Role of transcatheter arterial embolization for massive bleeding from gastroduodenal ulcers

Selective Arterial Embolization of Ruptured Hepatocellular Carcinoma with N-Butyl Cyanoacrylate and Lipiodol: Safety, Efficacy, and Short-Term Outcomes

The rupture of hepatocellular carcinoma (rHCC) is uncommon but causes sudden life-threatening bleeding. Selective transarterial embolization (STAE) is an effective bleeding-control option. The optimal embolic agent is unknown, and data on the use of cyanoacrylate glue are lacking. The objective of this study was to report the outcomes of cyanoacrylate-lipiodol embolization for rHCC. We retrospectively reviewed the files of the 16 patients (14 males; mean age, 72 years) who underwent emergency cyanoacrylate-lipiodol STAE at a single center in 2012-2023 for spontaneous rHCC. All 16 patients had subcapsular HCC and abundant hemoperitoneum. The technical success rate was 94% (15/16). Day 30 mortality was 19%; the three patients who died had severe hemodynamic instability at admission; one death was due to rebleeding. Liver enzyme levels returned to baseline by day 30. No rebleeding was recorded during the median follow-up of 454 days in the 10 patients who were alive with available data after day 30. Larger prospective studies with the collection of longer-term outcomes are needed to assess our results supporting the safety and effectiveness of cyanoacrylate-lipiodol STAE for rHCC. Randomized trials comparing this mixture to other embolic agents should be performed.

Transcatheter Arterial Embolization for Bleeding Related to Pelvic Trauma: Comparison of Technical and Clinical Results between Hemodynamically Stable and Unstable Patients

BACKGROUND

Endovascular intervention is now the primary line of therapy for arterial injury brought on by pelvic trauma since it can significantly reduce considerable morbidity associated with surgery and can swiftly access and control bleeding sites. Despite international guidelines and widespread awareness of the role of angioembolization in clinical practice, robust evidence comparing the outcomes of angioembolization in hemodynamically stable and unstable patients is still lacking. This study aims to directly compare the outcomes of angioembolization for the treatment of pelvic traumatic arterial injury in patients with hemodynamic stability vs. hemodynamic instability.

METHODS

In our multicenter retrospective investigation, we analyzed data from consecutive patients who underwent, from January 2020 to May 2023, angioembolization for traumatic pelvic arterial injury.

RESULTS

In total, 116 angioembolizations were performed. Gelatin sponges (56.9%) and coils (25.9%) were the most widely used embolic agents. The technical and clinical success rates were 100% and 91.4%, respectively. No statistically significant differences were observed between the two groups in terms of technical success, clinical success, procedure-related complication rate, or 30-day bleeding-related mortality.

CONCLUSIONS

Angioembolization is an effective and safe option for the management of traumatic pelvic arterial lesions even in hemodynamically unstable patients, despite technical variations such as greater use of prophylactic angioembolization.

A Multicenter Retrospective Cohort Study Evaluating the Clinical Outcomes of Patients with Coagulopathy Undergoing Transcatheter Arterial Embolization (TAE) for Acute Non-Neurovascular Bleeding

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.

Transcatheter Arterial Embolization (TAE) in the Management of Bleeding in the COVID-19 Patient

Background and Objectives: Increasing attention is being paid to the coagulation disorders associated with SARS-CoV-2 infection. Bleeding accounts for 3-6% of COVID-19 patient deaths, and is often a forgotten part of the disease. The bleeding risk is enhanced by several factors, including spontaneous heparin-induced thrombocytopenia, thrombocytopenia, the hyperfibrinolytic state, the consumption of coagulation factors, and thromboprophylaxis with anticoagulants. This study aims to assess the efficacy and safety of TAE in the management of bleeding in COVID-19 patients. Materials and Methods: This multicenter retrospective study analyzes data from COVID-19 patients subjected to transcatheter arterial embolization for the management of bleeding from February 2020 to January 2023. Results: Transcatheter arterial embolization was performed in 73 COVID-19 patients for acute non-neurovascular bleeding during the study interval (February 2020-January 2023). Coagulopathy was observed in forty-four (60.3%) patients. The primary cause of bleeding was spontaneous soft tissue hematoma (63%). A 100% technical success rate was recorded; six cases of rebleeding resulted in a 91.8% clinical success rate. No cases of non-target embolization were observed. Complications were recorded in 13 (17.8%) patients. The efficacy and safety endpoints did not differ significantly between the coagulopathy and non-coagulopathy groups. Conclusions: Transcatheter Arterial Embolization (TAE) is an effective, safe and potentially life-saving option for the management of acute non-neurovascular bleeding in COVID-19 patients. This approach is effective and safe even in the subgroup of COVID-19 patients with coagulopathy.

Efficacy and Safety of Ethylene-Vinyl Alcohol (EVOH) Copolymer-Based Non-Adhesive Liquid Embolic Agents (NALEAs) in Transcatheter Arterial Embolization (TAE) of Acute Non-Neurovascular Bleeding: A Multicenter Retrospective Cohort Study

Background and Objectives: Transcatheter arterial embolization (TAE) is part of the daily practice of most interventional radiologists worldwide. The ideal liquid embolic agent is far from being identified. Non-adhesive liquid embolic agents (NALEA) harden from the outside to the inside, resulting in deep penetration, known as "magma-like" progression, which permits a more distal embolization with good control of the embolic material. This multicenter retrospective cohort study aims to assess the efficacy, feasibility and safety of transcatheter arterial embolization (TAE) with ethylene-vinyl alcohol (EVOH)-based NALEAs (Onyx and Squid) in acute bleeding outside of the neurovascular area. Materials and Methods: This study is a multicenter analysis of retrospectively collected data of consecutive patients who had undergone, from January 2015 to December 2022, transcatheter arterial embolization with non-adhesive EVOH-based agents in the setting of acute non-neurovascular bleeding. Results: Fifty-three patients underwent transcatheter arterial embolization for acute non-neurovascular bleeding. Eight (15.1%) procedures were performed in patients with coagulopathy. The most used concentration of EVOH-based NALEAs was 34 (i.e., 8%), with a mean dose of 0.5 (±0.3) mL. The mean CT-to-groin time, the mean procedure time, the mean CT-to-embolization time and the mean fluoroscopy time were 22.9 (±12.4) min, 27.5 (±7) min, 50.3 (±13.1) min and 7.5 (±2.8) min, respectively. Technical success was achieved in all cases with a 96.2% clinical success rate. Complications were recorded in six (11.3%) patients. No statistically significant differences were observed between the group of patients with coagulopathy and the group of patients without coagulopathy in terms of efficacy and safety endpoints. Conclusions: Transcatheter arterial embolization (TAE) performed with non-adhesive EVOH-based embolic agents is an effective, feasible and safe strategy for the management of acute non-neurovascular bleeding, even in the subgroup of patients with coagulopathy.

