Transarterial embolization with n-butyl cyanoacrylate for the treatment of abdominal wall hemorrhage

[Management of anticoagulant-related soft tissue bleeding]

BACKGROUND AND OBJECTIVE

Spontaneous, severe, and life-threatening soft tissue bleeding (STB) in patients taking anticoagulants is associated with high morbidity and mortality due to the substantial blood loss and nonspecific clinical symptoms. The optimal management of these predominantly older patients with multiple comorbidities has not yet been unanimously clarified.

MATERIALS AND METHODS

This work comprises a literature search and analysis of the pertinent retrospective studies and case series.

RESULTS

Structured diagnostic workup with contrast-enhanced computed tomography (CT) is essential for planning transarterial embolization (TAE). Contrast agent extravasation, the signal flare phenomenon, and the hematocrit effect are all indicative of active bleeding or an anticoagulant-related hematoma. For TAE, coils, particles, and liquid embolic agents can be used alone or in combination. A back door/front door embolization should be strived for.

CONCLUSION

Transarterial embolization is the method of choice for managing anticoagulant-related localized or diffuse spontaneous soft tissue bleeding in the context of hemodynamic stabilization of the patient.

The prominent role of percutaneous transarterial embolization in the treatment of anterior abdominal wall hematomas: the results of three high volume tertiary referral centers

PURPOSE

Percutaneous transarterial embolization (PTE) represents a fast, safe and effective option for life-threatening anterior abdominal wall hematomas (AWHs) and those unresponsive to conservative treatment. Our study aims to assess cumulative results of safety, technical and clinical success of PTE performed in three high-volume tertiary referral centers and to evaluate the efficacy of the different embolic materials employed.

MATERIALS AND METHODS

A consecutive series of 124 patients (72.8 ± 14.4 years) with AWHs of different etiology submitted to PTE were retrospectively collected and analyzed. Clinical success, defined as absence of recurrent bleeding within 96 h from PTE, was considered as primary endpoint. The results of the comparison of three groups based on embolic agent employed were also analyzed.

RESULTS

Spontaneous AWHs accounted for 62.1%, iatrogenic for 21.8% and post-traumatic for 16.1% of cases. SARS-CoV-19 infection was present in 22.6% of patients. The most commonly embolized vessels were epigastric inferior artery (n = 127) and superior epigastric artery (n = 25). Technical and clinical success were 97.6 and 87.1%, respectively. Angiographic signs of active bleeding were detected in 85.5% of cases. Four (4%) major complications were reported. The comparison of the three groups of embolic agents (mechanical, particulate/fluid and combined) showed no statistically significant differences in terms of clinical success. SARS-CoV-2 infection was found to be an independent factor for recurrent bleeding and poor 30-day survival.

CONCLUSION

PTE performed with all the embolic agent employed in our centers is a safe and effective tool in the treatment of life-threatening anterior AWH of each origin.

Emergent vessel embolization for major traumatic and non-traumatic hemorrhage: Indications, tools and outcomes

Endovascular embolization of bleeding vessels in trauma and non-trauma patients is frequently used and is an important tool for bleeding control. It is included in the EVTM (endovascular resuscitation and trauma management) concept and its use in patients with hemodynamic instability is increasing. When the correct embolization tool is chosen, a dedicated multidisciplinary team can rapidly and effectively achieve bleeding control. In this article, we will describe the current use and possibilities for embolization of major hemorrhage (traumatic and non-traumatic) and the published data supporting these techniques as part of the EVTM concept.

Successful endovascular embolization for traumatic subcutaneous abdominal wall hematoma via the superficial inferior epigastric artery: a case report

Abdominal wall hematoma (AWH) after blunt trauma is common, and most cases can be treated conservatively. More invasive treatment is required in patients with traumatic AWH if active bleeding is identified or there is no response to medical treatment. Herein, we report a case of endovascular embolization for traumatic subcutaneous AWH. Almost endovascular treatment for AWH is done through the deep inferior epigastric artery. However, in this case, the superficial inferior epigastric artery was the bleeding focus and embolization target. After understanding the vascular system of the abdominal wall, an endovascular approach and embolization is a safe and effective treatment option for AWH.

Clinical Outcomes of Transcatheter Arterial Embolization Using N-butyl-2-cyanoacrylate (NBCA) in Cirrhotic Patients

Purpose

To evaluate the clinical outcomes of transcatheter arterial embolization (TAE) with n-butyl-2-cyanoacrylate (NBCA) for treatment of bleeding in cirrhotic patients.

