ARTERIAL EMBOLIZATION

LOWER GI HEMORRHAGE

Introduction

Last updated: apr 14, 2023

Acute lower GIB is defined as bleeding into the large bowel or bleeding into the small-bowel distal to the ligament of Treitz. This condition may present as either melena or hematochezia, depending on the site and severity of bleeding. Causes of lower GIB include inflammatory bowel disease, neoplasms, stress ulcers, surgical anastomoses, vascular lesions such as angiodysplasia, and diverticulosis, with diverticulosis accounting for 30% of cases.

75% of episodes of acute lower GIB due to diverticulosis stop spontaneously, especially in patients requiring transfusions of <4 units of blood over a 24-hour period. Hence, in a substantial number of patients with acute lower GIB, conservative management is likely to be sufficient.

Vasa recta

Recurrent bleeding and ischemic complications are less frequent when embolization is distal to a marginal artery 1 and when the length of devascularized bowel on completion angiography is a few centimeters or less. The use of a microcatheter allows for distal access and superselective embolization of single vasa recta at the site of bleeding.

 

Anatomy

File NameTypePermissionsChanged DateDateSize

 

Indications

  • Technical failure of endoscopic hemostasis including reserve procedures
  • Relapse bleeding after second endoscopic intervention
  • Endoscopically non-localizable source of bleeding

 

Contra indications

Absolute

  • Technical like access occlusion

Relative

  • Contrast agent allergy
  • Hyperthyroidism
  • Pregnancy
  • Sepsis
  • Acute kidney failure
  • Consumption coagulopathy

 

Workup

  • CTA abdomen and pelvis without and with IV contrast
  • Diagnostic/therapeutic colonoscopy
  • RBC scan abdomen and pelvis

 

Pre procedural

  • Correct any coagulopathy before embolization, (achieving hemostasis depends on ability to clot)
  • Make sure to place a clip during endoscopy, which can guide end-vascular treatment

 

Materials

Essentials

  • Sheath 6-9F
  • Cobra catheter
  • Microcatheter
  • Pushable 0.035" and 0.018" coils
  • Headway catheter from Microvention, in combination with detachable coils
  • >500 micron particles in case of non-traumatic embolisation

Non-Essentials

  • Steerable guiding catheter (Oscor)

 

Positioning the patient

  • Head first
  • Supine

Mesenteric anatomy
 

The procedure in steps

  • Time out
  • Positioneren patient
  • Wassen met chloorhexidine en steriel afdekken
  • Ultrasound guided femoral artery access
  • Selective catheterization for LGIB includes the superior and inferior mesenteric arteries, possibly the coeliac trunk.
  • In case of rectal bleeding and inconclusive presentation of the inferior mesenteric artery, angiography of the internal iliac artery including the middle and inferior rectal arteries should be performed
  • Embolization distal to the marginal artery 1 reduces the risk of ischemic complications
  • Sign out

 

Tips and tricks

  • Administration of glucagon or buscopan may be considered to reduce intestinal peristalsis.
  • Consider using a steerable guiding catheter (Oscor) for increased stability
  • Sometimes a "general" microcatheter doesn't do the trick, try a Headway from Microvention, in combination with detachable coils
  • Recurrent bleeding and ischemic complications are less frequent when embolization is distal to a marginal artery and when the length of devascularized bowel on completion angiography is a few centimeters or less.
  • The use of a microcatheter allows for distal access and superselective embolization of single vasa recta at the site of bleeding.
  • Longer injection durations improve sensitivity for small bleeds
  • Watch out for dual supply
  • In case of a rectal bleeding distinguish between contrast agent extravasation and venous washout. Watch for pooling in the venous phase. However, indirect signs such as evidence of pseudoaneurysms, vascular spasms or – in the case of inflammatory changes – blushing and focal hyperemia can also be interpreted as angio- graphic evidence of (intermittent) GI bleeding. Early venous discharge may indicate angiodysplasia.
  • In the absence of evidence of active contrast extravasation, blind or empirical embolization based on an endoscopic finding may be possible, although prior endoscopic clip marking may be helpful
  • Bleeding provocation by selective intra-arterial application of nitroglycerin, heparin or tPA may be considered 1

 

Complications

  • Bowel ischemia
    • Has been reported at the acute phase, post-embolization ischemia usually presents as duodenal stenosis at the chronic phase
  • Non-target embolisation 3%
    • Main hepatic artery; from temporary increase in the liver enzymes, to life-threatening hepatic failure
    • Coils in the left gastric or splenic artery rarely produce organ-threatening ischemia

 

Post-op

  • The utility of antibiotic treatment with first generation cephalosporins depends on the respective clinical conditions and should therefore be decided on a case-by- case basis.