Transcatheter arterial embolization for acute lower gastrointestinal bleeding using imipenem/cilastatin: a single-center retrospective study

BACKGROUND

Transcatheter arterial embolization (TAE) is a standard treatment for acute lower gastrointestinal bleeding (LGIB) in situations where endoscopic approaches are impossible or ineffective. Various embolic materials, such as metallic coils and N-butyl cyanoacrylate, are used. This study aimed to evaluate the clinical outcomes of an imipenem/cilastatin (IPM/CS) mixture as an embolic agent in TAE for acute LGIB.

RESULTS

Twelve patients (mean age, 67 years) with LGIB treated with TAE using IPM/CS were retrospectively evaluated between February 2014 and September 2022. All patients showed evidence of extravasation on computed tomography and 50% (6/12) also showed evidence on angiography. The technical success rate for TAE in this study was 100%, including in patients who showed active extravasation on angiography. The clinical success rate was 83.3% (10/12), with two patients experiencing rebleeding within 24 h after the procedure. No ischemic complications were observed, and no bleeding episodes or other complications were reported during the follow-up period.

CONCLUSIONS

This study revealed that using IPM/CS as an embolic agent in TAE for acute LGIB may be safe and effective, even in cases of active bleeding.

Material characterization of GPX®: A versatile in situ solidifying embolic platform technology

Endovascular embolization is a minimally invasive procedure during which blood flow to targeted tissues is selectively occluded. The list of clinical indications for embolization continues to expand. Liquid embolic agents are injectable compositions that transition into a solid or semi-solid form when introduced into blood vessels. The mechanism that triggers the liquid-to-solid transition is a key distinguishing feature of liquid embolic agents. GPX is a waterborne liquid embolic agent comprising oppositely charged polyelectrolytes: polyguanidinum and inorganic polyphoshate. In situ solidification is driven by electrostatic condensation of the polyelectrolytes, triggered by ionic strength differentials. We report in vitro characterization of the material properties of GPX, it is in vivo effectiveness in acute animal studies, and its potential for chemoembolization. The viscosity of GPX can be varied over a wide range by adjusting the polyguanidinium MW and/or concentration. Formulation of GPX with either tantalum microparticles (30 wt%) or iodinated radiocontrast agents (300 mgI ml^-1) did not significantly change the flow behavior of GPX; the viscosity was independent of shear rate and remained within a clinically practical range (80-160 cP). Formulation of GPX with doxorubicin substantially increased viscosity at low shear rates and resulted in a power law dependence on shear rate. High contrast and effective vascular occlusion were demonstrated in both swine kidneys and rete mirabile. Contrast from iodinated compounds was temporary, dissipating within hours. The doxorubicin in vitro release profile was linear over 90 days. The results demonstrate that GPX is a versatile liquid embolic platform that can be formulated with a wide range of viscosities injectable at clinically practical flow rates, with either transient or permanent contrast, and that can provide prolonged zero-order delivery of doxorubicin to embolized tissues.

Testicular choriocarcinoma with small bowel metastasis and active gastrointestinal bleeding

Testicular choriocarcinomas make up less than 1% of all germ-cell tumors and are highly malignant, attributable to hematogenous spread. While the most common sites of metastasis are the lungs and liver, metastatic spread to the gastrointestinal tract is rare wherein patients may present with GI distress or even an upper GI bleed. In this report, we present a case of known testicular choriocarcinoma in a 40-year-old male who presented to the emergency room with severe anemia and a suspected upper GI bleed.

Transarterial Embolization for Active Gastrointestinal Bleeding: Predictors of Early Mortality and Early Rebleeding

Background: The aim of this study was to determine predictive factors of early mortality and early rebleeding (≤30 days) following transarterial embolization (TAE) for treatment of acute gastrointestinal bleeding. Methods: All consecutive patients admitted for acute gastrointestinal bleeding to the interventional radiology department in a tertiary center between January 2012 and January 2022 were included. Exclusion criteria were patients: (1) aged < 18-year-old, (2) referred to the operation room without TAE, (3) treated for hemobilia, (4) with mesenteric hematoma, (5) lost to follow-up within 30 days after the procedure. We evaluated pre and per-procedure clinical data, biological data, outcomes, and complications. Results: Sixty-eight patients were included: 55 (80.9%) experienced upper gastrointestinal bleeding and 13 (19.1%) lower gastrointestinal bleeding. Median age was 69 (61−74) years. There were 49 (72%) males. Median hemoglobin was 7.25 (6.1−8.3) g/dL. There were 30 (50%) ulcers. Coils were used in 46 (67.6%) procedures. Early mortality was 15 (22.1%) and early rebleeding was 17 (25%). In multivariate analysis, hyperlactatemia (≥2 mmol/L) were predictive of early mortality (≤30 days). A high number of red blood cells units was associated with early rebleeding. Conclusion: This study identified some predictive factors of 30-day mortality and early rebleeding following TAE. This will assist in patient selection and may help improve the management of gastrointestinal bleeding.

Over-the-scope clip versus transcatheter arterial embolization for refractory peptic ulcer bleeding-A propensity score matched analysis

BACKGROUND

Transcatheter arterial embolization (TAE) or surgery are standard treatment of peptic ulcer bleeding (PUB) refractory to endoscopic hemostasis. Over-the-scope clips (OTSC) have shown superiority to standard endoscopic treatment.

OBJECTIVE

To compare OTSC treatment to TAE in refractory peptic ulcer bleeding.

PATIENTS AND METHODS

In this retrospective, multicenter study, 128 patients treated with OTSC (n = 66) or TAE (n = 62) for refractory PUB between 2009 and 2019 in four academic centers were analyzed. Primary endpoint was clinical success (hemostasis + no rebleeding within 7 days). Secondary endpoints were adverse events, length of ICU stay, and mortality. Propensity score matching was performed to adjust for differences in baseline characteristics.

RESULTS

Patients characteristics were similar in both groups but ulcers in the TAE group were larger, more often located in the duodenal bulb (85.5% vs. 65.2%; p = 0.014), and that the proportion of Forrest Ia bleedings was higher (38.7% vs. 19.7%; p = 0.018). Clinical success was comparable in both groups (74.2% vs. 59.7%; p = 0.092). Stay on the intensive care unit (ICU) was significantly longer in the TAE group (mean 8.0 vs. 4.7 days; p = 0.002). Serious adverse events after re-therapy (12.9% vs. 1.5%; p = 0.042) and in-hospital mortality were significantly higher in the TAE group (9.1 vs. 22.6%, OR 2.92 [95% CI 1.04-8.16]; p = 0.05). After propensity score matching, the differences found regarding ICU stay (4.9± 5.9 and 9.2 ± 11.2; p = 0.009) and in-hospital mortality (5% vs. 22.5%; OR 5.52 [95% CI: 1.11-27.43]; p = 0.048) stayed significant.

