Transcatheter Angiographic Embolization Research Articles

An unusual case of acute cholecystitis complicated by haemobilia and Mirizzi-like obstruction: A case report and review of literature

Introduction: Cystic artery pseudoaneurysm rupture presents a rare yet potentially fatal aetiology for upper GI bleed. While uncommon, its incidence has been rising with increased hepatobiliary surgical interventions, predominantly attributed to iatrogenic injury and rarely secondary to acute cholecystitis. Clinical manifestations typically include epigastric pain, upper GI haemorrhage, and obstructive jaundice. Due to its rarity, it is often excluded from initial differential diagnoses. Case report: This is an unusual case of a 54-year-old male who presented with acute cholecystitis complicated by haemobilia and Mirizzi-like obstruction, in the setting of cystic artery pseudoaneurysm rupture. Initially, urgent transcatheter angiographic embolization of the cystic artery was performed to achieve hemodynamic stability. However, a triphasic CT scan revealed the first attempt was unsuccessful, necessitating a second embolization. Subsequent imaging confirmed satisfactory embolization; however, a small area of liver necrosis was observed adjacent to the gallbladder. The patient was stable at discharge from the hospital and had an uncomplicated interval cholecystectomy. Discussion: This case highlights the complexity and challenges associated with diagnosing and managing cystic artery pseudoaneurysm rupture. Diagnosis often relies on arterial phase contrast-enhanced CT scan. While no guideline currently exist, management typically involves achieving hemodynamic stability through Transcatheter angiographic embolization, followed by interval cholecystectomy. Conclusion: Early recognition and intervention are crucial in managing cystic artery pseudoaneurysm rupture to prevent life-threatening haemorrhagic shock. Clinicians need to consider this rare condition in patients with upper GI bleeding and abnormal LFTs.

Transcatheter Angiographic Embolization of Percutaneous Nephrolithotomy-Related Bleeding: A Single-Center Experience

Background To evaluate the clinical characteristics and angiographic features of transcatheter angiographic embolization (TAE) in patients with active bleeding after percutaneous nephrolithotomy (PCNL). Methods Between 2009 and 2018, 45 patients who underwent TAE for hemorrhage control after PCNL were reviewed retrospectively. Patient clinical characteristics and angiographic features of TAE were analyzed. Results Of the 3148 patients, 45 (1.4%) patients were treated with TAE after PCNL. The interval from the bleeding episode to TAE was 3 days (1,6). Arterial laceration, arteriovenous fistula, and negative angiographic finding were found in 28 (62.2%), 7 (15.6%), and 10 patients (22.2%). Thirty-five patients (92.1%) achieved primary clinical success. The median-corrected hemoglobin decrease from bleeding episode to TAE was 52 g/L (25.25, 71.00). The median-corrected hemoglobin decrease rate from bleeding episode to TAE was 13.11 g/L·d (5.60, 26.12). The hemoglobin decrease from bleeding episode to TAE was lesser in negative angiographic patients (28.50 (10.75,51.25) g/L VS 53.7 (35.0,73.13) g/L) than in positive angiographic patients (P < 0.05). Conclusions TAE is a safe and effective treatment for post-PCNL bleeding patients. Previous kidney surgery is associated with a higher risk of TAE. Patients with bleeding from multiple negative angiographic findings can be considered for prophylactic embolization.

Gastric cancer complicated by bleeding: a systematic review

Bleeding as the most common complication of gastric cancer is a significant problem of modern surgery. Both oncologists and surgeons in ordinary hospitals deal with this adverse event. In addition to the well-known drugs for hemostasis, there are also generally recognized traditional methods of endoscopic hemostasis and transcatheter angiographic embolization. Surgical interventions do not lose their role too if previous hemostatic methods turned out to be ineffective. The reports devoted to radiotherapy for treatment and prevention of gastric bleeding following malignant process have been recently published. Such a wide choice of hemostatic methods prompted us to analyze the most significant recent studies regarding effectiveness of various methods and choice of the most optimal one.

