Clinical Outcomes of Angiography and Transcatheter Arterial Embolization for Acute Gastrointestinal Bleeding: Analyses according to Bleeding Sites and Embolization Types

Soo Min Noh; Ji Hoon Shin; Ha Il Kim; Sun-Ho Lee; Kiju Chang; Eun Mi Song; Sung Wook Hwang; Dong-Hoon Yang; Byong Duk Ye; Seung-Jae Myung; Suk-Kyun Yang; Jeong-Sik Byeon

doi:10.4166/kjg.2018.71.4.219

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Noh, Shin, Kim, Lee, Chang, Song, Hwang, Yang, Ye, Myung, Yang, and Byeon: Clinical Outcomes of Angiography and Transcatheter Arterial Embolization for Acute Gastrointestinal Bleeding: Analyses according to Bleeding Sites and Embolization Types

Original Article

Korean J Gastroenterol 2018;71(4):219-228.

Published online: 4 October 2018

DOI: https://doi.org/10.4166/kjg.2018.71.4.219

Clinical Outcomes of Angiography and Transcatheter Arterial Embolization for Acute Gastrointestinal Bleeding: Analyses according to Bleeding Sites and Embolization Types

Soo Min Noh, Ji Hoon Shin¹, Ha Il Kim, Sun-Ho Lee², Kiju Chang², Eun Mi Song², Sung Wook Hwang², Dong-Hoon Yang², Byong Duk Ye², Seung-Jae Myung², Suk-Kyun Yang², Jeong-Sik Byeon²

Department of Internal Medicine, Division of Gastroenterology, University of Ulsan College of Medicine, Seoul, Korea

¹Department of Radiology, Division of Gastroenterology, University of Ulsan College of Medicine, Seoul, Korea

²Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

Correspondence to: Jeong-Sik Byeon, Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea. Tel: +82-2-3010-3905, Fax: +82-2-476-0824, E-mail: jsbyeon@amc.seoul.kr

Received 26 July 2017 Revised 8 November 2017 Accepted 3 January 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background/Aims

The clinical outcomes of angiography and transcatheter arterial embolization (TAE) for acute gastrointestinal bleeding (GIB) have not been completely assessed, especially according to bleeding sites. This study aimed to assess the efficacy of angiography and safety of TAE in acute GIB.

Methods

This was a retrospective study evaluating the records of 321 patients with acute GIB who underwent angiography with or without TAE. Targeted TAE was conducted in 134 patients, in whom angiography showed bleeding sources. Prophylactic TAE was performed in 29 patients when the bleeding source was not detected but a specific vessel was strongly suspected by other examinations. The rate of technical success, clinical success, and complications were analyzed.

Results

The detection rate of bleeding source via angiography was 50.8% (163/321), which was not different according to the bleeding sites. The detection rate was higher if the probable bleeding source had already been found by another investigation (59.7% vs. 35.8%, p<0.001). TAE sites were upper GIB in 67, mid GIB in 74, and lower GIB in 22. The technical success rate was 99.3% (133/134), and the clinical success rate was 63.0% (104/163). The prophylactic embolization group showed lower clinical success rate than the targeted embolization group (44.8% vs. 67.9%, p=0.06). The TAE-related complication rate was 12.9% (21/163). Ischemia and/or infarction was more common after TAE for mid and lower GIB than for upper GIB (15.6% vs. 3.0%, p=0.007).

Conclusions

Angiography with or without TAE was an effective method for acute GIB. Targeted embolization should be performed if possible given that it has a higher clinical success rate.

Keywords: Angiography, Embolization, therapeutic, Gastrointestinal hemorrhage

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Fig. 1.

Flowchart of patients who underwent angiography with or without embolization.

Fig. 2.

Clinical outcomes after embolization for acute gastrointestinal bleeding.

Table 1.

Patient Demographic Data and Clinical Parameters (n=321)

Variable	No. of patients
Male	216 (67.3)
Age (yr)
18–60	154 (48.0)
61–80	146 (45.5)
≥81	21 (6.5)
Medications ^a	82 (25.5)
Coagulopathy ^b	87 (27.1)
Hemodynamic instability ^c	165 (51.4)
Bleeding site
UGI	99 (30.8)
Peptic ulcer disease	36
Malignant	22
Acute gastroduodenal lesion	6
Dieulafoy's lesion	4
Others ^d	17
No source identified	14
MGI	150 (46.7)
No source identified	46
Postoperative anastomotic bleedi	ng 19
Malignant	18
Angioectasia	17
Inflammatory bowel disease	15
Others ^e	35
LGI	48 (15.0)
Diverticulosis	16
Post operation bleeding	4
Angioectasia	4
Others ^f	21
No source identified	3
Unknown	24 (7.5)

Values are presented as n (%).

UGI, upper gastrointestinal; MGI, mid gastrointestinal; LGI, lower gas-trointestinal; NSAIDs, nonsteroidal anti-inflammatory drugs; PT, prothrombin time; INR, international normalized ratio; CMV, cytomegalovirus.

