VOL.
No.
125,
i
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SELECTIVE
ARTERIAL CONTROL OF GASTROINTESTINAL
STEWART
By
EMBOLIZATION MASSIVE UPPER BLEEDING*
R. REUTER, M.D., ROBERT L. BREE,
and
ELOISE,
MICHIGAN
AND
VINCENT MAJOR,
KEESLER
FOR
P. CHUANG, M.C., USAF
AFB,
M.D.,
MISSISSIPPI
ABSTRACT:
Massive upper gastrointestinal bleeding was controlled in i of i 5 patients by the use of selectively injected arterial emboli. Embolization is most successful in the treatment of patients with demonstrated arterial bleeding sites at angiography. This group of patients generally has ulcers and it is this group in whom vasopressin infusion has the lowest success rate. At the same time we were successful in controlling only i of 4 patients who were bleeding from diffuse hemorrhagic gastritis, those patients in whom vasopressin infusion is very successful. We, therefore, now embolize only patients in whom arterial bleeding
has
sites
failed
to
are
demonstrated
control
the
at
bleeding
indicates that with aminocaproic
short
manent
types
of embolic
material.
HE
generally
accepted
method
T
arterial
reported,
be
problems.
left
hours
in
the
to days
with
in the
per cent however, artery
the
thrombus formation. tion has been observed sions because of the present
bleeding
potential
we
from
peptic
We
tive *
24-27,
ulcers
than
gastrointestinal
must of
hormone
other
forms
method to
the
Seventy-Fifth
Meeting
of the
embolization
AND
METHOD
1973,
and
patients
July, for
1974,
massive
of several
units
of blood.
After demonstration of the bleeding site by selective angiography in each patient, the catheter was advanced into the orifice of
of the
bleeding.’2
Annual
selective
artery.
February, treated
transfusions
vaso-
depending gastric
therefore evaluated an alternaof controlling massive gastro-
have
Presented
in
Between have
also
blood clot mixed as the more per-
gastrointestinal bleeding by emof the bleeding artery (Table i). To date, only gastric and duodenal bleeders have been treated with this method. Of the 15 patients, #{182}4 were not candidates for operation because of coexisting heart, lung, liver or renal disease; all had required
pressin. Finally, vasopressin in fusions have been less successful in controlling bleeding massive
bleeding: bleeding
infusion
experience
bolization
several
available
Our
upper
fluid retenlong infu-
anti-diuretic
commercially
vasopressin
MATERIAL
has
problem
Second, following
whom
gastritis.
intestinal of the
of pais not
for
in
such as autogenous controlling bleeding
into that
First, the catheter
bleeding
an-
gastrovasocon-
vasopressin, various series
been controlled in 6o-8o tients.2’3-’2-’7 The method, without
for
of massive infusion of
strictive drugs, generally the bleeding artery. In been
or
hemorrhagic
acting occlusive agents, acid, are as successful in
giographic control intestinal bleeding is
have
angiography
from
mixed American
Roentgen
left
gastric
or gastroduodenal
on
whether
duodenal. with epsilon
or
Ray
Society,
the Autogenous
artery, bleeding
was
blood
aminocaproic
San
Francisco,
California,
clot acid
September
5974.
From the Departments of Radiology, Medical Center, Keesler (ATC), Keesler The opinions or asert ions contained reflecting the views
of the Department
University of Michigan AFB, Mississippi. herein are the private of the United
States
and
Wayne
County
General
of the
authors
and
views
Air Force
“9
or the Department
Hospital, are
not
Eloise,
to be construed
of Defense.
Michigan,
and
as official
USAF nor
as
S. R.
120
Reuter,
V. P. Chuang
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Age
Success
Sex
-
Left i.
62
Diagnosis gastric aneurysm
OF
Angiographic Findings Left gastric aneurysm
R. L.
Bree
SEPTEMBER,
CASES
Treatment Fat globules
Result
Follow-up
Control
M
No rebleed up to si Died of pneumonia
(angiography) 2.
48
M
Gastric
ulcer
3.