Treatment and outcome of gastrointestinal bleeding due to peptic ulcers and erosions – (BLUE study)

Objectives Peptic ulcers and erosions are the most common causes of upper gastrointestinal bleeding. The aim of this study was to investigate the management and outcomes of these patients. Materials and methods A total of 543 patients with endoscopically confirmed bleeding from peptic ulcers and erosions were included from March 2015 to December 2017. The patient characteristics, endoscopic findings, Forrest classification and endoscopic treatment were recorded. Moreover, the rebleeding rates, repeated endoscopies and transcatheter angiographic embolization and surgery incidences were registered. A follow-up endoscopy after discharge from the hospital was scheduled. Results Among the patients, high-risk stigmata ulcers were present in 36% (198/543) and low-risk stigmata ulcers and erosions in 60% (327/543) at first endoscopy. Endoscopic therapy was performed in 30% (165/543) of the patients, and hemostasis was achieved in 94% (155/165). The incidence of rebleeding was 9% (49/543) for the whole cohort and 14.8% (23/155) for those patients who had received successful endoscopic treatment. Moreover, rebleeding was significantly more frequent in duodenal ulcers than in gastric ulcers (11.9% vs 4.0%, p = .004). In a multivariable analysis, rebleeding was significantly related to comorbidity and Forrest classification. Transcatheter angiographic embolization and surgery were required in 6% (34/543) and 0.07% (4/543) of patients, respectively. Complete peptic ulcer healing was found at follow-up in 73.3% (270/368) of patients. Conclusions Endoscopic hemostasis was achieved in the majority of patients with high-risk ulceration, although the occurrence of rebleeding is a significant challenge, especially in patients with duodenal ulcers. Clinical trial registration: Bleeding Ulcer and Erosions Study (BLUE Study), ClinicalTrials.gov identifier: NCT03367897.

Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2021

1: ESGE recommends in patients with acute upper gastrointestinal hemorrhage (UGIH) the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Patients with GBS ≤ 1 are at very low risk of rebleeding, mortality within 30 days, or needing hospital-based intervention and can be safely managed as outpatients with outpatient endoscopy.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in patients with acute UGIH who are taking low-dose aspirin as monotherapy for secondary cardiovascular prophylaxis, aspirin should not be interrupted. If for any reason it is interrupted, aspirin should be re-started as soon as possible, preferably within 3-5 days.Strong recommendation, moderate quality evidence. 3: ESGE recommends that following hemodynamic resuscitation, early (≤ 24 hours) upper gastrointestinal (GI) endoscopy should be performed. Strong recommendation, high quality evidence. 4: ESGE does not recommend urgent (≤ 12 hours) upper GI endoscopy since as compared to early endoscopy, patient outcomes are not improved. Strong recommendation, high quality evidence. 5: ESGE recommends for patients with actively bleeding ulcers (FIa, FIb), combination therapy using epinephrine injection plus a second hemostasis modality (contact thermal or mechanical therapy). Strong recommendation, high quality evidence. 6: ESGE recommends for patients with an ulcer with a nonbleeding visible vessel (FIIa), contact or noncontact thermal therapy, mechanical therapy, or injection of a sclerosing agent, each as monotherapy or in combination with epinephrine injection. Strong recommendation, high quality evidence. 7 : ESGE suggests that in patients with persistent bleeding refractory to standard hemostasis modalities, the use of a topical hemostatic spray/powder or cap-mounted clip should be considered. Weak recommendation, low quality evidence. 8: ESGE recommends that for patients with clinical evidence of recurrent peptic ulcer hemorrhage, use of a cap-mounted clip should be considered. In the case of failure of this second attempt at endoscopic hemostasis, transcatheter angiographic embolization (TAE) should be considered. Surgery is indicated when TAE is not locally available or after failed TAE. Strong recommendation, moderate quality evidence. 9: ESGE recommends high dose proton pump inhibitor (PPI) therapy for patients who receive endoscopic hemostasis and for patients with FIIb ulcer stigmata (adherent clot) not treated endoscopically. (A): PPI therapy should be administered as an intravenous bolus followed by continuous infusion (e. g., 80 mg then 8 mg/hour) for 72 hours post endoscopy. (B): High dose PPI therapies given as intravenous bolus dosing (twice-daily) or in oral formulation (twice-daily) can be considered as alternative regimens.Strong recommendation, high quality evidence. 10: ESGE recommends that in patients who require ongoing anticoagulation therapy following acute NVUGIH (e. g., peptic ulcer hemorrhage), anticoagulation should be resumed as soon as the bleeding has been controlled, preferably within or soon after 7 days of the bleeding event, based on thromboembolic risk. The rapid onset of action of direct oral anticoagulants (DOACS), as compared to vitamin K antagonists (VKAs), must be considered in this context.Strong recommendation, low quality evidence.