 

Report

 

Literature

File NameTypePermissionsChanged DateDateSize

  1. Ryan, J. M., Key, S. M., Dumbleton, S. A., & Smith, T. P. (2001). Nonlocalized lower gastrointestinal bleeding: Provocative bleeding studies with intraarterial TPA, heparin, and tolazoline. Journal of Vascular and Interventional Radiology, 12(11), 1273–1277. https://doi.org/10.1016/s1051-0443(07)61551-6

  2. Mann, M. R., Kawzowicz, M., Komosa, A. J., Sherer, Y. M., Łazarz, D. P., Loukas, M., Tubbs, R. S., & Pasternak, A. (2021). The marginal artery of Drummond Revisited: A systematic review. Translational Research in Anatomy, 24, 100118. https://doi.org/10.1016/j.tria.2021.100118

  4. Poultsides GA, Kim CJ, Orlando R 3rd, et al. Angiographic embolization for gastroduodenal hemorrhage: safety, efficacy, and predictors of outcome. Arch Surg. 2008;143:457-461.

  5. Eriksson LG, Sundbom M, Gustavsson S, Nyman R. Endoscopic marking with a metallic clip facilitates transcatheter arterial embolization in upper peptic ulcer bleeding. J Vasc Interv Radiol. 2006;17:959-964.

  6. Dixon S, Chan V, Shrivastava V et al. Is there a role for empiric gastroduodenal artery embolization in the management of patients with active upper GI hemorrhage? Cardiovasc Intervent Radiol. 2013 Aug;36(4):970-7.

  7. Shin JH. Recent update of embolization of upper gastrointestinal tract bleeding. Korean J Radiol 2012;13 Suppl 1:S31-S39.

  9. van Leerdam ME. Epidemiology of acute upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol. 2008;22(2):209-24.

  10. Sildiroglu O, Muasher J, Arslan B, Sabri SS, Saad WE, Angle JF, Matsumoto AH, Turba UC. Outcomes of patients with acute upper gastrointestinal nonvariceal hemorrhage referred to interventional radiology for potential embolotherapy. J Clin Gastroenterol. 2014;48(8):687-92.

  11. Strate LL, Gralnek IM. ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding. Am J Gastroenterol. 2016 Apr;111(4):459-74.

  13. van Dam J, Brugge WR. Endoscopy of the upper gastrointestinal tract. N Engl J Med. 1999;341(23):1738-48.

  15. Lefkovitz Z, Cappell MS, Lookstein R, Mitty HA, Gerard PS. Radiologic diagnosis and treatment of gastrointestinal hemorrhage and ischemia. Med Clin North Am. 2002 Nov;86(6):1357-99.

  16. Lee EW, Laberge JM. Differential diagnosis of gastrointestinal bleeding. Tech Vasc Interv Radiol 2004; 7: 112-22

  18. Strate LL, Gralnek IM. ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding. Am J Gastroenterol. 2016 Apr;111(4):459-74.

  19. Chaudhry V, Hyser MJ, Gracias VH, Gau FC. Colonoscopy: the initial test for acute lower gastrointestinal bleeding. Am Surg. 1998 Aug;64(8):723-8.

  20. Cummings CL. Value of early capsular endoscopy for severe gastrointestinal bleeding. J Natl Med Assoc. 2004;96(12):1653-6.

  21. Appleyard M, Glukhovsky A, Swain P. Wireless-capsule diagnostic endoscopy for recurrent small-bowel bleeding. N Engl J Med. 2001;344(3):232-3.

  24. Lim JK, Ahmed A. Endoscopic approach to the treatment of gastrointestinal bleeding. Tech Vasc Interv Radiol. 2004 Sep;7(3):123-9.

  25. Nicholson AA, Ettles DF, Hartley JE, et al. Transcatheter coil embolotherapy: a safe and effective option for major colonic haemorrhage. Gut 1998; 43:79–84.

  26. Zuckier LS. Acute gastrointestinal bleeding. Semin Nucl Med. 2003 Oct;33(4):297-311.

  27. Imbembo AL, Diverticular disease of the colon. In: Sabiston D, Editor. Textbook of Surgery (14th edn). Philadelphia, PA:WB Saunders, 1992:910.

  29. Loffroy R, Rao P, Ota S, De Lin M, Kwak BK, Geschwind JF. Embolization of acute nonvariceal upper gastrointestinal hemorrhage resistant to endoscopic treatment: results and predictors of recurrent bleeding. Cardiovasc Intervent Radiol. 2010 Dec;33(6):1088-100. doi: 10.1007/s00270-010-9829-7. Epub 2010 Mar 16.

  31. Eriksson LG, Sundbom M, Gustavsson S, Nyman R. Endoscopic marking with a metallic clip facilitates transcatheter arterial embolization in upper peptic ulcer bleeding. J Vasc Interv Radiol. 2006 Jun;17(6):959-64.

