Efficacy and safety of transcatheter arterial embolization for active arterial esophageal bleeding: a single-center experience

Abstract

Purpose: The study aimed to evaluate the safety and clinical efficacy of transcatheter arterial embolization (TAE) for the treatment of arterial esophageal bleeding.

Methods: Nine patients (8 male, 1 female; mean age, 62.3±7.5 years) who underwent TAE for arterial esophageal bleeding between January 2004 and January 2020 were included. Preceding endoscopic treatment was unsuccessful in five patients and was not attempted in four patients due to the non-cooperation of the patients in endoscopic treatment. The etiologies of bleeding were esophageal cancer (n=4), Mallory-Weiss syndrome (n=3), erosive esophagitis (n=1), and esophageal ulcer (n=1). Technical and clinical success, recurrent bleeding, procedure-related complications, and clinical outcomes were retrospectively reviewed.

Results: The angiographic findings for bleeding were contrast media extravasation (n=8) or tumor staining without a definite bleeding focus (n=1). The bleeding focus at the distal esophagus (n=8) was the left gastric artery, whereas that at the middle esophagus (n=1) was the right bronchial artery. Technical success was achieved in all patients. The embolic agents were n-butyl cyanoacrylate (NBCA, n=5), gelatin sponge particles (n=2), microcoils (n=1), and NBCA with gelatin sponge particles (n=1). Clinical success was achieved in 77.8% of cases (7/9); two patients with recurrent bleeding one day after the first TAE showed culprit arteries different from the bleeding foci at the first TAE. One patient who underwent embolization of both the left and short gastric arteries died of gastric infract/perforation one month after TAE.

Conclusion: TAE can be an alternative to the treatment of arterial esophageal bleeding. TAE can be attempted in the treatment of recurrent bleeding, but there is a risk of ischemia/infarct in the gastrointestinal tract involved.

Figure 1. a, b

A 59-year-old male (No. 9) diagnosed with Mallory-Weiss syndrome presented with hematemesis. Enhanced axial CT scan (a) shows active bleeding (arrow) at the distal esophagus with a large amount of hematoma (asterisk) in the stomach. Left gastric arteriogram (b) shows active contrast extravasation (arrows). Embolization with n-butyl cyanoacrylate (NBCA) was performed (not shown). A linear array of mucosal breaks with superficial clots (arrowheads) at the distal esophagus were noted on the endoscopic image 8 h after embolization (inset).

Figure 2. a–f

A 56-year-old male (No. 5) diagnosed with esophageal cancer presented with hematemesis. Coronal contrast-enhanced CT scan (a) obtained 13 days before shows a huge distal esophageal mass (asterisk) extending to the stomach. Left gastric arteriogram (b) shows active contrast extravasation (arrows) from the left gastric artery (arrowheads). Left gastric arteriogram (c) after embolization with NBCA (arrows) shows the disappearance of the bleeding focus. The dense opacification of the bleeder with NBCA was noted (arrows, inset). Splenic arteriogram (d) one day later for recurrent bleeding shows multifocal tumor staining (arrows) from the short gastric arteries. Splenic arteriogram (e) after embolization using coils and gelatin sponge particles shows no remaining tumor staining. Follow-up CT scan (f) at one month shows gastric perforation (arrows) and fluid collection (asterisks) in the peritoneal cavity.

Figure 3. a, b

A 63-year-old male (No. 2) who underwent stent placement for esophageal cancer. Right bronchial arteriogram (a) shows active esophageal bleeding (arrows) from the right bronchial artery. Radiograph (b) shows the microcoils (arrows) used for the embolization of the right bronchial artery.