Materials and methods

A total of 35 cirrhotic patients (26 men, 9 women; mean age, 48.4 ± 11.1) who underwent TAE with NBCA for bleeding from January 2011 to December 2020 were retrospectively analysed. Only cirrhotic patients with active arterial bleeding confirmed on computed tomography (CT) were included. Fifteen patients were hemodynamically unstable before embolization procedure, and coagulopathy was observed in 32 patients. The mean MELD score and Child Pugh score were 24 ± 9.9 and 9.9 ± 2.2, respectively. The mean haemoglobin level and mean number of RBC units transfused before embolization were 7.4 ± 1.4 g/dL and 10.2 ± 4, respectively. The technical, clinical success rate and 30-day mortality rate were evaluated.

Results

Technical success and clinical success rates were achieved in 100% and 82.8% of patients, respectively. Overall 30-day mortality rate was 48%. No major complications related to the embolization procedure was seen. Only the greater number of RBC units transfused before the embolization procedure (OR = 1.81, 95% CI = 1.17-2.80, P = 0.007) was significantly associated with clinical failure. Greater number of RBC units transfused (OR = 1.53, 95% CI: 1.00-2.34, P = 0.004) and higher Child Pugh score (OR 2.44, 95% CI 1.26-4.71, P = 0.008) were significantly associated with higher 30-day mortality rate.

Conclusion

Transcatheter arterial embolization using NBCA can be used as the effective treatment option for bleeding in cirrhotic patients which has a high technical and clinical success despite the grave prognosis associated with cirrhosis.

Efficacy of Percutaneous Transarterial Embolization in Patients with Spontaneous Abdominal Wall Hematoma and Comparison between Blind and Targeted Embolization Approaches

Background: Endovascular treatment of abdominal wall hematomas (AWHs) has been increasingly used when conservative treatments were not sufficiently effective, and it is often preferred to surgical interventions. The aim of our study was to evaluate the safety and technical and clinical success of percutaneous transarterial treatment of AWH and to evaluate the efficacy of blind embolization compared to targeted embolization. Materials and Methods: We retrospectively enrolled 43 patients (23 men and 20 females) with spontaneous AWH who underwent digital subtraction angiography (DSA) and embolization, focusing on the presence of signs of bleeding at pre-procedural CT-Angiography (CTA) and at DSA. Furthermore, we divided patients into two groups depending on blind or targeted embolization approaches. Results: The mean age of the study population was 71 ± 12 years. CTA revealed signs of active bleeding in 31 patients (72%). DSA showed signs of active bleeding in 34 patients (79%). In nine patients (21%), blind embolization was performed. The overall technical success rate was 100%. Clinical success was achieved in 33 patients (77%), while 10 patients (23%) rebled within 96 h, and all of them were re-treated. No major peri-procedural complication was reported. The comparison between blind and targeted embolization showed no statistically significant differences for characteristics of groups and for clinical success rates (78% and 77%, respectively, −p = 0.71). The technical success was 100% in both groups. Conclusions: Our study confirms that transarterial embolization is a safe and effective option for the treatment of spontaneous AWHs, and it suggests that the efficacy and safety of blind embolization is comparable to non-blind.

Glue Embolization in the Management of Rectus Sheath Hematomas

OBJECTIVE

This study aims to describe the results achieved in the management of rectus sheath hematoma (RSH) using glue embolization.

METHOD

Data about all consecutive patients presenting with RSH, between January 2005 and December 2020 were retrospectively reviewed. RSHs were classified according to the Berna CT scan Classification. Clinical and technical outcomes were evaluated during in-hospital period and 1-month follow-up.

RESULTS

Among 74 patients presenting with RSH, CTA revealed an active bleeding in 61 (n = 42, 69% women; median age = 68.8 y range: 47-91). 19 cases of type 1 RSH (25.7%), under anticoagulation therapy and hemodynamically stable, were successfully managed conservatively. Conversely, endovascular embolization with cyanoacrylate glue diluted with ethiodized oil (Lipiodol Ultrafluid, Guerbet, France) was needed in n = 42 (56.8%) patients, in 16 cases after failure of conservative management; a single session of percutaneous glue embolization was adequate to achieve technical and clinical success in all patients with stabilization or progressive improvement of hemoglobin values after procedure (7.1 + 1.8 g/dL pre-procedure vs 11.1 + 1.6 g/dL post-procedure). No major complications occurred. Two minor complications were reported: 1 case (2.4%) of puncture site-related complication (local self-limiting hematoma) and 1 case (2.4%) of post-embolization syndrome (abdominal pain) spontaneously regressive. The median hospital stay was 7 d. At 30-day follow-up, 2 patients (2.7%) died of multiorgan failure.

CONCLUSIONS

In the management of RSH, glue embolization was shown to be safe and efficacious. Glue allowed the immediate occlusion of both the "front and back doors" of bleeding without the need to reach the bleeding point, preventing potentially life-threatening recurrence.