Multicenter case series of patients with small-bowel angiodysplasias treated with a small-bowel radiofrequency ablation catheter

Abstract

Background and aims: GI angiodysplasia is the most common cause of small-bowel bleeding. Argon plasma coagulation (APC) is preferred for ablation because of its availability, ease of use, and perceived safety, but it has limitations. An instrument capable of repeated use through the enteroscope, which covers more area of intestinal mucosa per treatment with low risk of damage to healthy mucosa, and which improves ablation, is desirable. A series of patients treated with a through-the-scope radiofrequency ablation (RFA) catheter is reported.

Methods: Patients with a previous diagnosis of small-bowel angiodysplasia (SBA) and ongoing bleeding with melena, hematochezia, or iron-deficiency anemia were eligible for treatment. A small-bowel radiofrequency ablation (SBRFA) catheter was passed through the enteroscope instrument channel. The treatment paddle was pushed against the SBA, achieving coaptive coagulation, and the SBA was treated up to 2 times at standard settings of 10 J/cm². The patients' demographics, pretreatment and posttreatment hemoglobin levels, time to recurrence of bleeding, and need for more therapy were recorded. This study was approved by the institutional review boards of the respective institutions.

Results: Twenty consecutive patients were treated from March until October 2018 and followed up until March 2019. There were 6 women (average age 68 years, standard deviation ± 11.1), and 14 men (average age 73 years, standard deviation ± 10.4). All had undergone at least 1 previous EGD and colonoscopy; 14 patients (70%) had SBA on video capsule endoscopy, and 14 patients had undergone previous endoscopic treatment of SBA with APC. A median of 23 treatments were applied (range, 2-99). The median follow-up time was 195 days (range, 30-240 days). Four patients, including 3 with a left ventricular assist device (LVAD), had recurrent bleeding between 45 and 210 days after treatment, and 2 patients received repeated blood transfusions. Three of those patients underwent repeated endoscopies, including a push enteroscopy and an upper endoscopy with no treatment, and a repeated enteroscopy with SBA treated with APC, respectively. One patient with LVAD underwent arterial embolization.

Conclusions: In this case series, bleeding recurred in 20% of patients in a follow-up time of ≤240 days. Notably, 3 of the 4 patients who had recurrent bleeding had an LVAD. These rates compare favorably with reported bleeding recurrence after APC of SBA. More studies on the benefits of SBRFA, which may include reduced risk of recurrent bleeding or prolonging the time to recurrent bleeding, resource utilization, and factors associated with bleeding recurrence are needed.

Keywords: APC, argon plasma coagulation; GIAD, GI angiodysplasia; LVAD, left ventricular assist device; RFA, radiofrequency ablation; SBA, small-bowel angiodysplasia; SBRFA, small-bowel radiofrequency ablation.

Figure 1

Mucosal vascular arborizing lesion consistent with an angiodysplasia was seen in the small bowel (arrow). The radiofrequency ablation catheter was used to push the intestinal fold away and expose the lesion.

Figure 2

During treatment the angiodysplasia bled. The rigidity of the instrument allowed us to push the paddle on the lesion in the direction indicated by the arrow and apply radiofrequency therapy.

Figure 3

The lesion was treated twice, producing the discolored rectangular treatment footprint. After treatment with the radiofrequency ablation catheter, the lesion appeared cherry-red, with a hint of the small cluster of vessels that formed the lesion (arrow). Bleeding stopped.

Figure 4

A lesion was indicated by the arrow.

Figure 5

The positions of the lesions were noted to sometimes change because of peristalsis or change in enteroscope dynamics when the instrument was passed. The paddle was pushed against the lesion, flattening the intestinal mucosa to enhance exposure of the lesion to the treatment paddle and maximize therapy in the direction of the arrow.

Figure 6

The treatment footprint was visible, and the angiodysplasia appeared completely obliterated as indicated by the arrow.

Figure 7

Two diminutive lesions, which on video capsule endoscopy could sometimes be seen oozing blood as smokestacks, were identified as indicated by the arrows.

Figure 8

The treatment paddle was used to flatten the mucosa and treat them in the direction indicated by the arrow.

Figure 9

The posttreatment footprint is indicated by the arrow.

Figure 10

One lesion had already been treated, as evidenced by the footprint. A second angiodysplasia was identified (arrow).

Figure 11

The treatment paddle was pushed against the lesion to enhance tissue apposition and coaptive coagulation in the direction of the arrow while avoiding the previously treated site.

Figure 12

The second treatment footprint was visible. The cherry-red island within the treatment site indicated the location of the treated angiodysplasia (arrow).

Figure 13

This image highlights the discolored treatment footprint (arrow). The cherry-red color of the treated angiodysplasia within the site after radiofrequency ablation is highlighted in the circle.