Upper Gastrointestinal Bleeding

Acute upper gastrointestinal bleeding (UGIB) is a common and potentially life-threatening emergency. Despite significant advances in intensive care resuscitation, medical treatment of gastric acid hypersecretion, and progress in endoscopic and surgical management, mortality from upper gastrointestinal hemorrhage has remained steady over the past four decades. One of the major challenges of managing UGIB involves identifying patients who are at high risk for rebleeding and death and who require admission to the intensive care unit. Regardless of the cause, initial evaluation of patients with UGIB is based on the degree of hemodynamic instability and the presumed rate of bleeding. Those patients with evidence of active bleeding and hemodynamic instability require aggressive resuscitation and hospitalization. Although diagnostic imaging may be useful in identifying the source of bleeding, endoscopy remains the “gold standard” diagnostic and therapeutic modality. Recent advances in transcatheter angiographic embolization have made this modality an attractive alternative to surgical intervention in patients who fail endoscopic management. However, in the hemodynamically unstable patient, surgical intervention is often necessary. In this review, we describe the most common causes of acute UGIB and detail the initial workup and management of each cause. This review contains 6 figures, 3 tables, and 71 references. Key words: acute upper gastrointestinal bleeding, angiographic embolization, Billroth, Dieulafoy, esophagogastroduodenoscopy, peptic ulcer disease, scintigraphy, varices

A new method for traumatic renal injury in a canine model

BackgroundSelective transcatheter angiographic embolization (TAE) is an important method for efficient and accurate hemostasis in organ injuries during emergency settings. Sometimes, TAE cannot be performed on patients because of the limitations imposed by their condition. MethodsA total of 32 canines with traumatic right renal wounds were prepared by stab injuries. The canines were randomly divided into four groups according to different treatments. Group A was the renal neoplasty group (n=8). Group B was the TAE group (n=8). Group C was the group with temporary transcatheter bung associated with the renal neoplasty (TTBR) (n=8), and Group D was the sham surgery control group (n=8). Clinical trauma database, outcomes, and complications were analyzed to determine the feasibility and efficacy of different methods. ResultsAll canines were rescued in a timely manner. There was gross hematuria in six canines (18.8%). Only one (3.1%) animal died during follow-up because of uremia. The complication rate was not statistically different according to management type (Groups A, B, and C vs. Group D; p=0.332, p=0.372, and p=0.345, respectively). Groups B and C did better in protecting the damaged renal function with respect to creatinine than Groups A and D (p=0.013 and p=0.032, respectively). However, Group C did a better job in protecting the damaged renal function than Group B (p=0.015). ConclusionUse of TTBR can protect the damaged organ's functions more efficiently. Combined with the hybrid operating shelter, the method is a good damage control method for treating similar trauma in emergencies.

