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326 G. Behrens and N.H. Patel
Results
• Technical success rates (occlusion of bleeding vessel) ranges from 77 to 98%.
• Technical failures are due to failure to catheterize, catheter instability precluding
embolization, or high risk of non-target embolization (anterior spinal artery).
Complications
• Procedural complications are uncommon (<5%).
• Major complications
◦ Spinal cord injury (<1%)
◦ Non-target embolization
◦ Renal failure secondary to contrast-induced nephropathy
◦ Vascular dissection
• Minor complications
◦ Infection
Keypoints
• Vascular complications following biopsies and drainage procedures are
uncommon but may be life threatening.
• Embolization materials used are tailored to the cause of the bleeding, but
typically include gelfoam, particles, or coils.
• Anatomical variants, and post-surgical changes, can delay visualization of
a bleeding vessel. Evaluation of any pre-procedure cross-sectional imaging
is mandatory.
• All contraindications to embolization are relative, and an embolization
procedure should not be unduly delayed for such relative contraindications.
Bibliography
1. Park HS, Lee AS. Postbiopsy arterioportal fistula in HCC. AJR February 2006 186: 556–561.
2. Chavan A, Harms J, Pichlmayr Jabbour N, Reyes J, Zajko A, Nour B, Tzakis AG, Starzl
TE, Van Thiel DH. Arterioportal fistula following liver biopsy. Three cases occurring in liver
transplant recipients. Dig Dis Sci 1995 40:1041–1044.
3. Piccinino F, Sagnelli E, Pasquale G, Giusti G. Complications following percutaneous liver
biopsy. A multicentre retrospective study on 68,276 biopsies. J Hepatol 1986 2: 165–173
4. Machicao VI, Lukens FJ, Lange SM, Scolapio JS. Arterioportal fistula causing acute
pancreatitis and hemobilia after liver biopsy. J Clin Gastroenterol. Apr 2002 34(4): 481–484.
32 Arterial Embolization Post-percutaneous Biopsy or Drainage 327
5. Fidelman N, Bloom A, Kerlan R et al. Hepatic arterial injuries after percutaneous biliary
interventions in the era of laparoscopic surgery and liver transplantation: Experience with
930 patients. Radiology June 2008 247(3): 880–886.
6. Ahmed O, Balzer JO, Vogl TJ. Bleeding hepatic pseudoaneurysm complicating percutaneous
liver biopsy with interventional treatment options. Eur Radiol Jan 2005 15(1):183–185.
7. Barley F, Kessel D, et al. Selective embolization of large symptomatic iatrogenic renal
transplant arteriovenous fistula, Cardiovasc Interv Radiol 2006 29: 1084–1087.
8. Arata MA, Cope C. Principles used in the management of visceral aneurysms. Tech Vasc
Intervent Radiol 2000 3: 124–129.
9. Dinkel HP, Danuser H, Triller J. Blunt renal trauma: minimally invasive management with
microcatheter embolization experience in nine patients. Radiology 2002 223: 723–30.
10. Yoon W, Kim JK, Kim YH, Chung TW, Kang HK. Bronchial and nonbronchial systemic
artery embolization for life-threatening hemoptysis: a comprehensive review. RadioGraphics
2002 22:1395–1409.
11. Do KH, Goo JM, Im JG, Kim KW, Chung JW, Park JH. Systemic arterial supply to the lungs
in adults: spiral CT findings. RadioGraphics 2001 21:387–402.
12. Swanson KL, Johnson CM, Prakash UB, McKusick MA, Andrews JC, Stanson AW.
Bronchial artery embolization: experience with 54 patients. Chest 2002 121: 789–795.
13. Yoon W, Kim YH, Kim JK, Kim YC, Park JG, Kang HK. Massive hemoptysis: prediction of
non-bronchial systemic arterial supply with chest CT. Radiology 2003 227: 232–238.
