Long term follow-up of transcatheter coil embolotherapy for major colonic haemorrhage

Twenty years of embolization for acute lower gastrointestinal bleeding: a meta-analysis of rebleeding and ischaemia rates

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.

Transarterial embolization of acute non-neurologic bleeding using Ethylene Vynil Alcohol Copolymer: a single-Centre retrospective study

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.

Management of acute lower gastrointestinal bleeding by pharmaco-induced vasospasm embolization therapy

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.

Pharmaco-induced vasospasm therapy for acute lower gastrointestinal bleeding: a preliminary report

PURPOSE

To report a novel technique and preliminary clinical outcomes in managing lower gastrointestinal bleeding (LGIB).

MATERIALS AND METHODS

Eighteen LGIB patients (11 men and 7 women, mean age: 66.2 years) were treated with artificially induced vasospasm therapy by semi-selective catheterization technique. Epinephrine bolus injection was used to initiate the vascular spasm, and followed by a small dose vasopressin infusion (3-5 units/h) for 3h. The technical success, clinical success, recurrent bleeding and major complications of this study were evaluated and reported.

RESULTS

Sixteen bleeders were in the superior mesenteric artery and 2 in the inferior mesenteric artery. All patients achieved successful immediate hemostasis. Early recurrent bleeding (<30 days) was found in 4 patients with local and new-foci re-bleeding in 2 (11.1%) each. Repeated vasospasm therapy was given to 3 patients, with clinical success in 2. Technical success for the 21 bleeding episodes was 100%. Lesion-based and patient-based primary and overall clinical successes were achieved in 89.4% (17/19) and 77.7% (14/18), and 94.7% (18/19) and 88.8% (16/18), respectively. None of our patients had complications of bowel ischemia or other major procedure-related complications. The one year survival of our patients was 72.2 ± 10.6%.

CONCLUSIONS

Pharmaco-induced vasospasm therapy seems to be a safe and effective method to treat LGIB from our small patient-cohort study. Further evaluation with large series study is warranted. Considering the advanced age and complex medical problems of these patients, this treatment may be considered as an alternative approach for interventional radiologists in management of LGIB.

Selective arterial embolization with ethylene-vinyl alcohol copolymer for control of massive lower gastrointestinal bleeding: feasibility and initial experience

PURPOSE

To evaluate the efficacy, safety, and clinical outcomes of superselective embolization using ethylene-vinyl alcohol copolymer (Onyx Liquid Embolic System; ev3 Neurovascular, Irvine, California) as the primary treatment for acute and massive lower gastrointestinal bleeding (LGIB).

MATERIALS AND METHODS

Between January 2008 and October 2013, all patients with focal massive LGIB who were treated by embolization were retrospectively analyzed. The study was approved by the hospital's ethics committee; informed consent was obtained in all cases. Onyx was chosen as the embolic agent in all cases in an intention-to-treat fashion. Embolization was indicated in 31 consecutive patients (mean age, 80 y ± 11.1). Multidetector computed tomography and digital subtraction angiography were performed in all patients.

RESULTS

Active bleeding was detected in all cases. A colonoscopy was performed in 11 patients. The correlation between multidetector computed tomography and angiography findings was 96.7%. The causes of bleeding were diverticula in 15 patients, iatrogenic in 7 patients, neoplasia in 3 patients, hemorrhoids in 2 patients, angiodysplasia in 2 patients, and unknown in 2 patients. Embolization was not possible in one patient, who required urgent left hemicolectomy. The technical success rate was 93.5%. The embolic material refluxed in one patient, causing an undesired embolization, without any clinical consequences. In the 30 patients who received embolization, the immediate bleeding control rate was 100%. Rebleeding at 30 days occurred in three patients (10%). There were no major complications, intestinal ischemia, or deaths attributable to the treatment. No patient needed surgery or new embolization during a mean follow-up period of 23.7 months (range, 1-71 mo).

CONCLUSIONS

Control of massive LGIB using superselective embolization with Onyx is feasible and safe.