6
M
Gastric
ulcer
4-
47
M
Hemorrhagic (endoscopy)
(upper
months
Active
bleeding
in fundus
o.
cc. Amicar
clot
Immediate
control
No
rebleed
up to 54 months
(endoscopy)
Active
bleeding
in fundus
o.
cc. Amicar
clot
Immediate
control
No
rebleed
up to i
gastritis
Gastritis bleeding
o.
cc. Amicar
clot
Immediate
control
No rebleed for 2 weeks Subsequent variceal and portacaval shunt
.
52
M
Gastric
6.
62
F
No diagnosis too much clot
.
62
M
Hemorrhagic a superficial (endoscopy)
8.
4!
M
Duodenal ulcer and angiography)
9.
22
M
Gastric ulcer
so.
64
M
Gastric phy)
is.
7
M
Pseudoaneurysm duodenal artery phy)
ulcer
GI)
1975
I
TABLE SUMMARY
and
(endoscopy)
Active lesser bleeding
established(endoscopy)
Active
gastritis fundal
with ulcer
(history
(endoscopy)
ulcer
with active in fundus
(angiogra-
of gastro(angiogra-
Active
curvature
bleeding
in fundus
bleeding
x.
cc. Amicar
clot
Immediate
s.
cc. Amicar
clot
Control
in body
pc
Gelfoam
control
months
bleed
No rebleed
up to 9 months
No
rebleed
up to 6 months
Immediate
control
No
rebleed up to 6 months
Active bleeding nal bulb
in duode-
z.s cc. Amicar
clot
lmmediate
control
No
rebleed
up to 2 months
Active bleeding
curvature
x.
clot
Immediate
control
No
rebleed
up to s8 months
Immediate
control
Bled 2 weeks later from gasIritis; expired i month later from hepatic failure
Active
Actively duodenal
lesser
bleeding
in fundus
bleeding gastroaneurysm
cc. Amicar
6 pc. Gelfoam
0.5
CC. Oxycel
Immediate
control
No rebleed up to 3 months
2.5
cc. Oxycel
Continuous bleed
slow
Vagotomy at days; later
o.
cc. Amicar
clot
Continuous ing
,.
cc. Amicar
clot
Continuous bleed
slow
Continuous bleed
slow
Failure 12.
7
M
Hemorrhagic (endoscopy)
gastritis
Gastritis
53.
84
F
Gastric
(autopsy)
Active lesser bleeding
14.
5
F
Hemorrhagic (operation)
gastritis
Gastritis
Hemorrhagic (endoscopy)
gastritis
i.
24
M
ulcer
curvature
Gastritis
(Amicar,
Lederle) was then injected in 9 patients, Gelfoam (Upjohn, Inc.) in 2, OxyCe! (Upjohn, Inc.) in 3 and fat emboli in (Table i). The Amicar-mixed autogenous blood clot was prepared by drawing io cc. of the patient’s blood into a glass syringe containing 0.5 to i cc. Amicar. ately after insertion patient’s abdominal
first
flush
with
This was done immediof the catheter into the aorta and prior to the
heparinized
saline. The time required for demonstration of the bleeding, usually about 30 minutes, allowed the blood to form a firm clot. The clot was removed from the back end of the syringe, cut into
5.0
Oxycel
cc.
cc.
0.5
pieces,
selective Gelfoam strip
bleed-
and
catheter emboli of Gelfoam
then
into
Oxycel
forced
cubes
fibers
cutting
small
pieces
them
with
with of
ter. Fat emboli were adipose tissue adjacent site. Following
repeat the
angiogram completeness
through
the
2
the
to 4 mm.
injected were
saline
injection was of the
i
Vagotomy and antrectomy at 24 hours; gastrectomy at 48 hours; expired at imonth
with a tuberculin syringe. were prepared by cutting
jecting
ture
at 20 hours
Vagotomy with pyloroplasty at 24 hours; expired at month
side. These cubes were saline. Oxycel emboli mixing
Expired
and pyloroplasty expired s month
0.2
to
on
along prepared
blood 0.3
through
then and
the
a
with by
and cc.
a
in-
cathe-
obtained from the to the femoral puncof obtained occlusion.
the
emboli, to
observe If bleed-
a
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Arterial
VoL.