Chapter 33
Acute Nonvariceal Upper Gastrointestinal Hemorrhage
Ian Gillespie and Hamish Ireland
Definition
Upper gastrointestinal hemorrhage (UGIH) is defined as significant bleeding from
the GI tract from the lips to the ligament of Treitz (duodeno-jejunal flexure); blood
loss distal to this represents lower GI bleeding and is discussed in a separate chapter.
Clinical Features
• Presentation is normally with hematemesis and/or melena. Fresh r ectal bleeding
(“bright red blood per rectum”) may also be due to UGIH and indicates brisk
bleeding.
• Hypotension implies severe life-threatening bleeding and necessitates urgent volume and red blood cell replacement. The patient should be investigated during
resuscitation while they are still bleeding.
• Most cases stop spontaneously or with endoscopic therapy.
• It is essential to have a local major gastrointestinal hemorrhage management
protocol in place. Endoscopists, radiologists, and surgeons must collaborate in
patient management.
Causes
The underlying cause of UGIH is often unclear at presentation. Clues in the patient’s
history include symptoms of gastroesophageal reflux or dyspepsia, excessive alcohol consumption, consumption of nonsteroidal anti-inflammatory drugs (NSAID)
or aspirin, pancreatitis, known upper gastrointestinal tumor, and history of surgery
or percutaneous intervention.
The commonest causes are
• Peptic ulceration, stress ulcers, and erosions.
• Iatrogenic: previous surgery, endoscopy or percutaneous intervention.
• Mallory Weiss tears: retching/vomiting.
Transcatheter Embolization and Therapy,
Techniques in Interventional Radiology, DOI 10.1007/978-1-84800-897-7_33,
C
Springer-Verlag London Limited 2010
329
330 I. Gillespie and H. Ireland
abc
Fig. 33.1 A patient with UGIB due to bleeding from the ampulla secondary to biliary stent inser-
tion: (a) Hemobilia (yellow arrowheads) seen on pre-contrast CT. (b) Shaded surface reformat
showing pseudoaneurysm (turquoise arrowhead) of pancreaticoduodenal artery. (c) The celiac axis
is occluded (turquoise arrowhead) adding difficulty to embolization
Less common causes include
• Hemobilia: most are related to biliary intervention and trauma (Fig. 33.1).
• Aortoenteric fistula – usually in a patient with a history of aortic surgery
(Fig. 33.2).
• Dieulafoy’s disease (enlarged submucosal artery).
• Tumors (seldom present with acute bleeding).
Fig. 33.2 Aortoduodenal fistula (white arrow). This is usually a complication of aortic surgery
33 Acute Nonvariceal Upper Gastrointestinal Hemorrhage 331
Diagnostic Evaluation
Laboratory
• Check hemoglobin and coagulation status. This will often be deranged in patients
with liver disease or if there has been large volume transfusion.
Endoscopy
• Endoscopy is the first-line investigation and may allow therapy including banding, sclerotherapy, adrenaline or thrombin injection, electro- or laser coagulation,
and clipping. Success rates approaching 90% are reported.
• If endoscopy reveals a source, consider repeat endoscopy if bleeding recurs.
• Always ask the endoscopist to place clips at the site of bleeding to localize the
lesion in patients proceeding to angiography.
Imaging
Triple-Phase Multidetector Computed Tomography Angiography (CTA)
• Pre-contrast to identify high-attenuation fresh thrombus, e.g., hemobilia
(Fig. 33.1). Helps distinguish pseudoextravasation caused by streak artifact from
bowel gas or metal.
• Arterial and venous phases
◦ to identify vascular abnormalities, e.g., aneurysms, pseudoaneurysms
(Fig. 33.1), arteriovenous shunting, and contrast extravasation (Fig. 33.3)
◦ produce an arterial roadmap for targeting embolotherapy
• Shows features of underlying diseases that may be relevant when the bleeding
has stopped.
Indications for Embolization
• Failure of endoscopy either to control the hemorrhage.
Contraindications to Embolization
These are all relative in patients with life-threatening bleeding.