^a Antiplatelet agents/anticoagulants/NSAIDs or steroid

^b Prolonged PT (INR >1.5) or thrombocytopenia (<50,000 μ L)

^c During or before the procedure, heart rate>120 beats per minute or systolic blood pressure <90 mmHg

^d Iatrogenic, angiodysplagia, diverticular, fistula, Crohn's disease, vasculitis, esophageal hematoma, pseudoaneurysm, esophagitis

^e Diverticulum, NSAIDs induced ulcer, vasculitis, trauma, radiation enteritis, salmonellosis, portal enteropathy, pseudoaneurysm, post procedure

^f Rectal ulcer, post polypectomy bleeding, neoplasia, inflammatory bowel disease, CMV infection, ischemic colitis, stercoral ulceration, NSAIDs induced colopathy, fistula, Dieulafoy's lesion, iliac artery aneurysm.

Table 2.

Indications and Diagnostic Yields of Angiography

	Angiography after detection of bleeding foc by other investigations (n=201)	Angiography with unknown bleeding focus (n=120)	p-value
Diagnostic studies detecting bleeding focus	Upper and/or lower gastrointestinal
prior to angiography	endoscopy (n=90)
	Abdominopelvic CT scan (n=37)
	Bleeding scan (n=31)
	CT enterography (n=25)
	Enteroscopy (n=14)
	Others ^a (n=4)
Diagnostic yield
Overall detection rate	120 (59.7%)	43 (35.8%)	<0.001
UGI lesion detection rate	39/74 (52.7%)	14/25 (56.0%)	0.775
MGI lesion detection rate	59/91 (64.8%)	25/59 (42.4%)	0.007
LGI lesion detection rate	22/33 (66.7%)	4/15 (26.7%)	0.014

UGI, upper gastrointestinal; MGI, mid gastrointestinal; LGI, lower gastrointestinal, CT, computed tomography.

^a By high clinical suspicion such as previous surgery site, etc.

Table 3.

Embolization Results according to the Bleeding Site

	Type of embolization		Bleeding focus detected prior to angiography	Technical success	Clinical success	Complication
	Targeted embolization	Prophylactic embolization	Bleeding focus detected prior to angiography	Technical success	Clinical success	Complication
Upper GI bleeding (n=67)	45 (67.2)	22 (32.8)	50 (74.6)	45 (100)	43 (64.2)	4 (6.0)
Mid GI bleeding (n=74)	67 (90.5)	7 (9.5)	49 (66.2)	67 (100)	43 (58.1)	13 (17.6)
Lower GI Bleeding (n=22)	22 (100)	0 (0)	19 (86.4)	21 (95.5)	18 (81.8)	4 (18.2)
p-value	<0.001		0.184	0.164	0.267	0.06

Values are presented as n (%).

GI, gastrointestinal.

Table 4.

Summary of 21 Complications of Embolization

No	Final diagnosis	Embolization vessel	Detection time ^a/diagnosis	Complication	Outcome
1	Gastric ulcer with Crohn's disease	Both GA	6 hr/CT	Splenic infarction	Recovery & discharged
2	Dieulafoy's lesion below esophagojejunostomy ring	SMA br	144 hr/EGD	Ischemic ulcer & bleeding	Recovery & discharged
3	Duodenal ulcer	GDA	3 month/EGD	Duodenal stricture	Observation
4	Pancreatitis induced duodenal bleeding	GDA	181 hr/EGD	Ischemic duodenitis	Recovery & discharged
5	Duodenal angiodysplasia	Both GA, left IPA	14 hr/laboratory test	Acute kidney injury	Died of hyperkalemia after 4 days
6	SB bleeding	SMA br	6 hr/clinically	Ischemic enteritis	Recovery & discharged
7	Radiotherapy related enteritis	SMA br	55 hr/CT	Ischemic enteritis	Operation & discharged
8	SB traumatic bleeding	SMA br	44 hr/colonoscopy	Ischemic enteritis	Recovery & discharged
9	SB angiodysplasia	SMA br	21 hr/CT	Ischemic enteritis	Operation & discharged
10	SB bleeding	SMA br	45 hr/CT	SB infarction with perforation	Operation & discharged
11	SB bleeding	SMA br	27 hr/CT	Ischemic enteritis	Recovery & discharged
12	SB bleeding	SMA br	66 hr/CT	Ischemic enteritis	Operation & successful hemostasis but died of leukemia
13	SB angiodysplasia	SMA br	21 hr/CT	Ischemic enteritis	Recovery & discharged
14	SB bleeding	SMA br	41 hr/CT	SB infarction with perforation	Operation & discharged
15	Splenic artery aneurysm	Splenic artery	116 hr/CT	Splenic infarction	Recovery & discharged
16	Jejunostomy site bleeding	SMA br	17 hr/CT	Ischemic enteritis	Operation & discharged
17	Jejunostomy site bleeding	SMA br	179 hr/CT	SB infarction	Operation & discharged
18	Ascending colon diverticular bleeding	g SMA br	551 hr/clinically	Ischemic colitis	Recovery & discharged
19	Post polypectomy bleeding	SMA br	13 hr/CT	Ischemic colitis	Operation & discharged
20	Post polypectomy bleeding	SMA br	16 hr/CT	Ischemic colitis	Recovery & discharged
21	Rectal AVM	IMA br	61 hr/sigmoidoscopy	Ischemic colitis	Operation & discharged

GA, indicates gastric artery; hr, hour; CT, computed tomography; SMA, superior mesenteric artery; br, branch; EGD, esophagogastroduodenoscopy

GDA, gastroduodenal artery; IPA, inferior phrenic artery; SB, small bowel; AVM, arteriovenous malformation; IMA, inferior mesenteric artery.

^a Time interval from the beginning of embolization to the time when the complications were detected and diagnosed.

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