Early Angiographic Embolization Research Articles

158 Transarterial Angiographic Embolization vs. Surgery in Patients With Bleeding Peptic Ulcers Uncontrolled At Endoscopy; A Multicenter Randomized Trial

Background Further bleeding after endoscopic hemostasis to bleeding peptic ulcers is associated with an at least 3-fold increase in mortality. We sought to determine if preemptive angiographic embolization (AE) to high risk ulcers can reduce further bleeding and improves patients' outcome. Method Patients with bleeding gastro-duodenal ulcers that required endoscopic hemostasis were enrolled if they fulfilled one of the following criteria; Forrest I a bleeding, ulcer size hypotensive (systolic blood pressure < 90 mmHg) or hemoglobin ≤ 9g/dl. They were randomized to undergo angiographic embolization within 12 hours of endoscopy plus an intravenous infusion of high dose proton pump inhibitor (IV-PPI) or IV-PPI alone. Our primary endpoint was re-bleeding within 30 days of randomization. Results Between January 2010 to October 2013, 222 patients were randomized (AE 109, no AE 113). One and 3 patients were excluded after randomization. Baseline characteristics were similar between groups; mean age 65.3 vs. 67.7), in patient bleeding (19.2 vs. 18.6%), mean transfusion before randomization (2.53 vs. 2.6u),mean systolic BP (109 vs. 105mmHg). In the AE group, mean time to angiography was 4.2 (SD 3.3) hour. Of 109 randomized to AE, 16(14.7%) did not receive AE; 6 of 16 re-bled and 3 died (2 after surgery and 1 from major bleeding), 10 without further bleeding and one died. On an ITT analysis, further bleeding occurred in 8/109 (7.3%) and 12/113 (10.6%) of AE and no AE group respectively (P=0.39, OR, 95%CI=0.67; 0.26-1.70). On a PP analysis, further bleeding occurred in 4/ 91 (4.4%) patients in the AE group compared to 12/110 (10.9%) patients on iv-PPI alone (P=0.089; OR, 95%CI=2.66, 0.8-8.5). There was no 30 day mortality in the AE group (0/ 91 vs. 5/110, P=0.065). Hospitalization and blood transfusion were less in the AE group (6.9 vs. 8.7 days, P=0.2 and 1.2 vs. 1.9U, P=0.09 respectively). Reduction in re-bleeding after AE was seen mostly in patients with ulcers≥1.5cm in size (2/40 vs. 10/43, P=0.027) [Figure 1]. Conclusions Early angiographic embolization after endoscopic hemostasis to patients with gastro-duodenal ulcers ≥1.5cm in size reduces re-bleeding.

157 Early Angiographic Embolization After Endoscopic Hemostasis to High Risk Bleeding Peptic Ulcers Improves Outcomes

157 Early Angiographic Embolization After Endoscopic Hemostasis to High Risk Bleeding Peptic Ulcers Improves Outcomes

157 Early Angiographic Embolization After Endoscopic Hemostasis to High Risk Bleeding Peptic Ulcers Improves Outcomes

157 Early Angiographic Embolization After Endoscopic Hemostasis to High Risk Bleeding Peptic Ulcers Improves Outcomes

158 Transarterial Angiographic Embolization vs. Surgery in Patients With Bleeding Peptic Ulcers Uncontrolled At Endoscopy; a Multicenter Randomized Trial