Correlation between Young and Burgess Classification and Transcatheter Angiographic Embolization in Severe Trauma Patients

Correlation between Young and Burgess Classification and Transcatheter Angiographic Embolization in Severe Trauma Patients

Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH). Main Recommendations MR1. ESGE recommends immediate assessment of hemodynamic status in patients who present with acute upper gastrointestinal hemorrhage (UGIH), with prompt intravascular volume replacement initially using crystalloid fluids if hemodynamic instability exists (strong recommendation, moderate quality evidence). MR2. ESGE recommends a restrictive red blood cell transfusion strategy that aims for a target hemoglobin between 7 g/dL and 9 g/dL. A higher target hemoglobin should be considered in patients with significant co-morbidity (e. g., ischemic cardiovascular disease) (strong recommendation, moderate quality evidence). MR3. ESGE recommends the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Outpatients determined to be at very low risk, based upon a GBS score of 0 – 1, do not require early endoscopy nor hospital admission. Discharged patients should be informed of the risk of recurrent bleeding and be advised to maintain contact with the discharging hospital (strong recommendation, moderate quality evidence). MR4. ESGE recommends initiating high dose intravenous proton pump inhibitors (PPI), intravenous bolus followed by continuous infusion (80 mg then 8 mg/hour), in patients presenting with acute UGIH awaiting upper endoscopy. However, PPI infusion should not delay the performance of early endoscopy (strong recommendation, high quality evidence). MR5. ESGE does not recommend the routine use of nasogastric or orogastric aspiration/lavage in patients presenting with acute UGIH (strong recommendation, moderate quality evidence). MR6. ESGE recommends intravenous erythromycin (single dose, 250 mg given 30 – 120 minutes prior to upper gastrointestinal [GI] endoscopy) in patients with clinically severe or ongoing active UGIH. In selected patients, pre-endoscopic infusion of erythromycin significantly improves endoscopic visualization, reduces the need for second-look endoscopy, decreases the number of units of blood transfused, and reduces duration of hospital stay (strong recommendation, high quality evidence). MR7. Following hemodynamic resuscitation, ESGE recommends early (≤ 24 hours) upper GI endoscopy. Very early ( MR8. ESGE recommends that peptic ulcers with spurting or oozing bleeding (Forrest classification Ia and Ib, respectively) or with a nonbleeding visible vessel (Forrest classification IIa) receive endoscopic hemostasis because these lesions are at high risk for persistent bleeding or rebleeding (strong recommendation, high quality evidence). MR9. ESGE recommends that peptic ulcers with an adherent clot (Forrest classification IIb) be considered for endoscopic clot removal. Once the clot is removed, any identified underlying active bleeding (Forrest classification Ia or Ib) or nonbleeding visible vessel (Forrest classification IIa) should receive endoscopic hemostasis (weak recommendation, moderate quality evidence). MR10. In patients with peptic ulcers having a flat pigmented spot (Forrest classification IIc) or clean base (Forrest classification III), ESGE does not recommend endoscopic hemostasis as these stigmata present a low risk of recurrent bleeding. In selected clinical settings, these patients may be discharged to home on standard PPI therapy, e. g., oral PPI once-daily (strong recommendation, moderate quality evidence). MR11. ESGE recommends that epinephrine injection therapy not be used as endoscopic monotherapy. If used, it should be combined with a second endoscopic hemostasis modality (strong recommendation, high quality evidence). MR12. ESGE recommends PPI therapy for patients who receive endoscopic hemostasis and for patients with adherent clot not receiving endoscopic hemostasis. PPI therapy should be high dose and administered as an intravenous bolus followed by continuous infusion (80 mg then 8 mg/hour) for 72 hours post endoscopy (strong recommendation, high quality evidence). MR13. ESGE does not recommend routine second-look endoscopy as part of the management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH). However, in patients with clinical evidence of rebleeding following successful initial endoscopic hemostasis, ESGE recommends repeat upper endoscopy with hemostasis if indicated. In the case of failure of this second attempt at hemostasis, transcatheter angiographic embolization (TAE) or surgery should be considered (strong recommendation, high quality evidence). MR14. In patients with NVUGIH secondary to peptic ulcer, ESGE recommends investigating for the presence of Helicobacter pylori in the acute setting with initiation of appropriate antibiotic therapy when H. pylori is detected. Re-testing for H. pylori should be performed in those patients with a negative test in the acute setting. Documentation of successful H. pylori eradication is recommended (strong recommendation, high quality evidence). MR15. In patients receiving low dose aspirin for secondary cardiovascular prophylaxis who develop peptic ulcer bleeding, ESGE recommends aspirin be resumed immediately following index endoscopy if the risk of rebleeding is low (e. g., FIIc, FIII). In patients with high risk peptic ulcer (FIa, FIb, FIIa, FIIb), early reintroduction of aspirin by day 3 after index endoscopy is recommended, provided that adequate hemostasis has been established (strong recommendation, moderate quality evidence).