CONCLUSIONS

OTSC treatment for refractory PUB was superior to TAE in terms of ICU stay and in-hospital mortality.

Efficacy, safety and outcomes of transcatheter arterial embolization with N-butyl cyanoacrylate glue for non-variceal gastrointestinal bleeding: A systematic review and meta-analysis

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.

Endovascular retrieval of a dislocated pushable coil in the common hepatic artery using a cerebral stent retriever

BACKGROUND

This is case of removing a dislocated pushable coil from the common hepatic artery (CHA) as a possible complication of using pushable coils in the embolization of an upper gastrointestinal bleeding (UGIB) from the gastroduodenal artery (GDA) by using a pRESET stent retriever (Phenox, Bochum, Germany) which is utilized mainly for treatment of endovascular stroke.

CASE PRESENTATION

An 88-year-old female patient was referred to our hospital to get an emergency embolization of the GDA causing an UGIB with a relevant drop of the hemoglobin level. During the routine embolization of the GDA using pushable coils, a complete dislocation of the last coil into the CHA took place leading to a relevant slowing down of the arterial blood flow to the liver. A decision was thereby made to remove the dislocated coil to avoid further possible complications which was successfully achieved.

CONCLUSIONS

Various stent retrievers have been proven to be effective in removing dislocated coils during intracerebral coiling of different pathologies. This case report is to our knowledge the first case report proving the high efficacy and safety of using yet another stent retriever, namely a pRESET stent retriever in removing a fully dislocated coil in the abdominal vessels, namely in this case the CHA.

Use of Phil Embolic Agent for Bleeding in Non-Neurological Interventions

Objective: To evaluate the safety and efficacy of the Phil liquid embolic agent in non-neurological embolization procedures. M&M: Thirty-five patients with a mean age of 62.5 years underwent percutaneous embolization using Phil for the treatment of visceral arterial bleedings in 20/35 patients (including three gluteal, one bladder, two superior mesenteric, three epigastric, one deep femoral, five internal iliac, four intercostal, and one lingual arteries), splanchnic pseudoaneurysms in 11/35 patients (including three hepatic, five splenic, and three renal arteries), pancreatic bleeding metastasis in 1/35 patient, and gastric bleeding varices in 3/35 patients. Phil is composed of a non-adhesive copolymer dissolved in DMSO (Anhydrous Dimethyl Sulfoxide) with different viscosity. Procedures were performed slowly under continuous fluoroscopic guidance to avoid embolization of non-target vessels. Results: Clinical success was obtained with a single intervention in 34 cases (97.15%), while a repeated procedure was required in one case (2.85%). No technical complications nor non-target embolization occurred. A case of post-embolic syndrome was noted (2.85%) in one patient. DMSO administration-related pain was successfully controlled by medical therapy. Conclusion: Phil can be considered a safe and effective embolic agent for the treatment of non-neurologic bleeding.

Systematic Review and Meta-Analysis of Prophylactic Transarterial Embolization for High-Risk Bleeding Peptic Ulcer Disease

The present systematic review determined the role of transarterial embolization (TAE) as a prophylactic treatment in bleeding peptic ulcers after initial successful endoscopic hemostasis. PubMed and Ovid Medline databases were searched from inception until July 2019 for studies that included patients deemed high-risk based on Forrest Classification, Rockall score ≥ 5, or endoscopic evaluation in addition to those who underwent prophylactic TAE after initial successful endoscopic hemostasis. Meta-analysis was performed to compare patients who underwent endoscopic therapy (ET) and TAE with those who underwent ET alone. The primary outcomes measured included rates of rebleeding, reintervention, and 30-day mortality. Secondary outcome measures evaluated length of hospitalization, technical success rates, and complications associated with TAE. Of 916 publications, 5 were eligible for inclusion; 310 patients with high-risk peptic ulcer bleeding underwent prophylactic TAE, and 255 were compared against a control group of 580 patients that underwent standard treatment with ET alone. Patients who underwent ET with TAE had lower 30-day rebleeding rates (odds ratio [OR], 0.35; 95% confidence interval [CI] 0.15-0.85; P = .02; I² = 50%). The ET with TAE group had a lower 30-day mortality rate (OR, 0.28; 95% CI, 0.10-0.83; P = .02; I² = 58%). There was no difference in pooled reintervention rates (OR, 0.68; 95% CI, 0.43-1.08; P = .10; I² = 0%) and length of hospitalization (mean difference, -0.32; 95% CI, -1.88 to 1.24; P = .69; I² = 0%). Technical success rate of prophylactic TAE was 90.5% (95% CI, 83.09-97.98; I² = 75.9%). Pooled proportion of overall complication rate was 0.18% (95% CI, 0.00-1.28; I² = 0%). Prophylactic TAE has lower rebleeding and mortality with a good success rate and low complications. Prophylactic TAE after primary ET may be recommended for selected patients with high-risk bleeding ulcers; however, further studies should be performed to establish this as a routine tool in patients with bleeding peptic ulcer disease.

Ulcer Disease in the Excluded Segments after Roux-en-Y Gastric Bypass: a Current Review of the Literature

Ulcer disease in excluded segments after Roux-Y gastric bypass (RYGB) is rare but can evolve into a life-threatening situation. The excluded segments exhibit a different behavior from that of non-altered anatomy; perforated ulcers do not result in pneumoperitoneum or free fluid, and therefore must be met with a low threshold for surgical exploration. The anatomical changes after RYGB impede routine access to the remnant stomach and duodenum. There are various options to address bleeding or perforated ulcers. While oversewing and drainage preserves the anatomy and forgoes resection, remnant gastrectomy offers a definitive solution. The importance of traditional risk factors such as smoking or use of non-steroidal anti-inflammatory drugs is unclear. Eradication of Helicobacter pylori and secondary prophylaxis with proton-pump inhibitors is advisable, albeit in double-dose.