332 I. Gillespie and H. Ireland
a
b
Fig. 33.3 (a, b) CTA axial slice and coronal reformat showing gastric hemorrhage (arrowheads)
• Severe coagulopathy: reduces success of embolotherapy and increases the risk of
puncture site bleeding. Consider leaving the arterial sheath in situ for removal,
once the coagulopathy has been corrected.
• Portal vein occlusion: may increase the risk of hepatic infarction following
hepatic arterial embolization.
• Very agitated patients: may require ventilation and pharmacologic paralysis.
• Patient has stopped bleeding: the exception is false aneurysm, this must be treated
due to the high risk of rebleeding.
Anatomy
• The upper GI tract has a rich arterial supply typically from several sources making infarction of the stomach or duodenum relatively uncommon (Table 33.1).
• Understanding the arterial anatomy is necessary to ensure successful embolization.
• Anatomical variations are common (Table 33.1).
• Failure to recognize anomalous arterial anatomy may lead to inadequate
embolization or inadvertent embolization of other organs.
• Upper GI surgery may alter the anatomy. Review the notes and discuss with the
surgeon to find out what was done surgically and whether there is a likely source
for hemorrhage (e.g., surgical anastomoses!).
33 Acute Nonvariceal Upper Gastrointestinal Hemorrhage 333
Table 33.1 Upper GI arterial anatomy
Site Normal arterial supply Variants
Esophagus Bronchial, left inferior phrenic, left
Stomach Left gastric (LGA)
Duodenum Gastroduodenal artery (GDA)
Liver Common hepatic artery (CHA) from
Gall bladder Cystic artery normally from right
Miscellaneous Arc of Buehler – a persistent congenital anastomosis between celiac and
gastric arteries
Splenic (via posterior/short gastric and
left gastroepiploic)
Hepatic (via gastroduodenal/right
gastroepiploic artery)
Right gastric – small and variable and
may not be seen
Pancreaticoduodenal arcade – anterior
and posterior branches (superior
from GDA and inferior from SMA)
celiac trunk
“Classic” anatomy in only 55% with
right (RHA), middle (MHA), and
left hepatic arteries (LHA)
originating from common hepatic
off celiac trunk. MHA arises from
right or left to supply medial
segment of left lobe
hepatic artery
SMA
Arc of Barkow – omental arcade acts as potential collaterals among
hepatic, splenic, and SMA via the anterior epiploic branches of the
gastroepiploic arteries
Complete gastroepiploic
arcade in 65%,
incomplete in 35%
RGA 40% from CHA,
40% from L/MHA, and
10% RHA
RHA from SMA 10–20%,
accessory RHA 6%
LHA from LGA 10–12%,
accessory LHA 10%
Replaced CHA from SMA
2%
From LHA or CHA
Equipment
• Selective catheters: cobra, sidewinder, microcatheter. May need catheters with
side holes for performing angiography as well as end-hole-only catheters for
embolization.
• Guide catheters or sheaths with integral valves are occasionally helpful.
Embolic Agents
• Gelfoam
• Coils – standard (0.035) and microcatheter compatible (0.018)
• Polyvinyl alcohol (PVA) particles – usually 350–500 μm
• Glue – use only with caution and experience
334 I. Gillespie and H. Ireland
Medication
• Buscopan or glucagon will halt peristalsis which may otherwise lead to the
mistaken identification of bowel gas movement as contrast extravasation.
Procedure
Treatment Plan
• The sole consideration is control of hemorrhage. Definitive treatment of underlying pathology comes later.
• Active resuscitation with fluid, red blood cells, and clotting factor replacement
(plasma and/or platelets) is mandatory and can be carried out during angiography.
• Offer to insert central and arterial lines as this may expedite angiography.
• Assistance of anesthetic/ITU staff is essential for resuscitation, monitoring, and
if necessary sedation and anesthesia.
• Establish relevance of previous surgery, surgical alternatives, and the potential
impact of embolization on subsequent surgery.
