Journal List > Korean J Gastroenterol > v.71(4) > 1007756

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

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.

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Fig. 1.
Flowchart of patients who underwent angiography with or without embolization.
kjg-71-219f1.tif
Fig. 2.
Clinical outcomes after embolization for acute gastrointestinal bleeding.
kjg-71-219f2.tif
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
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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