The current status and management of blunt adrenal gland trauma

Blunt adrenal gland trauma (BAGT) is a potentially devastating event if unrecognized during the treatment course of patients with trauma. Because of its rarity, no current algorithm or consensus exists for BAGT. In the present study, we demonstrated the feasibility and safety of transcatheter angiographic embolization (TAE) in BAGT and analyzed the clinical presentation and outcome of BAGT. We conducted a prospective collection and retrospective review at a level I trauma center in Taiwan. This study included all of the patients that sustained BAGT from May 2004 to May 2013. We retrieved and analyzed the patient demographic data, clinical presentation, BAGT grade, injury severity score, management, hospital stay, and mortality. The cohort consisted of 77 patients: 59 men and 18 women. The mean age was 34.3 ± 15.5 years. The right side was the predominant site of injury (59/77; 76.6%). Six patients underwent operation; 18 patients underwent angiography, including four TAEs, and the remaining patients underwent conservative management. The mortality rate was 9.1% (7/77), and a high injury severity score was an independent factor to predict mortality. In conclusion, BAGT is a rare injury with a benign prognosis. Most patients can be treated conservatively. Furthermore, this study demonstrates that both TAE and operation can be used to achieve hemostasis. The mortality of BAGT was related to severe associated injuries. BAGT is an indicator of severe multiple trauma; however, it does not increase mortality or prolong hospital stay.

A multicentre retrospective study of transcatheter angiographic embolization in the treatment of delayed haemorrhage after percutaneous nephrolithotomy.

The objective is to determine the timing and indications of transcatheter angiographic embolization (TAE) for delayed haemorrhage after percutaneous nephrolithotomy (PCNL). The medical records of 144 patients who underwent arteriography and TAE for delayed post-PCNL haemorrhage at five university hospitals between January 2005 and December 2012 were reviewed retrospectively. The mean time to the onset of post-PCNL haemorrhage was 10.5 days (2 - 30 days). Clinical presentation included sudden onset bleeding in 51 patients (35.4 %), intermittent bleeding in 67 patients (46. 5 %), and continuous slow bleeding in 26 patients (18.1 %). Hemodynamic instability occurred in 32 patients (22.2 %). The mean haemoglobin decrease from the first post-PCNL day to the day of TAE was 49.5 g/L (31.0 - 79.0 g/L). Renal arteriography showed pseudoaneurysms in 69 (47.9 %) patients, arteriovenous fistulas in 28 (19.4 %) patients, mixed arterial and arteriovenous lesions in 17 (11.8 %) patients, arterial lacerations in 23 (16.0 %) patients, and negative angiographic finding in seven (4.9 %) patients. TAE was successful in stopping bleeding in all 137 patients with vascular lesions. There were no major complications associated with TAE. TAE should be the recommended treatment for delayed post-PCNL haemorrhage in patients with hemodynamic instability and/or corrected haemoglobin decrease >30 g/L following conservative management. • Delayed haemorrhage after percutaneous nephrolithotomy occurs more than 24 hours postoperatively. • Angio-embolization is a safe and effective treatment for delayed post-PCNL haemorrhage. • Angio-embolization can treat hemodynamic instability and/or corrected haemoglobin decrease >30 g/L.