Access
• Use CTA to plan the route to the bleeding site and identify collateral supply –
coronal thick maximum intensity projection (MIP) images are especially helpful
for displaying arterial anatomy (Fig. 33.4).
• Consider upper limb approach if catheterization is difficult.
Angiography
• Go straight to the most likely artery identified by endoscopy or CTA.
• If the bleeding point is not obvious, then review both subtracted and native images
(removes bowel motion artifact).
• Celiac axis and SMA angiography are necessary for gastric or duodenal bleeding.
• Angiography of all potential feeding vessels should be repeated after emboliza-
tion to ensure that anastomotic collateral supply to the bleeding site has not been
overlooked.
Assessing the Lesion
Location
This should be known from endoscopy or CTA. Clips placed during endoscopy
enable targeting and can considerably shorten the procedure.
33 Acute Nonvariceal Upper Gastrointestinal Hemorrhage 335
a
b
c
Fig. 33.4 Massive hematemesis 2 months post-esophagolaryngectomy. Bleeding from pseu-
doaneurysm of the lingual artery demonstrating value of CTA. (a) Thick MIP CTA showing
lingual artery (white arrowhead), false aneurysm (black arrowhead), and extravasation (yellow
arrows). (b) Selective lingual artery DSA showing false aneurysm (red arrowhead) with active
extravasation. (c) Post-embolization
Angiographic Appearances
• Vascular abnormalities include aneurysms, pseudoaneurysms (Figs. 33.1, 33.2,
and 33.4), arteriovenous shunting, pooling of contrast, pathological tumor
circulation.
• Extravasation of contrast is the pathognomonic arteriographic feature indicating
the site of hemorrhage (Figs. 33.3 and 33.4).
◦ Contrast lingering after the angiographic run is completed. Extravascular con-
trast may mimic intravascular contrast (“pseudovein”). Prolonged filming
is necessary to distinguish intraluminal contrast (from extravasation) from
intravenous contrast (from an AV fistula).
◦ An occluded vessel. Vascular occlusions typically represent vessels in spasm
with or without superimposed thrombus. These vessels are likely to rebleed
at a later time, and empiric embolization is often helpful.
336 I. Gillespie and H. Ireland
Technique
• Start with cobra or sidewinder catheter shape.
• Microcatheters should be employed early in difficult or tortuous anatomy where
use of standard catheters may induce spasm and lead to a failed embolization
procedure.
• A guide catheter or sheath may occasionally help to stabilize access.
• Success is greater when the embolic agent is delivered as close to the point of
bleeding as possible.
Gastric Bleeding
• Start with the left gastric artery (LGA).
• If LGA embolization does not control hemorrhage, then look for supply from
short gastric, right gastric, gastroepiploic, and left inferior phrenic arteries.
• In erosive gastritis use gelfoam slurry to embolize each territory.
Duodenal Bleeding
• Start with gastroduodenal artery (GDA) – this is the most common site of bleeding in patients with pancreatitis and following pancreatic surgery (Fig. 33.5).
• Identify pancreaticoduodenal arteries via GDA or superior mesenteric artery
(SMA).
• Coil embolization will control hemorrhage from larger accessible vessels.
• Correctly sized coils should be positioned to close both “front and back doors”
(i.e., on both sides of the bleeding point). This may require catheterization from
both the celiac and SMA directions (Fig. 33.6).
• If bleeding occurs from multiple tiny vessels, gelfoam or PVA particles may
be useful. Deploy as selectively as possible to minimize the risk of nontarget
ischemia.
• Particles (PVA or gelfoam) may be utilized in the liver to occlude branches distal
to the site of hemorrhage prior to coiling the inflow artery.
• Glue may be used in place of coils but its accurate deployment is rather
unpredictable and it should only be used by experienced operators.
• Extreme care must be taken to avoid nontarget territory ischemia in SMA
territory.
Arterial Puncture Site
• Closure devices are especially helpful for agitated patients or those with impaired
clotting.