Endovascular Treatment of Gastrointestinal Hemorrhage

Role of Interventional Radiology (IR) in vascular emergencies among cirrhotic patients

Gastrointestinal hemorrhage remains one of the most common causes of morbidity and mortality among patients with liver cirrhosis. Mostly, these patients bleed from the gastroesophageal varices. However, nonvariceal bleeding is also more likely to occur in these patients. Because of frequent co-existing coagulopathy, cirrhotics are more prone to bleed from a minor vascular injury while performing percutaneous interventions. Ultrasound-guided bedside vascular access is an essential procedure in liver critical care units. Transjugular portosystemic shunts (TIPS) with/without variceal embolization is a life-saving measure in patients with refractory variceal bleeding. Whenever feasible, balloon-assisted retrograde transvenous obliteration (BRTO) is an alternative to TIPS in managing gastric variceal bleeding, but without a risk of hepatic encephalopathy. In cases of failed or unfeasible endotherapy, transarterial embolization using various embolic agents remains the cornerstone therapy in patients with nonvariceal bleeding such as ruptured hepatocellular carcinoma, gastroduodenal ulcer bleeding, and procedure-related hemorrhagic complications. Among various embolic agents, N-butyl cyanoacrylate (NBCA) enables better vascular occlusion in cirrhotics, even in coagulopathy, making it a more suitable embolic agent in an expert hand. This article briefly entails the different interventional radiological procedures in vascular emergencies among patients with liver cirrhosis.

ENDOVASCULAR DIAGNOSTICS AND TREATMENT OF HEMORRHAGES IN MILITARY AND CIVILIAN PATIENTS FOLLOWING ABDOMINAL SURGERY

OBJECTIVE

The aim: The retrospective analysis of the angiographic picture and clinical results of endovascular treatment of patients with postoperative abdominal and gastrointestinal bleeding was carried out.

PATIENTS AND METHODS

Materials and methods: The results of 447 endovascular diagnostic and therapeutic interventions in 391 patients (46 military and 345 civilians) with postoperative bleeding performed from 2012 to 2022 were studied. According to computer tomography with contrast enhancement, the source of bleeding was identified in 216 (67.7%) cases.

RESULTS

Results: In 345 (88.2%) patients, it was possible to reliably identify the source of bleeding on angiography. In 46 (11.8%) patients with an unexplained source of bleeding, the target arterial pool was determined on the basis of localization, volume, and features of surgical intervention and considered as preventive interventions. A total of 447 endovascular hemostatic interventions were performed on 391 patients. A stent graft was installed in 27 patients, 420 embolization were performed in 364 patients. Thus, in 43 (11.0%) patients, embolization was performed repeatedly, in 12 cases - three times, in 1 case - four times. In 16 cases (15 cases of prophylactic embolization), endovascular hemostasis was ineffective and required subsequent surgical intervention.

CONCLUSION

Conclusions: Endovascular interventions are an effective method of diagnosis and treatment of postoperative abdominal bleeding. Prophylactic embolization allows you to prevent the recurrence of postoperative bleeding with an instrumentally undiagnosed source, however, you need to be prepared for the multi-stage treatment aimed at sequentially shutting down the collateral blood supply to the damaged area.

Evaluation of Open Surgical and Endovascular Treatment Options for Visceral Artery Erosions after Pancreatitis and Pancreatic Surgery

Purpose: To report and compare the results of endovascular and open surgical treatment for erosion bleeding of visceral arteries following pancreatitis and pancreatic surgery. Materials and Methods: This retrospective study included 65 consecutive patients (46 males, mean age 63 ± 14 years) presenting with visceral artery erosions between January 2011 and December 2020. Endpoints were technical success, freedom from reintervention, stent-graft-related complications, and 30-day and one-year mortality. Results: The causes of erosion bleeding included complications of surgical treatment for the pancreas and upper gastrointestinal tract (75%), pancreatitis (19%), and spontaneous bleeding (6%). Pancreatectomy was performed in 34 (52%) patients, representing 2% of all pancreatectomy procedures (n = 1645) performed in our hospital during the study period. A total of 37 (57%) patients underwent endovascular treatment (EVT), and 28 (43%) patients had open surgery (OS) as a primary treatment. Eight of 37 (22%) patients in the EVT group underwent stent-graft treatment of the eroded vessels and 28 (78%) coil embolization. Six (9%) patients underwent reintervention with no significant differences between EVT and OS groups (11% vs. 7%, p = 0.692). Postoperative morbidity and complications in 52% of all patients were higher in the OS group than in the EVT group (41% vs. 68%, p = 0.029). The in-hospital 30-days mortality rate for all patients was 25%, and it was higher in the OS group than in the EVT group (14% vs. 39%, p = 0.017). Conclusions: An endovascular-first strategy for treating visceral arteries erosions may be preferred to reduce the complications associated with open surgery if patients are hemodynamically stable and have no anastomotic insufficiency. Endovascular treatment may be associated with better in-hospital survival when compared to primary open surgery. Further studies are required to identify the optimal approach.