Management of angiogram-negative acute colonic hemorrhage: safety and efficacy of colonoscopy-guided superselective embolization

BACKGROUND

We evaluated the efficacy and safety of superselective embolization with assistance of colonoscopy for acute colonic hemorrhage.

METHODS

Of 92 cases of acute colonic hemorrhage requiring colonoscopic intervention, 11 (12 %) could not be successfully treated. Of these, 10 patients (9 men, mean age 65.5 years, range 39-75 years) underwent superselective embolization. Hemorrhage was caused by diverticular disease (n = 8), polypectomy (n = 1), and vascular malformation (n = 1). In all 10 cases, the radiopaque clips were placed at the bleeding point via colonoscopy. Microcatheters were used in all procedures, and embolization was performed at the level of the vasa recta leading to or near the clips with Gelfoam particles, microcoils, or both.

RESULTS

Immediate hemostasis was achieved in all patients. In 6 of 10 patients (60 %), selective angiograms showed no active extravasation at the time of the procedure and the embolization was performed using clips as a landmark. In the remaining four patients, selective angiograms showed active extravasation from the vasa recta leading to the clips. The mean number of embolized vessels with no active extravasation and with active extravasation was 1.83 (range 1-3) and 1.25 (range 1-2), respectively. The mean duration of clinical follow-up was 11.6 months (range 1-29 months). One patient (10 %) bled from a different site than the treated site a month after embolization, but the bleeding ceased after endoscopic intervention. All the patients (100 %) were evaluated for objective evidence of ischemia by colonoscopy. Four of the 10 patients (40 %) were found endoscopically to have small areas of ischemia involving only the mucosa, but they remained asymptomatic. There was no bowel infarction or stricture.

CONCLUSIONS

Colonoscopy-assisted superselective embolization may be a safe and useful procedure for acute colonic hemorrhage without active extravasation on angiogram.

An uncommon case of haemorrhagic enteric fever treated successfully with super-selective embolisation using polyvinyl alcohol particles and coils

Lower gastrointestinal haemorrhage due to enteric fever is uncommon and potentially fatal. The majority of patients recover with conservative treatment, with surgery reserved for life-threatening bleeding. Given the advances in radiologically guided procedures, there have been numerous reports of successful embolisation for gastrointestinal haemorrhage, although few of these involved enteric fever as the causative agent. We report an uncommon case of haemorrhagic enteric fever treated successfully with embolisation using polyvinyl alcohol particles and coils.

Current treatment of lower gastrointestinal hemorrhage

Massive lower gastrointestinal bleeding is a significant and expensive problem that requires methodical evaluation, management, and treatment. After initial resuscitation, care should be taken to localize the site of bleeding. Once localized, lesions can then be treated with endoscopic or angiographic interventions, reserving surgery for ongoing or recurrent bleeding.

Factors predictive for a positive invasive mesenteric angiogram following a positive CT angiogram in patients with acute lower gastrointestinal haemorrhage

INTRODUCTION

Computed tomographic mesenteric angiography (CTMA) is increasingly adopted in patients with massive lower gastrointestinal (LGI) bleeding. However, a positive computed tomography scan does not always translate to a positive invasive mesenteric angiography (MA) when performed. The aim of this study was to identify factors that could predict a positive invasive MA following a positive CTMA.

METHODS

A review of all patients with LGI haemorrhage who had a positive CTMA followed by an invasive MA was performed.

RESULTS

From July 2009 to October 2012, 33 positive CTMA scans from 30 patients were identified. Of the 33 bleeding points, 28 were in the colon, while 5 were in the small intestine. Diverticular disease accounted for 20 of the bleeding points. The median duration from the CTMA to the invasive MA was 165 (74-614) min. Of the 33 invasive MAs that were performed, only 14 demonstrated positive extravasation. Factors that were significant for a positive invasive MA included non-diverticular aetiology (odds ratio (OR), 6.75, 95 % confidence interval (CI), 1.43-31.90, p = 0.029) and haemoglobin <100 g/l (OR, 14.44, 95 % CI, 1.56-133.6, p = 0.009). When the invasive MA procedure was performed within <150 min of the positive CTMA scan, it was 2.89 (95 % CI, 0.69-12.12) times more likely to be associated with a positive invasive MA.