Background Further bleeding after endoscopic hemostasis to bleeding peptic ulcers is associated with an at least 3-fold increase in mortality. We sought to determine if preemptive angiographic embolization (AE) to high risk ulcers can reduce further bleeding and improves patients' outcome. Method Patients with bleeding gastro-duodenal ulcers that required endoscopic hemostasis were enrolled if they fulfilled one of the following criteria; Forrest I a bleeding, ulcer size hypotensive (systolic blood pressure < 90 mmHg) or hemoglobin ≤ 9g/dl. They were randomized to undergo angiographic embolization within 12 hours of endoscopy plus an intravenous infusion of high dose proton pump inhibitor (IV-PPI) or IV-PPI alone. Our primary endpoint was re-bleeding within 30 days of randomization. Results Between January 2010 to October 2013, 222 patients were randomized (AE 109, no AE 113). One and 3 patients were excluded after randomization. Baseline characteristics were similar between groups; mean age 65.3 vs. 67.7), in patient bleeding (19.2 vs. 18.6%), mean transfusion before randomization (2.53 vs. 2.6u),mean systolic BP (109 vs. 105mmHg). In the AE group, mean time to angiography was 4.2 (SD 3.3) hour. Of 109 randomized to AE, 16(14.7%) did not receive AE; 6 of 16 re-bled and 3 died (2 after surgery and 1 from major bleeding), 10 without further bleeding and one died. On an ITT analysis, further bleeding occurred in 8/109 (7.3%) and 12/113 (10.6%) of AE and no AE group respectively (P=0.39, OR, 95%CI=0.67; 0.26-1.70). On a PP analysis, further bleeding occurred in 4/ 91 (4.4%) patients in the AE group compared to 12/110 (10.9%) patients on iv-PPI alone (P=0.089; OR, 95%CI=2.66, 0.8-8.5). There was no 30 day mortality in the AE group (0/ 91 vs. 5/110, P=0.065). Hospitalization and blood transfusion were less in the AE group (6.9 vs. 8.7 days, P=0.2 and 1.2 vs. 1.9U, P=0.09 respectively). Reduction in re-bleeding after AE was seen mostly in patients with ulcers≥1.5cm in size (2/40 vs. 10/43, P=0.027) [Figure 1]. Conclusions Early angiographic embolization after endoscopic hemostasis to patients with gastro-duodenal ulcers ≥1.5cm in size reduces re-bleeding.

Early angiographic embolization is more effective than delayed angiographic embolization in patients with duodenal ulcer bleeding

Though angiographic embolization (AE) is a type of effective treatment modality for duodenal ulcer bleeding, the optimum time at which to perform the procedure, early or delayed, is unknown. The authors compared the prognosis of early AE (EAE) and delayed AE (DAE) in patients with duodenal ulcer bleeding. A total of 54 patients with duodenal ulcer bleeding were evaluated with first-look endoscopy followed by AE. The patients were divided into two groups, the EAE group and DAE group, according to endoscopic attempts to stop the bleeding during the first-look endoscopy. The success rate of AE, rebleeding rate, and number of patients who underwent surgery was not significantly different between the EAE group and DAE group (91.3% vs 93.5%, 21.7% vs 29.0% and 4.3% vs 16.1%, respectively; P > 0.05). With respect to death and intensive care unit (ICU) care rate, multivariate analysis showed more favorable results in the EAE group (0% vs 22.6%, P = 0.016 and 4.3% vs 57.4%, P = 0.003, respectively). Multivariate analysis also showed that prolonged prothrombin time (PT) > 1.2 international normalized ratio and the endoscopic attempt were independent factors associated with ICU care. When the AE was performed early with correction for prolonged PT, the patients with duodenal ulcer bleeding had a more favorable prognosis.

Management of Hemorrhage in Severe Pelvic Injuries

Major pelvic trauma results in high mortality. No standard technique to control pelvic hemorrhage has been identified. In this retrospective study, the clinical course of hemodynamically instable trauma patients with pelvic fractures treated according to an institutional algorithm focusing on basic radiologic diagnostics, external fixation, and early angiographic embolization was evaluated. Study variables included demographics, data on the type and extent of injury, achievement of time from admission to hemorrhage control, complications of angiography, red blood cell needs, and outcome. Standard statistical tests were used. Of 1,476 pelvic fracture patients, 45 fulfilled the inclusion criteria. Two patients presented with severe intra-abdominal hemorrhage and underwent emergency laparotomy with pelvic packing. Forty-two patients underwent angiographic embolization before (n = 24) or after (n = 18) a computed tomography scan. Applying the clinical algorithm, pelvic hemorrhage was controlled in all but one patient who died before any intervention could be initiated (97.8%). The hourly need for red blood cell transfusions decreased during 24 hours after angiographic embolization when compared with before the procedure (3.7 +/- 3.5 vs. 0.1 +/- 0.1 U/h; p < 0.001). In patients undergoing angiographic embolization, the mean time to hemorrhage control was 163 minutes +/- 83 minutes. Hospital mortality was 26.2%. Two patients required reembolization because of hemorrhage from other than the primary bleeding site. One patient developed gluteal necrosis, and nine subsequently required renal replacement therapy. Application of a clinical algorithm focusing on basic radiologic diagnostics, external fixation, and early angiographic embolization was effective and safe to rapidly control hemorrhage in hemodynamically instable trauma patients with pelvic fractures.