125,
No.
ing
persisted,
Embolization
additional
of Upper
emboli
were
in-
jected in o. cc. increments until the bleeding was successfully controlled. The catheter was then generally left in place from I to 6 additional hours in case bleeding recurred and further embolization was required. RESULTS
Gastrointestinal
Bleeding
most
of
were
again
the
patent
a few
branches
previously
occluded but no active was seen (Fig. i). In the patients Gelfoam and Oxycel, however, left gastric artery was thrombosed second examination, indicating had propagated proximally from the occlusion (Fig. 2). The patient fat emboli fell between the two
Successful control of the bleeding was achieved in I I of the i patients (Table i). Success could be evaluated easily since all patients had nasogastric tubes in place and changes in the rate of bleeding could be
with
judged rinses.
In 7 though
there was patients
gastritis
which
by changes In 9 patients,
in the color in whom
of the control
saline was
immediate, the nasogastric return changed from bright red to pink to almost clear over a 5 to I 5 minute period. In 2 additional patients, who were also considered to be controlled, the bleeding slowed immediately but the nasogastric return did not become clear for I to 3 hours. Follow-up of the I I successfully
treated
patients
bleeding problem i i months tion. Further bleeding had The
other
after embolizanot occurred
patient
ther bleeding for 2 weeks, repeat massive hemorrhage endoscopy to be caused gastritis. an 18
The hour
bleeding infusion
died a month later The 4 patients by who
major
embolization had
a large
branch
sanguinated had diffuse complications i month
Follow-up to 36 hours the
patients
of hepatic who were continued
of the
had
in 20 hours. hemorrhagic
following receiving
no
fur-
with
he
but
to bleed. eroding
gastric
In 8 of the observed
autopsy
I
bolization. ing
5 days
to
most
remain-
gastric mucosa operation, or
following
embolization.
no mucosal necrosis, frequently had changes probably
antedated
patient,
I
who
in an attempt
from
diffuse
later
gastric
mucosa,
a!of
the
em-
received
to control
hemorrhagic
5 days
eration sloughed was
#{231} patients the by endoscopy,
In
cc. ofOxycel
but
2.5
bleed-
gastritis, revealed
but
op-
areas
no
of
bleeding
seen.
The other gastritis,
were
3, who of
emas
short
and
many
12
in clot,
2
5 of re-
ceiving Gelfoam, i receiving Oxycel, and the patient receiving fat emboli. In all patients receiving Amicar-mixed blood clot,
of intermediate
small
emboli
duration,
as it passes
catheter.
Fragmentation
important
advantage
sion, supply Also,
of because
through emboli the
the is
an
many
the branches peripheral the occlu-
the
less likely that collateral blood will develop around the occlusion. the small emboli hopefully are flow
directed sults
performed
acting,
permanent. In the first group, the most commonly used is autogenous blood clot, which has the advantage of being an endogenous material. Also, it fragments into
which
surgery
embolization Amicar
a
ex-
died
Several materials may be used for bolic occlusion. These can be grouped
small embolic fragments shower of the bleeding artery, causing occlusions. The more peripheral
One, into
artery,
secondary to gastric following embolization.
angiograms
in
failure. not controlled
ulcer
left
was
open
DISCUSSION
at which time a was shown by by hemorrhagic
was controlled of epinephrine
gastric
occluded.
that 8 months
were still alive and well 2 to I following embolization. One patient died of pneumonia unrelated to his original
interval.
ing
branches bleeding receiving the entire at the that clot the site of receiving extremes,
revealed
9
this
121
the in an
toward lack increased
the bleeding of peripheral
blood
artery,
resistance flow. Most
in reautog-
enous blood clot emboli are absorbed within a few hours.’3 For this reason, we have mixed the blood clot with epsilon aminocaproic acid (Amicar) to prolong its duration of occlusion. Amicar reacts with plasmm to form a fibrin which has an increased
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122
S. R. Reuter, V. P. Chuang
#{149} .