CONCLUSIONS

Patients with non-diverticular aetiologies and lower haemoglobin levels are associated with a positive invasive MA following a positive CTMA. It is prudent to consider performing the invasive MA within 150 min after a positive CTMA.

The efficacy and long-term outcome of microcoil embolotherapy for acute lower gastrointestinal bleeding

OBJECTIVE

To evaluate the clinical efficacy as well as long-term clinical outcomes of superselective microcoil embolization for lower gastrointestinal bleeding (LGIB).

MATERIALS AND METHODS

Between 1997 and 2009, 26 patients with intended transcatheter embolotherapy for LGIB were retrospectively reviewed. Embolization was performed only when the catheter could be advanced to or distal to the mesenteric border of the bowel. The main purpose of our study was to assess technical success, recurrent bleeding rate and complications. We also evaluated the long-term clinical outcome, including late recurrent LGIB, bowel ischemia and the survival rate.

RESULTS

Twenty-two bleeding sources were in the territory of superior mesenteric artery and four in the inferior mesenteric artery. Technical success was achieved in 22 patients (84.6%). The target vessel of embolization was vasa recta in seventeen patients and marginal artery in the remaining five patients. Early rebleeding occurred in two patients (7.7%) and bowel ischemia in two patients, of whom the embolized points were both at the marginal artery. Delayed recurrent bleeding (> 30 days) occurred in two angiodysplasia patients. Five patients (19.2%) died within the first 30 days of intervention. Long-term follow-up depicted estimated survival rates of 58.2 and 43.1% after one, and five years, respectively.

CONCLUSION

Transcatheter embolotherapy to treat LGIB is effective with low rebleeding and ischemic complications. Considering the advanced age and complex medical problems of these patients, the minimal invasive embolotherapy may be used as both a primary and potentially definitive treatment of LGIB.

Can superselective embolization be definitive for colonic diverticular hemorrhage? An institution's experience over 9 years

INTRODUCTION

Superselective mesenteric embolization is effective in arresting colonic diverticular hemorrhage with minimal complications, but long-term results are lacking. We aimed to review the short- and long-term outcome of superselective embolization in arresting colonic diverticular hemorrhage in an Asian population.

METHODS

A retrospective review of all patients who underwent superselective embolization for bleeding colonic diverticula from December 2000 to March 2009 was performed. These cases were drawn from a database of embolization for active gastrointestinal hemorrhage. Short-term outcomes (< or =30 days from procedure) identified included rebleeding, ischemia, or any further intervention for any of these two complications. Readmission for rebleeding and/or definitive surgery after 30 days (long-term outcome) was also documented.

RESULTS

Twenty-three patients, median age 65 years (range 41-79 years), formed the study group. Nineteen (82.6%) patients had active hemorrhage from right colonic diverticula while four (17.4%) had left-sided diverticular bleeding. Technical success was achieved in all 23 (100%) patients. SHORT-TERM OUTCOME: Five (21.7%) patients rebled within the same admission, and all underwent surgery. One patient perished from ensuing anastomotic dehiscence and septic shock and accounted for the only mortality (4.3%) in our series. There was no patient with ischemic complications. Another two (8.7%) patients underwent elective surgical resection on the advice of their surgeons in the absence of rebleeding. LONG-TERM OUTCOME: The median follow-up was 40 months (5-99 months). Of the remaining 16 (69.6%) patients for whom the procedure was definitive initially, four (25.0%) rebled within 2 years from the primary procedure, and elective surgery was performed in one of them. Another had repeat embolization, while the other two were successfully managed conservatively. These three patients refused surgical intervention. One patient was lost to follow-up, and the remaining 11 patients had no further complications.

CONCLUSION

Superselective embolization for active colonic diverticular hemorrhage is safe and effective and should be considered as a first line treatment if possible and available. The procedure could act as a bridge to a subsequent more definitive elective surgery or be definitive as seen in over 50% of our patients over a period of 40 months.