Transcatheter embolotherapy after external surgical stabilization is a valuable treatment algorithm for patients with persistent haemorrhage from unstable pelvic fractures: Outcomes of a single centre experience

PurposeThe management of hemodynamically unstable patients with severe pelvic fractures remains a challenge. Various treatment strategies have been advocated. This study analyzed the value of transcatheter angiographic embolization (TAE) for persistent haemodynamic instability after initial fracture stabilization. Materials and methodsFrom January 2002 to July 2011, 803 patients were identified with pelvic fractures, 295 of them (37%) were presenting with unstable pelvic fractures. Fifteen patients, all with unstable fractures (2%), remained hypotensive (systolic blood pressure<90mmHg) despite adequate fluid resuscitation and emergent surgical fracture stabilization, subsequently underwent TAE. ResultsThe median age in the TAE-group was 57.9 years±20.12 (min 22; max 82) and the median ISS (injury severity score) was 35.8±11.7 (min 22; max 66). 13 out of 15 patients (87%) received initial external fixation and 2 patients (13%) where treated with a C-Clamp before TAE. Radiological success, defined as absence of contrast extravasation on completion angiography, was observed in all 15 patients. In total 3 (20%) patients died during the period of hospitalization, none of them owing to persistent or recurrent pelvic haemorrhage. In the remaining 12 patients, no early or late complications of TAE were identified. Preperitoneal pelvic packing was performed in two patients, both had open pelvic fractures. ConclusionTAE is a safe and very efficient procedure to treat persistent haemorrhage in patients with unstable pelvic fractures initially treated by surgical fracture stabilization procedures. On the long term, no early or late bleeding recurrence could be demonstrated with an overall survival rate of 80%. Preperitoneal pelvic packing can be reserved for patients with open fractures and active bleeding.

Angiographic embolization in the treatment of arterial pelvic hemorrhage: evaluation of prognostic mortality-related factors

PurposeThe control of arterial bleeding associated with pelvic ring and acetabular fractures (PRAF) remains a challenge for emergency trauma care. The aim of the present study was to uncover early prognostic mortality-related factors in PRAF-related arterial bleedings treated with transcatheter angiographic embolization (TAE).MethodsForty-nine PRAF patients (46 pelvic ring and three acetabular fractures) with arterial pelvic bleeding controlled with TAE (within 24 h) were evaluated.ResultsAll large arterial disruptions (n = 7) were seen in type C pelvic ring injuries. The 30-day mortality in large vessel (iliac artery) bleeding was higher (57 %) than in medium- or small-size artery bleeding (24 %). Overall 30-day mortality was 29 %. No statistically significant difference in the first laboratory values between the survivors and nonsurvivors was found. However, after excluding patients dying of head injuries (n = 5), a reasonable cut-off value was identified for the base excess (BE; lower than −10 mmol/l) obtained on admission.ConclusionsPRAF patients with exsanguinating bleeding from the large pelvic artery have the worst prognosis. Very low BE values (<−10.0 mmol/l) on admission for exsanguinating patients have a negative predictive value for survival, thus anticipating a poor outcome in bleeding controlled with TAE only and an increased risk of death. In critical cases, an aggressive bleeding control protocol prompts extraperitoneal pelvic packing prior to TAE. PRAF-related rupture of the external iliac artery is rare and indicates surgical techniques in controlling and restoring blood supply to the lower leg.