#{149} ,..
I
and R. L. Bree SEPTEMBER,
#{182}975
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VOL.
Arterial
No.
125,
resistance
to
periments, lyses within
most
up
to An
Embolization
fibrinolysis.7
24
In
animal
Amicar-mixed hours,
weeks.5 interesting
of Upper
clot have
some
but
2
observation
accompany-
ing the use of Amicar-mixed clot bleeding artery appears to remain while most of the surrounding, teries
become
patent
only explanation sistence is the
by
we
work
can
that the the intima
is decreased. activator
However, in arterial
mm
portance
to
circulating of
this
24
find
is that the occluded, normal ar-
hours.’#{176}
The
this peret al.,’6 who
for
of Warren
have found activator in
pared
ex-
emboli lasted
amount
of
of damaged
plasmin
vessels
the amount of plaswalls is small comactivator,
observation
and
is not
the
certain.
im-
Gastrointestinal
Bleeding
It is apparent, from
however, vessels
normal
that while
terial branch appears A more controlled type sion might be produced spheres sion.’
123
clot
the
does
lyse
bleeding
ar-
to remain occluded. of temporary occluby gelatin micro-
of known Such emboli autogenous blood
size and duration of occluhave the advantages of clot but have a more con-
trollable
of occlusion.
duration
Occlusion
manentlv
lasting
can
from
able, non-autogenous Oxvcel4 or Gelfoam. not absorbed for up periments peripherally pulsation.’
have and Therefore,
by
that
compressed an
to
using
materials, Although to 2 weeks,
shown
perabsorb-
weeks
be obtained
such Gelfoam animal it
by occluded
is
pushed arterial artery
as is ex-
S. R.
124
Reuter,
V.
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may appear to open and branches contrast medium over a period hours. However, in the patients series
occlusions
appear
to
with
have
propagation
Oxycel
become
back
gastric
to
or
the
Chuang
fill with to 24 in this
Gelfoam
permanent,
of thrombus
occlusion
up
P.
with
from
the
point
orifice
of
the
of
left
artery.
Finally, achieved
permanent with the use
acrylate,’4
lead
occlusions can of isobutyl-2-cyano-
shot,”
Ivalon,”
or
be
Although massive arterial bleeding can be controlled with any of these embolic materials, our experience indicates that adequate control can be achieved with that
the
autogenous
more
materials
blood
permanent
are
types
and
of occlusive
tritis
bleeding
site
ting
factors.
Occasionally
such
blood
can
preferred
in
this
type
ing
is
with
localized,
bleeding
Of
site
giograms, (91 per without tive
such
ulcers.
the
was
we
artery shown in all
One,
by
3 and
was
3
had
endoscopy; they
occurs in whom a on the an-
bleeding in io embolized
patients were demonstration
aneurysm, other
generally
the
controlled
cent). Four angiographic
extravasation.
The
as
patients demonstrated
died
with treated
of ac-
a left
successfully.
hemorrhagic the
gastric
treatment
following
failed
gastric
sur-
gery. Probably the same rich anastomotic circulation which prevents gastric necrosis also hinders the control of diffusely bleeding lesions
such
tions.
We
tients
with
as
gastritis
therefore hemorrhagic
or
multiple
recommend
patient embolized
and
it is not
occurred
gastritis
vertent creas. painful, result
be treated
clot
that
Also,
the
animal
this
ischemia
pancreatic
or pan-
artery during false aneu-
be
The
have
embolized
effects
of
shown
without pancreatic
are less certain. It is known of small pancreatic arteries 8-20 microns in diameter
had
in
occurred.
gastroduodenal branches
severe of
symptoms
had with
mad-
is
infarction may be do not appear to of the spleen.