Hemophilia A Pseudoaneurysm in a Patient with High Responding Inhibitors Complicating Total Knee Arthroplasty: Embolization: A Cost-Reducing Alternative to Medical Therapy

Joint hemorrhages are very common in patients with severe hemophilia. Inhibitors in patients with hemophilia are allo-antibodies that neutralize the activity of the clotting factor. After total knee replacement, rare intra-articular bleeding complications might occur that do not respond to clotting factor replacement. We report a 40-year-old male with severe hemophilia A and high responding inhibitors presenting with recurrent knee joint hemorrhage after bilateral knee prosthetic surgery despite adequate clotting factor treatment. There were two episodes of marked postoperative hemarthrosis requiring extensive use of substitution therapy. Eleven days postoperatively, there was further hemorrhage into the right knee. Digital subtraction angiography diagnosed a complicating pseudoaneurysm of the inferior lateral geniculate artery and embolization was successfully performed. Because clotting factor replacement therapy has proved to be excessively expensive and prolonged, especially in patients with inhibitors, we recommend the use of cost-effective early angiographic embolization.

The need for early angiographic embolization in blunt liver injuries.

Although nonoperative management of blunt liver injury (BLI) has become standard practice, adjuncts to nonoperative therapy, such as angiographic embolization, have not been well characterized. Patients with BLI were retrospectively identified at our American College of Surgeons-verified Level I trauma center from January 1997 through February 2001. Patients were stratified into four groups: those who received angiographic embolization (AE) as an early intervention when BLI was initially diagnosed (EARLY-AE); those who underwent AE after liver-related operation or later in the hospital course (LATE-AE); those treated with operation only (OR-ONLY); and nonoperative patients who also did not undergo AE (NO-OR). There were 126 patients with BLI, of whom 94 were NO-OR, 20 were OR-ONLY, 6 had LATE-AE, and 6 had EARLY-AE. The NO-OR group had significantly lower liver Abbreviated Injury Scale scores. Liver Abbreviated Injury Scale scores were not different between the EARLY-AE, LATE-AE, and OR-ONLY groups. Liver-related mortality was not lower for those treated with AE. There was a trend toward lower mortality for just the EARLY-AE group compared with the LATE-AE and OR-ONLY groups (0% vs. 50% and 35%). The number of units of packed red blood cells transfused and the number of liver-related operations were lower in the EARLY-AE compared with the LATE-AE group, but liver-related complications were not different between the EARLY-AE, LATE-AE, or OR-ONLY groups. AE was successful in arresting hemorrhage in 83% of the cases. In this small series, we observed similar morbidity and mortality with AE compared with operative therapy. EARLY-AE did decrease blood use and the number of liver-related operations. AE can be performed on severely injured patients with comparable liver-related mortality and complications. Further study of the timing of and outcomes from AE is needed.

Early detection of arterial bleeding in acute pelvic trauma.

To determine the accuracy of intravenous contrast-enhanced computerized tomography (CECT) in the detection of potentially life-threatening retroperitoneal hemorrhage in patients sustaining pelvic fractures, acetabular fractures or both. Retrospective review of sequential patients identified over a 1-year period by using a prospectively collected trauma database at two Level I trauma centers. A group of patients admitted to one of two Level I trauma centers with pelvic or acetabular injuries between September 1, 1995, and September 30, 1996, was identified by using a prospectively collected trauma database. From this cohort, we selected those individuals who had undergone intravenous CECT scanning within 24 hours after admission and who had an Abbreviated Injury Score more than 3 because of their pelvic injury. Those individuals who required arterial embolization for uncontrolled hemodynamic shock were categorized as having "significant arterial bleeding" attributable to their pelvic injury. Individuals who regained hemodynamic ,stability without embolization were categorized as having "no significant arterial bleeding." Two observers who were blinded to clinical information and the results of angiography reviewed all injury radiographs and computed tomographic scans. The presence or absence of contrast extravasation on intravenous CECT was recorded. Each case was then categorized into a 2 x 2 table depending on the presence of contrast extravasation on CECT and the need for arterial embolization to determine the accuracy of the "contrast extravasation sign." Of the 192 eligible patients, 111 met the inclusion criteria. Eleven patients required an angiogram for ongoing hemodynamic instability. The sensitivity of extravasation on contrast enhanced computed tomography representing a significant arterial bleeding was 80%, and the specificity was 98%. The predictive value of a positive contrast "extravasation sign" was 80%, whereas the predictive value of a negative test was 98%. The likelihood ratio of a positive test was 40.4, and the likelihood ratio of a negative test was 0.204. The finding of contrast extravasation on CECT is highly suggestive of significant arterial bleeding that requires early angiographic embolization to restore hemodynamic stability.