Gastric Dieulafoy's lesion with subepithelial lesion-like morphology

Most cases of Dieulafoy's lesion, a rare cause of upper gastrointestinal bleeding, occur in the upper gastric corpus, usually with no edematous bulging or fold convergence around the mucosal defect. This report describes a case of Dieulafoy's lesion with subepithelial lesion (SEL)-like morphology. Endoscopic treatment by hemoclipping was difficult. Because of repeated bleeding, abdominal dynamic contrast computed tomography (CT) was conducted. Results showed a large caliber, tortuous artery branching directly from the celiac artery and feeding into the gastric wall of the gastric fundus. Rupture of this vessel in the submucosa was thought to be responsible for the SEL-like morphology. All findings indicated endoscopic treatment from the gastric mucosal side was too difficult. Therefore, we treated the lesion using interventional radiology (IR) technique of vascular embolization. If an SEL-like Dieulafoy's lesion cannot be treated by endoscopic hemostasis, then IR might be necessary to treat the vascular anomaly.

Embolization for delayed arterial bleeding after percutaneous self-expandable metallic stent placement in patients with malignant biliary obstruction

OBJECTIVES

To retrospectively evaluate the safety and efficacy of transcatheter arterial embolization (TAE) for delayed arterial bleeding secondary to percutaneous self-expandable metallic stent (SEMS) placement in patients with malignant biliary obstruction (MBO).

METHODS

From January 1997 to September 2017, 1858 patients underwent percutaneous SEMS placement for MBO at a single tertiary referral center. Among them, 19 patients (mean age, 70.2 [range, 52-82] years; 13 men) presented with delayed SEMS-associated arterial bleeding and underwent TAE.

RESULTS

The incidence of delayed arterial bleeding was 1.0% (19/1858) after SEMS placement, with a median time interval of 225 days (range, 22-2296). Digital subtraction angiography (DSA) showed pseudoaneurysm alone close to the stent mesh (n = 10), pseudoaneurysm close to the stent mesh with contrast extravasation to the duodenum (n = 3), pseudoaneurysm close to the stent mesh with arteriobiliary fistula (n = 1), in-stent pseudoaneurysm alone (n = 4) and in-stent pseudoaneurysm with arteriobiliary fistula (n = 1). Bleeding was stopped after the embolization in all patients. Overall clinical success rate was 94.7% (18/19). One patient with recurrent bleeding was successfully treated with a second embolization. Overall 30-day mortality rate was 26.3% (5/19). A major procedure-related complication was acute hepatic failure in one hilar bile duct cancer patient (5.3%), which was associated with an obliterated portal vein.

CONCLUSION

TAE is safe and effective for the treatment of delayed arterial bleeding after percutaneous SEMS placement for MBO.

ADVANCES IN KNOWLEDGE

This study demonstrated TAE is safe and effective for arterial bleeding after SEMS placement after MBO through the largest case series so far.

Clinical Outcome of the Visible Coil During Endoscopy After Transcatheter Arterial Embolization for Gastrointestinal Bleeding

PURPOSE

This study was designed to evaluate the clinical outcome of the visible coil during endoscopy after transcatheter arterial embolization (TAE) for gastrointestinal bleeding.

METHODS

We retrospectively reviewed the medical records of 1415 patients who underwent TAE for gastrointestinal bleeding between 2001 and 2017. Among these 1415 patients, 70 underwent TAE using coils and consecutive follow-up endoscopy. Finally, 11 patients with an extravascular coil seen on follow-up endoscopic examination were included in this study. We evaluated the underlying cause of the gastrointestinal bleeding, the technical and clinical success rates, the type of extravascular coil after TAE, and the clinical outcomes of the extravascular coil seen on follow-up endoscopic examination.

RESULTS

Of the 11 patients, the most common underlying cause of gastrointestinal bleeding was a duodenal ulcer (n = 7). On angiography, the bleeding artery was most commonly found in the gastroduodenal artery (n = 6). The technical success and clinical success rates of TAE were 100% and 90.9%, respectively. The type of extravascular coil found on endoscopic examination was classified by submucosal migration (n = 6) and protrusion (n = 5). On second-look endoscopic evaluation, 10 of 11 (90.9%) patients showed healing ulceration. On the final-look endoscopic evaluation, healing ulceration without further bleeding was seen in one (9.1%) patient and scar formation was seen in ten (90.9%) patients.

CONCLUSIONS

Extravascular coil after TAE for gastrointestinal bleeding is rare, and the most common underlying cause is duodenal ulcer bleeding. The extravascular coils eventually show a healing process with adequate treatment of underlying bowel pathologies.

[Transcatheter embolization in prevention of recurrent bleeding from stomach ulcers]

AIM

To evaluate an efficacy of endovascular hemostasis in patients with gastric ulcerative bleeding and high risk of recurrent bleeding and death.

MATERIAL AND METHODS

The work is based on a study of the results in 30 patients with gastric ulcerative bleeding, high risk of recurrent bleeding (rebleeding forecast system (RFS) score over 17) and high risk of death (SAPS II score over 30). We attempted transcatheter embolization of left gastric artery to prevent rebleeding. The control group consisted of 60 patients with gastric ulcerative bleeding and the same RFS and SAPS II values in whom angiography and endovascular hemostasis were not performed.

RESULTS

Technical success of endovascular hemostasis was achieved in 25 (83.3%) cases. In 5 cases embolization was not performed. Complications after transcatheter angiography and embolization were absent. Recurrent bleeding after technically successful embolization was observed in 3 (12.0%) patients. In all cases PVA microemboli were used. Mortality was 11.1% (3 patients).

CONCLUSION

Endovascular hemostasis in patients with severe comorbidities (SAPS II score over 30) and high risk of rebleeding (RFS score over 17) reduced incidence of recurrent bleeding from 36.7% to 11.1%.

Successful endovascular treatment of endoscopically unmanageable hemorrhage from a duodenal ulcer fed by a renal artery: A case report

A 52-year-old woman was admitted with hypovolemic shock. Emergency endoscopy revealed three hemorrhagic duodenal ulcers (all stage A1) with exposed vessels. Two ulcers were successfully treated by endoscopic clipping; however, the remaining ulcer on the posterior wall of the horizontal portion of the duodenum could not be clipped. Because her vital signs were rapidly worsening, we performed transcatheter arterial embolization (TAE) as it is less invasive than surgery. Computed tomography aortography showed that the duodenal hemorrhage was sourced from the lower branch of the right renal artery. In general, the duodenum is fed by branches from the gastroduodenal artery or superior mesenteric artery. However, this patient had three right renal arteries. The lower branch of the right renal artery at the L3 vertebral level was at the same level as the horizontal portion of the duodenum. Complete hemostasis was achieved by TAE using metallic coils and n-butyl-2-cyanoacrylate. After TAE, she recovered from the hypovolemic shock and was discharged from hospital. She has had no recurrence of the hemorrhagic duodenal ulcer for over 1 yr, and follow-up endoscopy showed no necrosis or stricture of the duodenum. Although she developed a small infarct of her right kidney, her renal function was satisfactory. In summary, the present case is the first reported case of hemorrhagic duodenal ulcer in which the culprit vessel was a renal artery that was successfully treated by TAE. Computed tomography aortography before TAE provides valuable information regarding the source of a duodenal hemorrhage.