A comparison of surgery versus transcatheter angiographic embolization in the treatment of nonvariceal upper gastrointestinal bleeding uncontrolled by endoscopy

Patients with recurrent nonvariceal upper gastrointestinal bleeding who have failed endoscopic therapy pose a challenge. Percutaneous transcatheter angiographic embolization (TAE) is an alternative to surgery but remains controversial. This study compares the treatment outcomes in patients with recurrent nonvariceal upper gastrointestinal bleeding. A retrospective single-centre study of consecutive patients who underwent TAE (January 2007-December 2010) compared with patients treated surgically (January 2004-December 2010) was conducted. Patient demographics, comorbidities, rebleeding rates, length of stay and mortality were compared. Thirty [23 men; age (SD) 66.5±15.6 years] and 63 [41 men; age (SD) 68.2±15.0 years, NS] patients underwent TAE and surgery after a mean (SD) of 1.7±1.0 and 2.1±1.1 (NS) gastroscopies, respectively, for gastric ulcers (n=28), duodenal ulcers (n=53), small-bowel diverticuli (n=7), jejunal ulcer (n=1) and gastric Dieulafoy's lesions (n=2). Ten (33.3%) and 44 (69.8%) patients who underwent TAE and surgery, respectively, had an American Society of Anesthesiologists status of at least 2 (P=0.001). Higher rebleeding rates were observed after TAE compared with surgery [n=14 (46.7%) vs. 8 (12.7%), P=0.001]; however, there were no significant differences in 30-day mortality (16.7 vs. 19.0%, NS), complication rates (46.7 vs. 60.3%, NS) and length of stay (45.1±9.8 vs. 25.5±18.1 days, P=0.06). Twenty-four out of 30 patients (80%) who underwent TAE achieved haemostasis after a median (SD) of 2.0 (1.2) TAE procedures. Rebleeding occurred in five out of seven patients (71%) who underwent TAE for small-bowel diverticular bleeding. TAE averted the need for surgery in high-risk patients. Its role in low surgical risk patients or patients with small-bowel diverticular bleeding requires further study.

Su1787 A Comparison of Surgery vs. Transcatheter Angiographic Embolization in the Treatment of Non-Variceal Upper Gastrointestinal Bleeding Uncontrolled by Endoscopy. a Comparison of Surgery vs. Angiographic Embolization in the Treatment of Upper Gastrointestinal Bleeding Uncontrolled by Endoscopy

Su1787 A Comparison of Surgery vs. Transcatheter Angiographic Embolization in the Treatment of Non-Variceal Upper Gastrointestinal Bleeding Uncontrolled by Endoscopy. a Comparison of Surgery vs. Angiographic Embolization in the Treatment of Upper Gastrointestinal Bleeding Uncontrolled by Endoscopy

Clinical re-evaluation of the relationship between gluteal injuries and embolized arteries in patients with massive hemorrhage following pelvic fracture.

Transcatheter angiographic embolization (TAE) has been widely accepted as a treatment for hemorrhagic shock associated with pelvic fracture. Gluteal muscle necrosis is a rare but potentially fatal complication of TAE. This study aimed to clarify factors associated with safer embolization procedures by evaluating relationships between embolic site and risk of gluteal skin injury. We classified embolized arteries into six groups: group A, nonselective embolization from the main internal iliac artery; group B, selective embolization including the superior gluteal artery but excluding the inferior gluteal artery; group C, selective embolization including the inferior gluteal artery but excluding the superior gluteal artery; group D, selective embolization including both the superior and inferior gluteal arteries; group E, selective embolization excluding both the superior and inferior gluteal arteries; and group F, no embolization. We assessed the frequency of gluteal injuries, relationships between gluteal injuries and embolized arteries, and the contributions of selective embolization, conservation of the superior or inferior gluteal artery, and conservation of both the superior and inferior gluteal arteries to reducing the risk of gluteal injury. Gluteal skin injuries were seen at 15 of 160 sites (9.4%). A significant difference was noted between the nonselective embolization group (group A: 10/82, 12.2%) and selective embolization excluding both the superior and inferior gluteal arteries (group E: 1/39, 2.6%) (p=0.042). If possible, we recommend selective embolization avoiding the superior and inferior gluteal arteries.