  32. Anthony S, Milburn S, Uberoi R. Multi-detector CT: review of its use in acute GI haemorrhage. Clin Radiol. 2007 Oct;62(10):938-49.

  33. Ernst O, Bulois P, Saint-Drenant S, Leroy C, Paris JC, Sergent G. Helical CT in acute lower gastrointestinal bleeding. Eur Radiol. 2003;13(1):114-7

  34. Mirsadraee S, Tirukonda P, Nicholson A, Everett SM, McPherson SJ. Embolization for non-variceal upper gastrointestinal tract haemorrhage: a systematic review. Clin Radiol 2011;66:500-509.

  35. Loffroy R, Guiu B, D'Athis P, Mezzetta L, Gagnaire A, Jouve JL, Ortega-Deballon P, Cheynel N, Cercueil JP, Krausé D. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol. 2009 May;7(5):515-23.

  36. Aina R, Oliva VL, Therasse E, et al. Arterial embolotherapy for upper gastrointestinal hemorrhage: outcome assessment. J Vasc Interv Radiol 2001;12:195-200.

  37. Mirsadraee S, Tirukonda P, Nicholson A, Everett SM, McPherson SJ. Embolization for non-variceal upper gastrointestinal tract haemorrhage: a systematic review. Clin Radiol 2011;66:500-509.

  38. Loffroy R, Guiu B, Cercueil JP, Lepage C, Latournerie M, Hillon P, Rat P, Ricolfi F, Krausé D. Refractory bleeding from gastroduodenal ulcers: arterial embolization in high-operative-risk patients. J Clin Gastroenterol. 2008 Apr;42(4):361-7.

  39. Loffroy R, Guiu B, D'Athis P, Mezzetta L, Gagnaire A, Jouve JL, Ortega-Deballon P, Cheynel N, Cercueil JP, Krausé D. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol. 2009 May;7(5):515-23.

  40. Poultsides GA, Kim CJ, Orlando R 3rd, Peros G, Hallisey MJ, Vignati PV. Angiographic embolization for gastroduodenal hemorrhage: safety, efficacy, and predictors of outcome. Arch Surg 2008;143:457-461.

  42. Gordon RL, Ahl KL, Kerlan RK, Wilson MW, LaBerge JM, Sandhu JS, Ring EJ, Welton ML. Selective arterial embolization for the control of lower gastrointestinal bleeding. Am J Surg. 1997;174(1):24-8.

  43. Funaki B, Kostelic JK, Lorenz J, Ha TV, Yip DL, Rosenblum JD, et al. Superselective microcoil embolization of colonic hemorrhage. AJR Am J Roentgenol 2001;177:829-836 7.

  44. Bandi R, Shetty PC, Sharma RP, Burke TH, Burke MW, Kastan D. Superselective arterial embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 2001;12:1399-1405.

  45. Maleux G, Roeflaer F, Heye S, Vandersmissen J, Vliegen AS, Demedts I, et al. Long-term outcome of transcatheter embolotherapy for acute lower gastrointestinal hemorrhage. Am J Gastroenterol 2009;104:2042-2046

  46. Leitman IM, Paull DE, Shires GT 3rd. Evaluation and management of massive lower gastrointestinal hemorrhage. Ann Surg 1989;209:175-180

  47. Rosenkrantz H, Bookstein JJ, Rosen RJ, Goff WB 2nd, Healy JF. Postembolic colonic infarction. Radiology 1982;142:47-51.

  48. Koh DC, Luchtefeld MA, Kim DG, Knox MF, Fedeson BC, Vanerp JS, et al. Efficacy of transarterial embolization as definitive treatment in lower gastrointestinal bleeding. Colorectal Dis 2009;11:53-59

  49. Lipof T, Sardella WV, Bartus CM, Johnson KH, Vignati PV, Cohen JL. The efficacy and durability of super-selective embolization in the treatment of lower gastrointestinal bleeding. Dis Colon Rectum 2008;51:301-305

DISCLAIMER

The information contained herein has been obtained from sources believed to be reliable. However, no warranty as to the accuracy, completeness or adequacy of such information is implied. No liability is accepted for errors, omissions or inadequacies in the information contained herein or for interpretations thereof. The reader assumes sole responsibility for the selection of these materials to achieve its intended results. The opinions expressed herein are subject to change without notice.

Thank you! ×
Opps! Some went wrong... Your submission did not go through :-(×
Stacks Image 14

WEBDESIGN

Stacks Image 20

PHOTOGRAPHY

Stacks Image 26

E-COMMERCE

Stacks Image 32

SEO

Stacks Image 38

COLORS

Stacks Image 44

CRM

EXCELLENCE IS NOT A SKILL, IT'S AN ATTITTUDE

WEBDESIGN - PHOTOGRAPHY - GRAVENDEEL