Role of transcatheter arterial embolization for massive bleeding from gastroduodenal ulcers

Abstract

Intractable bleeding from gastric and duodenal ulcers is associated with significant morbidity and mortality. Aggressive treatment with early endoscopic hemostasis is essential for a favourable outcome. In as many as 12%-17% of patients, endoscopy is either not available or unsuccessful. Endovascular therapy with selective catheterization of the culprit vessel and injection of embolic material has emerged as an alternative to emergent operative intervention in high-risk patients. There has not been a systematic literature review to assess the role for embolotherapy in the treatment of acute upper gastrointestinal bleeding from gastroduodenal ulcers after failed endoscopic hemostasis. Here, we present an overview of indications, techniques, and clinical outcomes after endovascular embolization of acute peptic-ulcer bleeding. Topics of particular relevance to technical and clinical success are also discussed. Our review shows that transcatheter arterial embolization is a safe alternative to surgery for massive gastroduodenal bleeding that is refractory to endoscopic treatment, can be performed with high technical and clinical success rates, and should be considered the salvage treatment of choice in patients at high surgical risk.

Keywords: Angiography; Embolization; Endoscopy; Massive bleeding; Peptic ulcer.

Figure 1

Arteriogram images of bleeding from a bulbar duodenal ulcer in a 76-year-old man. A, B: Arteriogram showing contrast medium extravasated from a slender branch of the gastroduodenal artery (GDA) into the duodenum (arrows); C, D: After microcatheterization, selective glue embolization (radiopaque because of associated lipiodol (arrows) preserving the GDA ensured control of the bleeding, with no early or late recurrences.

Figure 2

Bleeding Dieulafoy lesion in an 87-year-old man. A, B: Selective angiography shows contrast medium extravasation from the left gastric artery at the celiac trunk, indicating active bleeding (arrows); C: After arterial microcatheterization, bleeding was controlled after embolization of the left gastric artery using a Glubran/Lipidol mixture (1:3) (arrows).

Figure 3

Digital subtraction images from a 37-year-old man with massive hematemesis. A, B: Selective angiography shows a bleeding ulcer in the fundus of the stomach. Extravasation of contrast medium from a branch of the left gastroepiploic artery is seen (arrows); C: The control angiogram after glue embolization throughout the splenic artery shows complete and selective occlusion of the bleeding branch, with no active bleeding. The patient was discharged from the hospital 4 d later.

Figure 4

Typical sandwich embolization in a 75-year-old woman with bleeding from a postbulbar duodenal ulcer at endoscopy. A: Angiography before embolization, guided by clip position (arrow): no evidence of active bleeding; B: Result after coil embolization of the distal and proximal GDA (with gelatine sponge in the arterial trunk), including the anterior and posterior superior pancreaticoduodenal arteries and the right gastroepiploic artery, to prevent retrograde flow (arrows). No ischemic complications were reported.