None
pancreatitis patients
would
spleen
experiments
results
series
However,
a spleen in a paand Tadavarthy
can
effects.’
embolization that occlusion with microspheres
a
was
alone.
of the
spleen
in
of vasopresembolization
complication
has infarcted hyperspienism,
consistently
pa-
the
the
con-
artery
clot.
that
and be
Prochaska
et al.” have occluded a splenic the embolization of a bleeding rysm.
organ
necrosis
gastric
Although splenic serious sequelae from embolization
Maddison6 tient with
amounts
must
hours to the
embolization
as pa-
bleeding
autogenous
potential
used
small
gastric
with
for
other
embolization.
clear
used
ischemic,
left
in
quantity
not
that
also had in addition
have
occurred bleeding
the
with
the
with
this patient sin infusion
in
injections left gastric
have in
of the
reported
in whom
of
or
was
temporarily
each
have
experimentally.8
ulcerathat
even
with
et al.9
adverse
gastritis
made
is a possibility
sidered
reserved localized
large
clot
repeated until the
a segment
Another
I I
and
at least
cent
be a
not
The
mixed
However,
of patient.
Our experience also indicates that embolic control of upper gastrointestinal bleeding is more successful when the bleed-
areas.
tients.
infarction
be made to clot by the addition of a few drops of thrombin. However, the resulting clot is not particularly firm or easy to cut, and an artificial embolic material may be
of mucosa he was
much
of material,
per
angiography
was occluded. We embolic material
artery
some patients, particularly those who have received several transfusions, or who have a coagulopathy, the blood will not clot because of the depletion of platelets or clot-
to
at
Athgas-
to control the bleeding. in whom observation of was possible following
slough and
the embolization, of emboli were
84
should whom
in
from the denuded of 2.5 cc. of Oxycel
1975
According to from diffuse
in
is seen
whom infusion fails Of the 8 patients the gastric mucosa
becomes
made
SEPTEMBER,
controlled
Embolization patients
In
be
be
can
clot.
cannot
unless
Bree
patients. for those
pa-
blood
necessary
L.
by vasopressin infusion. anasoulis et al.,2 bleeding
the
tient’s
not
clot,
R.
embolization, only I patient
plastic
microspheres.
Amicar-mixed
and
were
pancreatitis
the to
patients
in
suggest
In
both
that
of
the
embolization, occjuded
by
em-
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VOL.
125,
No.
Embolization
Arterial
i
3. Control
of massive bleeding coma. (A) Gastroduodenal angiogram. of the posterior pancreaticoduodenal
FIG.
from
of Upper
a duodenal
Gastrointestinal
ulcer
with
Bleeding
Amicar-mixed
clot in a
125
41
old man with
year
hepatic
Arterial
phase.
Contrast
medium
extravasates
from
a proximal
branch
arcade (arrow). (B) Capillary phase. The extravasated contrast medium layers in the duodenal bulb (arrow). (C) Gastroduodenal angiogram following embolization of the gastroduodenal artery with 1.5 cc. of Amicar-mixed autogenous blood clot. Both posterior and anterior pancreaticoduodenal arcades are occluded. No extravaSation is seen in the region of the duodenal bulb. (D) Gastroduodenal angiogram 24 hours after embolization. The pancreaticoduodenal arcades and gastroepiploic artery are again patent, although some residual thrombus remains. No extravasation of contrast medium is seen. The apparent occlusion of the transverse pancreatic artery (arrow) is caused by reversal of blood flow in this vessel; the contrast medium washed out toward the gastroduodenal artery.
boli
3). However,
(Fig.
are large
relative
pancreatic occlusions mally. This should an
extensive
velop
The
from
though potential
pancreatitis complication
have
had
It
should
no
probably allow the
several
indication
be
stressed
we and
i
the
though
to de-
is probably
the
use
occur proxiformation of
circulation
pancreas
body with circulation,
supply
emboli
microspheres,
collateral
distally.
organ in the for collateral
the
to
the
best possibilities receiving its blood
different must of that
that
arteries. be the
considered method,
we
most
of
these
terminal
bleeders.
were
bleeding
massively,
refused
existing
to
heart,
no
91
per
cent
the
because
kidney,
of
or
extravasation
excluded,
(io
Al-
of
the
u
tion
appears
to
over
infusion
as a method
have
sive
bleeding.
