ARTERIAL EMBOLIZATION

NON VARICEAL UPPER GI HEMORRHAGE

Introduction

Last updated: apr 11, 2023

Upper gastrointestinal bleeding (UGIB) is a common medical emergency, with a reported mortality of 2-10%. Patients identified as being at very low risk of either needing an intervention or death can be managed as outpatients. For all other patients, intravenous fluids as needed for resuscitation and red cell transfusion at a hemoglobin threshold of 70-80 g/l are recommended. After resuscitation is initiated, proton pump inhibitors (PPIs) and the prokinetic agent erythromycin may be administered, with antibiotics and vasoactive drugs recommended in patients who have cirrhosis. Endoscopy should be undertaken within 24 hours, with earlier endoscopy considered after resuscitation in patients at high risk, such as those with hemodynamic instability. Endoscopic treatment is used for variceal bleeding (for example, ligation for esophageal varices and tissue glue for gastric varices) and for high risk non-variceal bleeding (for example, injection, thermal probes, or clips for lesions with active bleeding or non-bleeding visible vessel). Patients who require endoscopic therapy for ulcer bleeding should receive high dose proton pump inhibitors after endoscopy, whereas those who have variceal bleeding should continue taking antibiotics and vasoactive drugs. Recurrent ulcer bleeding is treated with repeat endoscopic therapy, with subsequent bleeding managed by interventional radiology or surgery. Recurrent variceal bleeding is generally treated with transjugular intrahepatic portosystemic shunt.

Splenic vascularization

  • AsTP Arteries of the Tail of the Pancreas
  • CHA Common Hepatic Artery
  • CPA Caudal Pancreatic Artery
  • GPA Great Pancreatic Artery
  • IPB Inferior Polar Branch
  • LGA Left Gastric Artery
  • LGOA Left Gastro‑omental Artery
  • LLA Lower Lobar Artery
  • PGA Posterior Gastric Artery
  • RGOA Right Gastro‑omental Artery
  • SGAs Short Gastric Arteries
  • SPAs Short Pancreatic Arteries
  • SPB Superior polar Branch
  • SPA Splenic Artery
  • TPA Transverse Pancreatic Artery
  • ULA Upper Lobar Artery

 

Anatomy

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Forrest
 

Indications

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

Cause
  • Peptic Ulcer Disease (PUD) 50%
    • NSAID associated
  • Mallory Weiss tears 5-15%
  • Angiomas 5-10%
    • Antral vascular ectasia different from portal hypertensive gastropathy
  • Dieulafoy's lesion < 5%
  • Neoplasm < 5%
  • Metastases (colon, lung, breast)
  • Aortoenteric fistula after aortic repair surgery
  • Hemobilia after instrumentation
  • Chronic pancreatitis with hemosuccus pancreaticus
  • Iatrogenic after biopsy or endoscopy

 

Contra indications

Absolute

  • Technical like coeliac trunk 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 gastroduodenoscopy

 

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
  • Detachable 0.018" coils
  • >500 micron particles in case of non-traumatic embolisation

Non-Essentials

  • Steerable guiding catheter (Oscor)

 

Positioning the patient

  • Head first
  • Supine

Distal pancreatic artery
PSAE

The ideal location for embolisation is between the distal pancreatic artery (DPA) and the great pancreatic artery (GPA), to avoid devascularization of the pancreas and ischemic pancreatitis; as well as to preserve blood supply to the spleen

 

The procedure in steps

  • Time out
  • Positioneren patient
  • Wassen met chloorhexidine en steriel afdekken
  • Ultrasound guided femoral artery access
  • Selective catheterization for UGIB includes the celiac and superior mesenteric arteries.
  • Start with celiac artery angiogram with a 4-5F curved catheter (Cobra C2 or Rosch Celiac RC2, Cook Medical) to evaluate not only the splenic artery anatomy but also sources of collaterals to the spleen, including the left gastric artery, gastroepiploic arteries, and pancreatic artery branches.
  • The initial artery catheterized is the one most suspected of bleeding, which is of course the celiac for UGIB.
  • 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
  • If no extravasation is seen, superselective angiography is advised,
    • GDA
    • LGA
    • Splenic artery
  • A microcatheter is always necessary for a distal and superselective injections
  • Longer injection durations improve sensitivity for small bleeds
  • Watch out for dual supply
    • typical in case of bleeding secondary to an ulcer that erodes into the gastroduodenal artery; embolization in this case needs to start distally to prevent persistent ‘‘back-door’’ hemorrhage from the right gastroepiploic and superior pancreaticoduodenal arteries
  • Several prior studies have shown that empiric embolization based on endoscopic findings, in the absence of contrast extravasation, can be performed safely and successfully
    • The GDA should be embolized using the ‘‘sandwich technique’’, in which both ends of the artery are filled with coils to avoid retrograde bleeding from the superior mesenteric circulation.
    • If there is suspicion that smaller muscular branches terminating to a clip are the culprits, then those should be embolized with any of the materials available.
  • 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

 

Report

 

Literature

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