Palliative Embolization for Refractory Bleeding

Abstract

Bleeding is a common and often challenging complication of malignancy. Etiologies of hemorrhage in this patient population vary, and bleeding may present as an acute, life-threatening emergency or a chronic, low-volume blood loss. For patients with advanced malignancies, interventions to manage bleeding must be balanced by the patient's life expectancy and quality of life. As such, minimally invasive procedures such as transarterial embolization are useful therapeutic options in appropriately selected patients. There is a rich history of palliative transarterial embolization for refractory bleeding in cancer patients. This technique was first applied in the 1970s and has since become an established treatment tool for malignancy-related bleeding throughout the body. While the preponderance of published data comprised case reports and small retrospective studies, the use of embolization continues to expand as experience grows and techniques are refined. In this review, we summarize the literature and provide our perspective on embolization for refractory bleeding in cancer patients.

Keywords: embolization; hemorrhage; interventional radiology; malignancy; palliative care.

Fig. 1

The classic “hairpin” turn of the anterior spinal artery on angiography (arrow).

Fig. 2

A patient underwent transthoracic needle biopsy of a pulmonary nodule. This was complicated by the development of an iatrogenic pulmonary artery pseudoaneurysm (arrow). This lesion was successfully excluded with a self-expanding stent graft.

Fig. 3

A patient with metastatic gastrointestinal stromal tumor developed a large intraparenchymal hepatic hemorrhage (left) resulting in pain and hypotension. This mildly hypervascular lesion (middle image, arrow) was successfully embolized with calibrated microspheres. Postprocedure CT (right image) demonstrated successful resolution of hemorrhage.

Fig. 4

Patient presented with a refractory bleeding from a large gastric carcinoma (left image, arrow). Angiography demonstrated an area of active extravasation from the proximal left phrenic artery (right image, arrow); additional tumor supply was seen from the right and left gastric arteries (not shown). All three arteries were embolized to stasis with gelatin sponge.

Fig. 5

A patient with renal cell carcinoma was found to have active bleeding on endoscopy ( a ) from a metastasis involving the duodenum noted on a CT scan ( b , arrow). Angiography revealed the metastasis with arterial blood supply (arrowheads) from branches of the middle colic artery shared with loops of small bowel. Endovascular coils in the gastroduodenal artery from a previously unsuccessful attempt at tumor embolization are also present (arrow) ( c ). Cone-beam CT ( D ) was used to isolate arterial branches that supplied the tumor alone and could therefore be embolized safely with gelatin sponge. Postembolization angiography demonstrated significant devascularization of the tumor following embolization ( e ).

Fig. 6

A patient with renal cell carcinoma presented with refractory hematuria. CT ( a ) demonstrated a right lower pole renal mass (asterisk) with blood clots (arrow) within the collecting system. Embolization of the lesion was performed with absolute ethanol [preembolization ( b ) and postembolization ( c ) angiograms are noted]. Subsequent CT imaging demonstrated complete devascularization of the lesion (arrow) ( d ).

Fig. 7

A patient with advanced renal cell carcinoma, with tumor noted on CT (arrowhead, left image) extending into the inferior vena cava (arrow) presented with persistent hematuria. A hypervascular lesion was noted on angiography essentially replacing the entire renal arterial vascular supply; embolization of the kidney was performed with absolute ethanol (middle image). Postprocedure CT imaging demonstrated complete devascularization of the renal lesion and its extension into the inferior vena cava (arrows, right image).

Fig. 8

A patient with a history of myelodysplastic syndrome developed thrombocytopenia and BK virus cystitis. This was initially managed with urinary diversion with bilateral nephrostomy tubes. Due to persistent gross hematuria, selective embolization of the bilateral vesical arteries was performed. Intraprocedural CT was performed to delineate the arterial anatomy.

Fig. 9

A patient with cervical cancer underwent chemoradiation therapy, complicated by vesicovaginal fistula formation. The patient presented to the emergency department with massive vaginal bleeding resulting in hemodynamic instability. CT angiography demonstrated active extravasation immediately superior to the vaginal packing material, seen as dense material on the sagittal CT reconstructions (arrow). Emergent angiography demonstrated a large right uterine artery pseudoaneurysm (arrow) that was successfully embolized with cyanoacrylate/Ethiodol.