Transcatheter Arterial Embolization for Bleeding Peptic Ulcers: A Multicenter Study

PURPOSE

To investigate the outcomes of transcatheter arterial embolization (TAE) for the treatment of peptic ulcer bleeding (PUB).

MATERIALS AND METHODS

This is a retrospective, multicenter study, which investigated all patients who underwent TAE for the treatment of severe upper gastrointestinal hemorrhage from peptic ulcers in five European centers, between January 1, 2012 and May 1, 2017. All patients had undergone failed endoscopic hemostasis. Forty-four patients (male; mean age 74.0 ± 11.1 years, range 49-94), with bleeding from duodenum (36/44; 81.8%) or gastric ulcer (8/44; 18.2%) were followed up to 3.5 years (range 2-1354 days). In 42/44 cases, bleeding was confirmed by pre-procedural CT angiography. In 50% of the cases, coils were deployed, while in the remaining glue, microparticles, gel foam and combinations of the above were used. The study's outcome measures were 30-day survival technical success (occlusion of feeding vessel and/or no extravasation at completion DSA), overall survival, bleeding relapse and complication rates.

RESULTS

The technical success was 100%. The 30-day survival rate was 79.5% (35/44 cases). No patients died due to ongoing or recurrent hemorrhage. Re-bleeding occurred in 2/44 cases (4.5%) and was successfully managed with repeat TAE (one) or surgery (one). The rate of major complications was 4.5% (2/44; one acute pancreatitis and one partial pancreatic ischemia), successfully managed conservatively. According to Kaplan-Meier analysis survival was 71.9% at 3.5 years.

CONCLUSIONS

TAE for the treatment of PUB was technically successful in all cases and resulted in high clinical success rate. Minimal re-bleeding rates further highlight the utility of TAE as the second line treatment of choice, after failed endoscopy.

Successful endovascular treatment of a 13-month-old child with gastrointestinal bleeding due to Dieulafoy syndrome of duodenum

Dieulafoy disease can manifest itself with spontaneous massive recurrent gastrointestinal bleeding in children. We report a case of successful management of a 13-month-old child with Dieulafoy disease of duodenum when traditional methods of examination and treatment failed.

Emergency transcatheter arterial embolization for massive gastrointestinal arterial hemorrhage

To evaluate the different arteriographic manifestations of acute arterial massive hemorrhage of the gastrointestinal (GI) tract and the efficacy of emergency transcatheter arterial embolization (ETAE).A total of 88 patients with acute massive GI bleeding who experienced failure of initial endoscopy and/or conservative treatment were referred to our interventional department for acute GI arteriography from January 2007 to June 2015. After locating the source of bleeding, appropriate embolic agents, such as spring coil, hydroxyl methyl acrylic acid gelatin microspheres, polyvinyl alcohol (PVA) particles, etc., were used to embolize the targeted vessels. The angiographic manifestations and the effects of embolization of acute arterial massive hemorrhage of the GI tract were retrospectively analyzed.Of the 88 patients, 54 were diagnosed with arterial hemorrhage of the upper GI tract and 34 with arterial hemorrhage of the lower GI tract. Eighty cases were associated with positive angiography, which showed the following: contrast extravasation (only); gastroduodenal artery stenosis; pseudoaneurysm (only); pseudoaneurysm rupture with contrast extravasation; pseudoaneurysms merged with intestinal artery stenosis; GI angiodysplasia; and tumor vascular bleeding. Eight cases were diagnosed with negative angiography. Seven-two patients underwent successful hemostasis, and a total of 81 arteries were embolized. The technical and clinical success rates (no rebleeding within 30 days) in performing transcatheter embolization on patients with active bleeding were 100% and 84.71%, respectively (72 of 85). Within 30 days, the postoperative rebleeding rate was 15.29% (13/85). Of these rebleeding cases, 2 patients were formerly treated with "blind embolization," 7 underwent interventional embolic retreatment, and 3 had surgical operations. All cases were followed-up for 1 month, and 3 patients died from multiple organ failure. No serious complications such as bowel ischemia necrosis were observed.ETAE is a safe, effective, and minimally invasive treatment; because of the diversified arteriographic manifestations of acute GI hemorrhage, the proper selection of embolic agents and the choice of reasonable embolization method are essential for successful hemostasis.

Acute ischemic pancreatitis: A rare complication of empirical gastroduodenal artery embolization

Empirical embolization of the gastroduodenal artery (GDA) is accepted as a safe and effective treatment option for endoscopy-refractory nonvariceal upper gastrointestinal bleeding (UGIB) in patients with high surgical risk. Nontarget embolization is a recognized complication of transarterial embolization, however, symptomatic pancreatic injury is extremely rare. We report a patient who developed acute ischemic pancreatitis immediately after embolization of the GDA, which was confirmed intraoperatively. Interventionists as well as referring clinicians need to be aware of this rare but life threatening complication.

Migrating coil

We describe a rare case of a 60-year-old man with known history of peptic ulcer disease who presented with melena and epigastric pain secondary to coil migration into duodenal mucosa 4 years after the initial therapeutic embolisation of the gastroduodenal artery. Upper endoscopy revealed oozing duodenal ulcer at the same site of the previously located duodenal ulcer 4 years ago and metal coil impacted at the duodenal mucosa. It is unclear if the coil migration is the effect or the cause of the bleeding duodenal ulcer. Our patient was treated by surgical intervention due to failed endoscopic haemostasis and medical management.

[Endovascular arterial embolization for duodenal bleeding as an alternative to surgical approach]

AIM

To present possibilities of transcatheter arterial embolization (TAE) in duodenal bleeding management.

MATERIAL AND METHODS

Treatment of 212 patients with acute duodenal bleeding for the period from 2012 to 2014 was analyzed. In 32 (22.5%) patients of the study group bleeding recurrence or its high risk was indication for TAE.

RESULTS

Change of surgical tactics for bleeding from upper gastrointestinal tract including endoscopic hemostasis optimization, wide introduction of TAE and sharp decrease of surgical activity reduced overall mortality to 1.6% in 2012--2014.

CONCLUSION

TAE is effective to control bleeding and reduces mortality rate especially in high risk and elderly patients.

