Transcatheter arterial embolization for advanced gastric cancer bleeding: A single-center experience with 58 patients

Abstract

To investigate computed tomography and angiography findings and clinical outcomes after transcatheter arterial embolization for acute upper gastrointestinal bleeding from advanced gastric cancers.From January 2005 to December 2014, 58 patients with pathologically proven gastric cancer were treated at our institution with transcatheter arterial embolization due to acute upper gastrointestinal bleeding recalcitrant to endoscopic treatment. The electronic medical records for each patient were reviewed for clinical presentation, endoscopy history, computed tomography and angiographic findings, blood transfusion requirements, and follow-up results.Angiography findings were positive in 13 patients (22.4%): contrast extravasation was found in 9 patients and pseudoaneurysm in 4 patients. All patients with positive angiograms underwent selective embolization treatment. Those with negative angiography findings underwent empirical embolization. Gelfoam, n-butyl cyanoacrylate, coils, or a combination of these were used as embolic agents. The overall clinical success rate was 72.4% (42/58), and the success rate for patients with positive angiography was 53.8% (7/13). The median survival was 97.5 days (range, 7-1415 days), and the 1-month survival rate was 89.6% (52/58). The 1-month survival rate of the clinical success group was 95.2% (40/42), which was significantly higher than that of the clinical failure group (P = .04). The clinical success group also required significantly fewer transfusions (2.43 units, range 0-24 units) (P = .02).Transcatheter arterial embolization is a highly effective treatment for advanced gastric cancer with active bleeding. It should be considered as an additional treatment, especially when endoscopic or surgical treatment fails or when these approaches are difficult.

Figure 1

A 63-year-old male presented with hematemesis. (A) Contrast-enhanced CT scan showed wall thickening of the gastric body at the lesser curvature. A fine arterial channel was encased by the tumor (white arrow). (B) Celiac arteriography revealed tumor staining supplied by the left gastric artery (LGA) without active bleeding or pseudoaneurysm. (C) Selective angiogram of the LGA also showed no active bleeding or pseudoaneurysm. However, based on the CT scan, we decided to perform glue embolization of the LGA as the feeding artery. (D) After the tip of microcatheter was positioned more distal to the LGA, we performed embolization using NBCA mixed with lipiodol (white arrow). (E) Completion angiography revealed that the distal branches of the LGA were successfully embolized with a glue cast (white arrow), while the proximal LGA was intact.

Figure 2

A 76-year-old male presented with hematemesis. (A) Contrast-enhanced CT showed focal wall thickening of the gastric pylorus and a pseudoaneurysm (white arrow) at the medial wall. A fine arterial channel (white arrowhead) was suspected to be connected to the pseudoaneurysm. (B) Celiac arteriography revealed contrast filling the pseudoaneurysm (white arrow) from a fine feeding artery (white arrowhead) arising from the proper hepatic artery. (C) After the microcatheter tip was advanced closer to the bleeding point, NBCA mixed with lipiodol could fill the pseudoaneurysm (white arrow) without overflowing into the proper hepatic artery. (D) Completion angiography revealed that the pseudoaneurysm and the feeding artery were successfully embolized with a glue cast (white arrow), while the proper hepatic artery was intact.

Figure 3

A 67-year-old male presented with hematemesis and melena. (A) Contrast-enhanced CT showed diffuse wall thickening of the gastric body, antrum, and pylorus, with contrast media extravasation from the LGA (white arrow). (B) Celiac arteriography showed no active bleeding or pseudoaneurysm. (C) Selective angiogram of the LGA showed equivocal findings with aneurysmal changes (white arrows). (D) The microcatheter was advanced to the branch of the LGA, and microcoil embolization was performed (white arrow). (E) Follow-up angiogram revealed residual aneurysmal changes in the LGA (white arrow). (F) After the microcatheter tip was located at the aneurysmal portion, additional embolization was performed using NBCA mixed with lipiodol (white arrow). (G) Selective angiogram of the gastroduodenal artery (GDA) showed equivocal findings with aneurysmal changes (white arrows), and we conducted embolization using NBCA mixed with lipiodol. (H) Completion angiography revealed that the abnormal vessels with aneurysmal changes at the LGA and GDA were successfully embolized with a glue cast (white arrow). However, the patient underwent total gastrectomy due to stomach wall perforation.