Angio embolization staunches GI hemorrhage when surgery fails

May 23, 2008

Angiographic embolization is deployed routinely for colonic hemorrhage and hemobilia, but it has received limited attention for treating upper gastrointestinal tract bleeding. An international group of surgeons and radiologists evaluated the safety and efficacy of angiographic embolization for GI hemorrhage and found that it can be used in a select group of patients.

Angiographic embolization is deployed routinely for colonic hemorrhage and hemobilia, but it has received limited attention for treating upper gastrointestinal tract bleeding. An international group of surgeons and radiologists evaluated the safety and efficacy of angiographic embolization for GI hemorrhage and found that it can be used in a select group of patients.

Dr. George Poultsides and colleagues retrospectively reviewed 70 procedures performed in 57 patients from 1996 to 2006. Poultsides is from the surgery department at the University of Connecticut School of Medicine and the Hartford Hospital. His coauthors are from UConn's radiology department and the University of Athens in Greece. They published their results in the Archives of Surgery (2008;143:5:457-461).

The majority of patients had duodenal ulcer or postsphincterotomy bleeding. Comorbidities included the use of immunosuppresants and renal failure at presentation.

Angiograpic procedures were performed with standard percutaneous transfemoral catheterization using a 5-French or 6-Fr sheath. Embolic agents used were cellulose sponge plugs, vascular coils, platinum microcoils, and polyvinyl alcohol particles.

The results found that embolization reached a technical success rate of 94% (66 of 70 procedures). In most cases, the gastroduodenal arteries were embolized. Among the 66 successful procedures, permanent embolic agents were used in 33 cases.

A little more than half of the patients (51%) had in-hospital cessation of bleeding without additional endoscopic, radiologic, or surgical intervention. The primary clinical success rate was higher for duodenal ulcer and gastric cancer.

When embolization failed in 28 cases, the mean interval to rebleeding was 3.08 days, with 13 patients undergoing repeat embolization. Rebleeding occurred in 25 patients despite a repeat procedure. Of the 14 patients with angiographic failure, eight were salvaged with repeat endoscopy and six died. The authors noted that when embolization succeeded, the mortality rate was 9%. When it failed, that rate jumped to 36%.

A major predictor of outcome for embolization was a transfusion requirement of more than six units of blood prior to surgery. Coagulopathy has been shown to adversely affect the success rate of embolization, leading the authors to recommend that aggressive correction of coagulation parameters be enforced.

Despite the fact that bleeding occurred in nearly half of the patients, Poultsides' group said that emoblization was a viable option in poor candidates for surgery. In an accompanying commentary, however, surgeon Dr. Michael Zenilman from State University of New York Downstate Medical Center advised against using angiographic embolization as primary therapy (Arch Surg 2008;143:5:461-462).

"This article shows that angiography can be used as a nonoperative adjunct, but be careful," Zenilman wrote. "It is not as good as endoscopy, it does not always work, and it can be dangerous. Use it only in the patients with favorable anatomy or in those who have comorbidities that preclude surgery."

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