Evaluation of gastrointestinal bleeding: Update of current radiologic strategies

Gastrointestinal bleeding (GIB) is a common presentation with significant associated morbidity and mortality, the prevalence of which continues to rise with the ever-increasing aging population. Initial evaluation includes an esophagoduodeonscopy and/or colonoscopy, which may fail to reveal a source. Such cases prove to be a dilemma and require collaboration between gastroenterology and radiology in deciding the most appropriate approach. Recently, there have been a number of radiologic advances in the approach to GIB. The purpose of this review is to provide an evidence-based update on the most current radiologic modalities available and an algorithmic approach to GIB.

Application of cyanoacrylate in difficult-to-arrest acute non-variceal gastrointestinal bleeding

Gastrointestinal bleeding is a common medical emergency. Although endoscopic treatment is effective in controlling non-variceal upper gastrointestinal bleeding, in cases of persistent bleeding radiological or surgical interventions are required. Application of cyanoacrylate for treatment of difficult-to-arrest non-variceal upper gastrointestinal bleeding is poorly investigated. We describe patients in whom cyanoacrylate for acute non-variceal gastrointestinal bleeding was used to stop the bleeding after failure of conventional endoscopic treatment. Five patients were treated with cyanoacrylate application (injection and/or spraying) for persistent bleeding (duodenal ulcer in 3, gastric ulcer in 1 and gastric Dieulafoy's lesion in 1) despite conventional endoscopic therapies. Hemostasis was achieved in all patients (100%). One patient (20%) developed recurrent bleeding 4 days after initial treatment. No complications or adverse events attributed to the cyanoacrylate application during the follow-up period of 57 days were observed. Application of cyanoacrylate is a safe and effective method to achieve immediate hemostasis when conventional endoscopic treatment is unsuccessful. This technique is easy to perform and should be considered in cases of patients with difficult-to-arrest acute non-variceal upper gastrointestinal bleeding.

Reduced hemoglobin and increased C-reactive protein are associated with upper gastrointestinal bleeding

AIM: To investigate the early upper gastrointestinal endoscopy (endoscopy) significantly reduces mortality resulting from upper gastrointestinal (GI) bleeding.

METHODS: Upper GI bleeding was defined as 1a, 1b, 2a, and 2b according to the Forrest classification. The hemoglobin (Hb), and C-reactive protein (CRP) were examined at around the day of endoscopy and 3 mo prior to endoscopy. The rate of change was calculated as follows: (the result of blood examination on the day of endoscopy - the results of blood examination 3 mo prior to endoscopy)/(results of blood examination 3 mo prior to endoscopy). Receiver operating characteristic curves were created to determine threshold values.

RESULTS: Seventy-nine men and 77 women were enrolled. There were 17 patients with upper GI bleeding: 12 with a gastric ulcer, 3 with a duodenal ulcer, 1 with an acute gastric mucosal lesion, and 1 with gastric cancer. The area under the curve (AUC), threshold, sensitivity, and specificity of Hb around the day of endoscopy were 0.902, 11.7 g/dL, 94.1%, and 77.1%, respectively, while those of CRP were 0.722, 0.5 mg/dL, 70.5%, and 73%, respectively. The AUC, threshold, sensitivity, and specificity of the rate of change of Hb were 0.851, -21.3%, 76.4%, and 82.6%, respectively, while those of CRP were 0.901, 100%, 100%, and 82.5%, respectively.

CONCLUSION: Predictors for upper GI bleeding were Hb < 11.7 g/dL, reduction rate in the Hb > 21.3% and an increase in the CRP > 100%, 3 mo before endoscopy.

Glue embolization for gastroduodenal ulcer bleeding: contribution to hemodynamics and healing process

BACKGROUND

Although the morbidity of bowel ischemic events after glue embolization has been suggested, a causal relationship between glue and ischemia has not been clearly established.

PURPOSE

To evaluate the efficiency and safety of transcatheter arterial embolization with n-butyl cyanoacrylate (NBCA-TAE) for upper gastrointestinal hemorrhage (GIH).

MATERIAL AND METHODS

Between October 2006 and October 2012, 21 patients with upper GIH underwent NBCA-TAE, and endoscopic data were obtained within 30 days of follow-up. Shock index prior to and immediately after NBCA-TAE were compared to determine changes in hemodynamics. Days to Forrest type III, as assessed by follow-up endoscopy, was used as an indicator of the healing process. Other clinical outcomes included days for starting ingestion and for hospital discharge.

RESULTS

Sixteen gastric and five duodenal ulcers, classified into Forrest type I, were treated. Immediate hemostasis was achieved in all the patients, and no re-bleeding occurred within the follow-up period. Shock index significantly (P < 0.001) improved from before (0.99 ± 0.076) to immediately after NBCA-TAE (0.67 ± 0.038). Sequential mucosal healing processes were observed in all the patients, and the number of days to Forrest type III was 9.6 ± 7.1. The number of days for starting ingestion and hospital discharge was 9.0 ± 4.5 and 15 ± 7.7 days, respectively.

CONCLUSION

NBCA-TAE is an effective and safe method for the control of nonvariceal upper GIH, in terms of contribution to hemodynamics and healing process of the gastroduodenal mucosa.

Transcatheter arterial embolization with N-butyl cyanoacrylate for acute life-threatening gastroduodenal bleeding uncontrolled by endoscopic hemostasis

PURPOSE

To investigate the feasibility, efficacy, and safety of transcatheter arterial embolization with N-butyl cyanoacrylate (NBCA) for gastroduodenal nonvariceal bleeding uncontrolled by endoscopic hemostasis.

MATERIALS AND METHODS

Between January 2006 and December 2011, a total of 317 patients underwent emergent endoscopic therapy for nonvariceal gastroduodenal bleeding, but hemostasis was not achieved in 20 cases. Emergent surgery was performed immediately following endoscopy in two patients. Arteriography was performed in the remaining 18 patients, and embolization with NBCA was performed in 15 patients (mean age, 71.3 y) in whom the bleeding site was detected on arteriography. For embolization, NBCA was mixed with iodized oil at a ratio of 1:1.5-1:4, and no other embolic material was used in the procedure. Technical and clinical success rates, recurrent bleeding, procedural time, complications, and clinical outcomes were determined for each procedure.

RESULTS

Embolization with NBCA was technically and clinically successful in all procedures, without major complications. No patient receiving embolization with NBCA experienced recurrent bleeding or required further treatment after the one-session procedure. All patients were discharged after clinical improvement. The time between puncture of the femoral artery and completion of embolization ranged from 25 to 240 minutes (mean, 66 min), and the time between the microcatheter reaching the ultimate catheter location selected for embolization and hemostasis ranged from 142 to 550 seconds (mean, 322s).

