselective embolisation, OR, 0.313; p = 0.01 for NBCA) and fewer major complications (OR, 0.087; p ˂ 0.001 for superselective embolisation, OR, 0.272; p = 0.007 for NBCA). CONCLUSIONS TAE is an effective treatment modality for LGIB. Superselective embolisation is essential to reduce recurrent bleeding and avoid major complications. NBCA appears to be a preferred embolic agent. KEY POINTS • Transcatheter arterial Embolisation (TAE) is a safe and effective treatment for lower gastrointestinal tract haemorrhage. • Superselective embolisation is essential to improve outcomes. • N-butyl cyanoacrylate (NBCA) appears to be a preferred embolic agent with better clinical outcomes.
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Affiliation(s)
- Joon Ho Kwon
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, 50 Yonsei-ro Seodaemun-gu, Seoul, 120-752, Korea
| | - Man-Deuk Kim
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, 50 Yonsei-ro Seodaemun-gu, Seoul, 120-752, Korea.
| | - Kichang Han
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, 50 Yonsei-ro Seodaemun-gu, Seoul, 120-752, Korea
| | - Woosun Choi
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, 50 Yonsei-ro Seodaemun-gu, Seoul, 120-752, Korea
| | - Yong Seek Kim
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, 50 Yonsei-ro Seodaemun-gu, Seoul, 120-752, Korea
| | - Junhyung Lee
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, 50 Yonsei-ro Seodaemun-gu, Seoul, 120-752, Korea
| | - Gyoung Min Kim
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, 50 Yonsei-ro Seodaemun-gu, Seoul, 120-752, Korea
| | - Jong Yun Won
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, 50 Yonsei-ro Seodaemun-gu, Seoul, 120-752, Korea
| | - Do Yun Lee
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, 50 Yonsei-ro Seodaemun-gu, Seoul, 120-752, Korea
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50
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Senadeera SC, Vun SV, Butterfield N, Eglinton TW, Frizelle FA. Role of super-selective embolization in lower gastrointestinal bleeding. ANZ J Surg 2018. [PMID: 29537132 DOI: 10.1111/ans.14441] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Lower gastrointestinal bleeding (LGIB) is a common acute general surgical condition that is typically self-limiting; however in refractory cases it can necessitate life-saving intervention. When bleeding is refractory, super-selective embolization (SSE) becomes an important management strategy. This study aims to evaluate outcomes of this procedure at our institution and identify predictors of clinical success. METHODS A retrospective analysis of patients with positive computed tomography angiograms for LGIB at a tertiary centre between December 2007 and May 2017. RESULTS Of 87 600 acute general surgical admissions, 2700 were for LGIB. Computed tomography angiography demonstrated active bleeding in 104 patients who then had mesenteric angiograms. SSE was performed in 77 patients of whom 66 (86%) demonstrated active bleeding. Technical success was achieved in 75 patients (97%). Clinical success was achieved in 63 patients (81%). Re-bleeding occurred in 14 patients (19%), with four requiring surgery. One patient went forward for re-embolization. Bowel ischaemia occurred in four patients (5.2%), with two requiring bowel resection. A 30-day mortality following SSE was 6.5%, with one death attributable to bowel ischaemia and four deaths from medical comorbidity. Median age (years) of those who had clinical success was 78 (interquartile range (IQR) 16.4) and those who did not was 65 (IQR 20.2) (P = 0.031). Clinical success was more common in those who had diverticular related bleeding (61.9%) compared to other pathologies (38.1%) (P = 0.036). CONCLUSION SSE was successful in a high proportion of patients in this series with low complication rates. Clinical success was higher in those who were older or with diverticular related bleeding.
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Affiliation(s)
- Sajith C Senadeera
- Department of General Surgery, Christchurch Public Hospital, Canterbury, New Zealand.,Department of Radiology, Christchurch Public Hospital, Canterbury, New Zealand
| | - Simon V Vun
- Department of General Surgery, Christchurch Public Hospital, Canterbury, New Zealand
| | | | - Tim W Eglinton
- Department of General Surgery, Christchurch Public Hospital, Canterbury, New Zealand
| | - Frank A Frizelle
- Department of General Surgery, Christchurch Public Hospital, Canterbury, New Zealand
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