Transcatheter embolization as the new reference standard for endoscopically unmanageable upper gastrointestinal bleeding

Acute nonvariceal upper gastrointestinal bleeding (UGIB) is a major medical emergency problem associated with significant morbidity and mortality. Endoscopy is considered the first method of choice to detect and treat UGIB. Endoscopic therapy usually achieves primary hemostasis, but 10%-30% of these patients have repeat bleeding. In patients in whom hemostasis is not achieved with endoscopic techniques, treatment with transcatheter angiographic embolization (TAE) or surgery is needed. Surgical intervention is usually an expeditious and gratifying endeavor, but it can be associated with high operative mortality rates. A large number of studies support the use of TAE as salvage therapy as an alternative to surgery. However, few studies have compared the results of TAE with that of emergency surgery in terms of efficiency, the frequency of repeat bleeding, and complications. Recently, Ang et al retrospectively compared the outcome of TAE and surgery as salvage therapy of UGIB after failed endoscopic treatment. There were no significant differences in 30 d mortality, complication rates and length of stay although higher rebleeding rates were observed after TAE compared with surgery. In this commentary, we discuss the advantages and drawbacks of these two therapeutic strategies for UGIB. We also attempt to define the exact role of TAE for acute nonvariceal UGIB.

Gluteal Muscle Necrosis following Transcatheter Angiographic Embolization for Pelvic Ring Fracture

Gluteal Muscle Necrosis following Transcatheter Angiographic Embolization for Pelvic Ring Fracture

Sepsis Caused by Peripelvic Soft Tissue Infections in Critically Injured Patients With Multiple Injuries and Unstable Pelvic Fracture

In critically injured patients with multiple injuries and unstable pelvic fracture, late mortality almost invariably results from sepsis. We analyzed the clinical features of 11 patients with sepsis caused by soft tissue infections surrounding the fractured pelvis, of 830 patients with pelvic fracture after blunt trauma treated at our level I trauma center over the past 25 years. Soft tissue infection was defined as abscess formation in subcutaneous tissue or muscle diagnosed by computed tomography or an operation. Mean injury severity score was 48, and mean systolic blood pressure on arrival was 66 mm Hg. All patients had multiple concomitant injuries and prolonged hemorrhagic shock. Open pelvic fracture was present in five patients. Mean blood transfusion volume within 24 hours was 12,611 mL. Intra-aortic balloon occlusion was performed in three patients and transcatheter angiographic embolization in nine patients. Embolic sites of transcatheter angiographic embolization were bilateral internal iliac arteries (n = 9), lumbar artery (n = 5), median sacral artery (n = 2), and circumflex femoral artery (n = 2). Infection sites included the gluteal (n = 11), femoral (n = 6), sacral (n = 4), lumbar (n = 4), anterior iliac (n = 2), inguinal (n = 1), and perineal (n = 1) regions. Necrotic changes of infected soft tissue were found in all patients. They underwent open drainage and daily debridement with pulsatile irrigation followed by intravenous antibiotics. All patients developed severe sepsis, five of whom subsequently died of multiple organ failure. In critically injured patients with multiple injuries and unstable pelvic fracture, peripelvic soft tissue infections occasionally cause sepsis. Peripelvic infections are often accompanied by necrotic changes and easily develop into severe sepsis or multiple organ failure. Identifying high-risk patients and early diagnosis with prompt surgical treatment are indispensable for the patients' survival.

Gluteal Soft Tissue Necrosis After Transcatheter Angiographic Embolization for Pelvic Fracture: a Report of Two Cases

In this paper, two cases of the gluteal soft tissue necrosis after pelvic fractures will be discussed. In the case of a 29-year-old man, a localized area of skin necrosis on the buttock appeared after transcatheter arterial embolization (TAE) of the right internal iliac artery (IIA). In the second case, a 52-year-old man, who was treated using TAE of the bilateral IIA's, developed an extensive area of necrosis in the gluteus maximus muscle with subsequent severe infection. In both cases, complete excision of the necrotic tissue and reconstructive flap surgery were imperative. Gluteal soft tissue necrosis is clinically important as one of the serious complications of TAE.