CONCLUSIONS

In this limited series, embolization with NBCA was found to be a safe, feasible, and effective treatment for gastroduodenal arterial bleeding when endoscopic hemostasis had failed.

Successful Embolization of a Cytomegalovirus-Related Duodenal Ulcer in a Kidney-Pancreas Transplant Recipient

One of the complications that can occur in pancreas transplant is a massive intestinal hemorrhage, although such a hemorrhage is very rarely caused by ulcers due to cytomegalovirus infection. Treatment is fundamentally based on relaparatomy, although in some cases interventional radiology can be an efficient alternative because it allows the exact bleeding point to be located and therapeutic embolization to be performed. In this case, a man with diabetes type 1 who was given a simultaneous kidney-pancreas transplant had an ulcer due to cytomegalovirus infection develop in the duodenal graft (in the early postoperative period), causing a severe hemorrhage in the lower part of the gastrointestinal tract that was controlled via selective embolization of a branch of the pancreaticoduodenal artery.

Imipenem/cilastatin sodium (IPM/CS) as an embolic agent for transcatheter arterial embolisation: a preliminary clinical study of gastrointestinal bleeding from neoplasms

PURPOSE

To evaluate the feasibility and usefulness of imipenem/cilastatin sodium (IPM/CS) as an embolic agent for intestinal bleeding from neoplasms.

MATERIALS AND METHODS

Seven patients who underwent 11 transarterial embolisations (TAEs) using IPM/CS as an embolic material for duodenal or small/large intestinal tumour bleeding from January 2004 to December 2011 were retrospectively evaluated. A mixture of IPM/CS and contrast medium was introduced through the microcatheter positioned at the feeding artery to the tumour until extravasation disappeared or stasis of blood flow to the tumour staining was observed.

RESULTS

Haemostasis was obtained in all patients. Therefore, the technical success rate was 100%. Rebleeding was observed in four patients. All of them underwent repeat TAE using IPM/CS, and haemostasis was obtained successfully. No complication was identified following laboratory and clinical examinations. No haemorrhagic death occurred. Haemorrhagic parameters, including blood haemoglobin and the amount of blood transfusion, improved after TAE.

CONCLUSION

The safety, feasibility, and effectiveness of TAE using IPM/CS as an embolic material for intestinal bleeding from neoplasms were suggested by this study. The mild embolic effect of IPM/CS may be adequate for oozing from tumours. Although rebleeding may occur after embolotherapy using IPM/CS, repeat embolisation is effective as treatment for rebleeding.

Bedside bleeding control, review paper and proposed algorithm

Bleeding is a common occurrence in practice, but occasionally it may be challenging issue to overcome. It can come from numerous sources such as, trauma, during or post-surgical intervention, disorders of platelet and coagulation factors and increased fibrinolysis, wounds and cancers. This paper was inspired from our experience with a patient admitted to a local long term acute care facility with a large fungating right breast cancerous wound. During her hospital stay spontaneous bleeding from her breast cancerous mass was encountered and became more frequent and significant over the period of her stay. Different hemostatic technologies were used to control her bleeding. We felt that it was important to share our experience with our colleagues to help with potential similar situation that they may face.

Mini-loop ligation of a bleeding duodenal Dieulafoy's lesion

Two percent of gastrointestinal hemorrhages are caused by Dieulafoy’s lesions, which are located in duodenum in only 15% of cases. There are no recommendations regarding the prime endoscopic treatment technique for this condition. A 61-year-old woman presented with melena without signs of hemodynamic instability. During an urgent upper endoscopy, blood oozing from the normal mucosa of the duodenum was seen and this was classified as a Dieulafoy’s lesion. A mini-loop was opened at the rim of a transparent ligation chamber, at the end of the endoscope, and after aspiration of the lesion, closed and detached. Complete hemostasis was achieved without early or postponed complications. In every day clinical practice, mini-loop ligation is rarely used because of possible complications, such as site ulceration, organ perforation, re-bleeding and possible inexperience of the operator. To the best of our knowledge this is the first case of successful treatment of bleeding duodenal Dieulafoy’s lesion by mini-loop ligation.

Challenges in the management of acute peptic ulcer bleeding

Acute upper gastrointestinal bleeding is a common medical emergency worldwide, a major cause of which are bleeding peptic ulcers. Endoscopic treatment and acid suppression with proton-pump inhibitors are cornerstones in the management of the disease, and both treatments have been shown to reduce mortality. The role of emergency surgery continues to diminish. In specialised centres, radiological intervention is increasingly used in patients with severe and recurrent bleeding who do not respond to endoscopic treatment. Despite these advances, mortality from the disorder has remained at around 10%. The disease often occurs in elderly patients with frequent comorbidities who use antiplatelet agents, non-steroidal anti-inflammatory drugs, and anticoagulants. The management of such patients, especially those at high cardiothrombotic risk who are on anticoagulants, is a challenge for clinicians. We summarise the published scientific literature about the management of patients with bleeding peptic ulcers, identify directions for future clinical research, and suggest how mortality can be reduced.

Management of duodenal ulcer bleeding resistant to endoscopy: Surgery is dead!

Acute massive duodenal bleeding is one of the most frequent complications of peptic ulcer disease. Endoscopy is the first-line method for diagnosing and treating actively bleeding peptic ulcers because its success rate is high. Of the small group of patients whose bleeding fails to respond to endoscopic therapy, increasingly the majority is referred for embolotherapy. Indeed, advances in catheter-based techniques and newer embolic agents, as well as recognition of the effectiveness of minimally invasive treatment options, have expanded the role of interventional radiology in the management of hemorrhage from peptic ulcers over the past decade. Embolization may be effective for even the most gravely ill patients for whom surgery is not a viable option, even when extravasation is not visualized by angiography. However, it seems that careful selection of the embolic agents according to the bleeding vessel may play a role in a successful outcome. The role of the surgeon in this clinical sphere is dramatically diminishing and will certainly continue to diminish in ensuing years, surgery being typically reserved for patients whose bleeding failed to respond all previous treatments. Such a setting has become extremely rare.

Transcatheter arterial embolization of acute arterial bleeding in the upper and lower gastrointestinal tract with N-butyl-2-cyanoacrylate

PURPOSE

To assess the clinical utility and safety of transcatheter arterial embolization with N-butyl-2-cyanoacrylate (NBCA) for urgent control of acute arterial bleeding in the upper and lower gastrointestinal tract.

MATERIALS AND METHODS

Therapeutic NBCA embolization was performed in 37 patients (39 cases; mean age, 67.8 years) with acute upper (n = 16) or lower (n = 23) gastrointestinal tract bleeding after endoscopic management had failed. Transcatheter arterial embolization was performed using 1:1 to 1:5 mixtures of NBCA and iodized oil. The most common etiologies of bleeding were colonic diverticulosis (n = 13), malignancy (n = 11), and benign ulcer (n = 7). Coagulopathy was present in 11 patients, and 23 patients were hemodynamically unstable before NBCA embolization. Histologic examination for bowel ischemia was also performed in five patients who underwent excision of the lesion after NBCA embolization.

RESULTS

The technical success rate was 100%. Recurrent bleeding occurred in two patients. Complete hemostasis was achieved in all 11 patients with coagulopathy. Ulcers induced by transcatheter arterial embolization were noted in 6 of 20 patients who underwent endoscopic examination; the ulcers were successfully treated with conservative measures. Histologic examination revealed that despite inflammatory reactions in and around the vessels, no intestinal necrosis secondary to NBCA embolization was found. Hepatic abscess occurred in two cases, and ischemia of the lower limb occurred in one case; these complications were managed by percutaneous drainage and bypass surgery.

CONCLUSIONS

Transcatheter arterial embolization with NBCA is a good treatment option with a high rate of complete hemostasis and a low recurrent bleeding rate, even in patients with coagulopathy.

Optimal nonsurgical management of peptic ulcer bleeding, including arterial embolization is associated with a mortality below 1%

BACKGROUND

Management of high-risk peptic ulcer bleeding (PUB) consists in a high-dose infusion of proton pump inhibitors (PPIs) with double endoscopic treatment. If bleeding recurs, a second endoscopic treatment is required. Surgical management should be performed in case of endoscopic treatment failure, or if a second rebleeding occurs. Arterial embolization of PUB has been shown efficient and safe in small retrospective series, but optimal medical treatment was not used.

OBJECTIVE

Prospective assessment of the feasibility and the efficacy of arterial embolization of endoscopically unmanageable PUB, after optimal medical treatment.

PATIENTS

All consecutive patients referred to our intensive care unit (ICU) for high-risk PUB received high-dose PPIs and underwent double endoscopic treatment when possible. Arterial embolization was proposed in primary failure to endoscopic treatment, in case of failure of the second endoscopic treatment, or if a second recurrence occurred.

RESULTS

One hundred and twenty-eight patients with PUB were enrolled between January 2008 and December 2009. Arterial embolization, performed in 11 patients, was efficient in nine patients. Surgery was performed in two patients (one after inefficient embolization, and one with embolization-related complication). One patient died during hospitalization.

CONCLUSION

Arterial embolization seems to be efficient for endoscopically unmanageable PUB. In our series, one patient developed severe complication related to the procedure and died. If arterial embolization could be proposed before surgery in case of refractory PUB, large prospective studies are needed.

Mesenteric angiography for acute gastrointestinal bleed: predictors of active extravasation and outcomes

BACKGROUND

Ongoing gastrointestinal bleeding (GIB) following endoscopic therapy and deciding between mesenteric angiography and surgery often challenge surgeons. We sought to identify predictors of positive angiographic study (active contrast medium extravasation) and characterize outcomes of embolization for acute GIB.

METHODS

We retrospectively analyzed angiographies for GIB at 2 teaching hospitals from January 2005 to December 2008. The χ2, Wilcoxon rank sum and t tests determined significance. A Cox proportional hazards model was used for multivariate analyses.

RESULTS

Eighteen of 83 (22%) patients had active extravasation on initial angiography and 25 (30%) were embolized. Patients with active extravasation had more packed red blood cell (PRBC; 5.3 v. 2.8 units, p < 0.001) and fresh frozen plasma (4.8 v. 1.7 units, p = 0.005) transfusions 24 hours preangiography and were more likely to be hemodynamically unstable at the time of the procedure (67% v. 28%, p = 0.001) than patients without active extravasation. Each unit of PRBC transfused increased the risk of a positive study by 30% (hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.2-1.6 per unit). Embolization did not decrease recurrent bleeding (53% v. 52%) or length of stay in hospital (28.1 v. 27.5 d, p = 0.95), but was associated with a trend toward fewer emergency surgical interventions (13% v. 26%, p = 0.31) and greater 30-day mortality (33% v. 7%, p = 0.006) than nonembolization. Blind embolization was performed in 10 of 83 (12%) patients and was found to be an independent predictor of death in patients without active extravasation (HR 9.2, 95% CI 1.5-55.9).

CONCLUSION

The number of PRBC units transfused correlates with greater likelihood of a positive study. There was a significant increase in mortality in patients who underwent angioembolization. Large prospective studies are needed to further characterize the indications for angiography and blind embolization.

National audit of the use of surgery and radiological embolization after failed endoscopic haemostasis for non-variceal upper gastrointestinal bleeding

BACKGROUND

Following non-variceal upper gastrointestinal bleeding (NVUGIB), 10-15 per cent of patients experience further bleeding. Although surgery has been the traditional salvage therapy, there is renewed interest in transcatheter arterial embolization (TAE). This study examined the use, clinical characteristics and outcomes of patients receiving salvage surgery or TAE after failed endoscopic haemostasis for NVUGIB.

METHODS

A UK national audit of upper gastrointestinal bleeding was undertaken in May and June 2007. A logistic regression model was used to identify clinical predictors of endoscopic failure.

RESULTS

Data were analysed from 4478 patients involving 212 UK centres. Some 533 (11·9 per cent) experienced further bleeding, of whom 163 (30·6 per cent) proceeded to salvage therapy with surgery (97), TAE (60) or both (6). Among surgical patients (mean age 71 years), 66·0 per cent (68 of 103) had a Rockall score of at least 3 and emergency surgery was carried out between midnight and 08.00 hours in 21 per cent, with a consultant surgeon present in 89 per cent of operations. Some 9 per cent of patients had further bleeding after TAE, resulting in later surgery. The mortality rate was 29 per cent after surgery, 10 per cent after TAE and 23·2 per cent among those with further bleeding after the index endoscopy that was managed by endoscopy alone. The strongest predictors of endoscopic failure were coagulopathy (odds ratio 3·27, 95 per cent confidence interval 2·37 to 4·53) and a haemoglobin level of 10 g/dl or less (odds ratio 2·22, 1·71 to 2·87, for haemoglobin 8-10 g/dl).

CONCLUSION

Salvage surgery and embolization are required in fewer than 4 per cent of patients with NVUGIB. The high postoperative mortality rate, reflecting age, co-morbidity and severity of bleeding, warrants a prospective study to establish the effectiveness and safety of TAE as an alternative to surgery in the management of bleeding after failure of endoscopic therapy.