First,
at success
patients). 2 major for
co-
liver
dis-
success rate in these patients was 73 per If the 4 patients
localized are
operate
lung,
ease. Our over-all tremely difficult (ii of #{182}5 patients). raphy
a
were they
surgeons
had
Al-
it occurs.
patients
excent who
angiograte
was
Embolizaadvantages treating
it is extremely
mas-
simple
126
S. R. Reuter,
and
the
results
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Second,
can
the patient
be assessed does not
V. P. Chuang
arterial
immediately.
many for of the drugs and checking that the catheter tip does not come out of the bleeding artery, therefore, are not necessary. Although much further experience will be necessary before embolization can be considered as safe and effective as it is simple, our predoses hours
drugs. The side effects
of vasoconstrictive of monitoring
liminary
results
are
County
General
Eloise,
Michigan
Since
6.
the
MAXWELL,
Hospital
8.
PFEFFER,
209,
of control
this
paper
massive
we
nal
Mallory-Weiss
lacerations;
The bleeding was conin the first six and no has occurred up to six months of follow-up. The bleeding in the patient with gastritis was controlled for 24 hours, when further bleeding necessitated a gastrotomy with ligation of several bleeding sites. A repeat bleed one month later was successfully controlled by vasoinfusion. we have
ulcers
or
#{182}7 (94
per
9.
controlled
Mallory-Weiss cent)
massive
upper
2.
ATHANASOULIS,
were
3.
of hyper280.
D. Interactions thrombin clotNature, 1966,
into 1962,
blood 764-769.
51,
vessels
in
dogs.
J. M., FLYE, M. W., and JOHNSI. S. Left gastric artery embolization for control of gastric bleeding: complication.
PROCHASKA,
Radiology, 1973, 107, 521-522. S. R., and CHUANG,
V. P.
REUTER,
lized II.
bleeding
material.
with
1974,
N.
K.,
86-91.
G. I. by cath-
BRIDI,
treated
7.
Brit.
of
embo-
14,
and
fistula
embolization.
Control
autogenous
Radiologe,
G. K., ATALLAH, Renal arteriovenous
RIZK,
eter
Radiol.,
46,
1973,
222-224. 12.
J., DOTTER, C. T., and ANTONOVIC, R. Selective vasoconstrictor in fusion in management of arterio-capillary gastrointestinal hemorrhage. AM. J. ROENTGENOL., RAD.
R#{246}SCH,
&
THERAPY
lacerations,
16
R#{246}SCH,
and
NYLANDER,
J.,
NUCLEAR
MED.,
1972,
arterial of acute
Radiology, 14.
of
R#{246}SCH,
1972,
ii#{243}, 279-
J.,
Twenty-second of
597-603.
BAUM, S., and NUS BAUM, M. Control intestinal hemorrhage by selective
of gastromesenteric
17.
New
AssociYork,
KNIGHT, L., OvITT, T. W., and AMPLATZ, K. Therapeutic arterial embolization. Radiology,
S. M.,
C., 112,
13-16.
B. A.,
WARREN,
ci
vascular
endothelium.
20,
14.
213-2
R. E., W. Bleeding
WHITE,
arterial
Meeting,
Radiologists,
1974.
transcatheter 1974,
303-306.
Annual
University
SNYDER,
16.
method bleeding.
N. L., and DOTTER, C. T. occlusion of gastric coronary
May8-II,
com-
: new
GOLDMAN,
#{182}5. TADAVARTHY,
G. Personal
M. J.
BROWN,
gastrointestinal
102,
Percutaneous
vein.
C. T., and embolization
DOTTER,
Selective for control
controlled.
C. A., BAUM, S., WALTMAN, A. C., RING, E. J., IMBEMBO, A., and VANDER SALM, T. J. Control of acute gastric mucosal hemorrhage: intra-arterial infusion of posterior pituitary extract. New England 7. Med., #{182}974, 290,
8,
R. B., LAZARINI-ROBERTSON, A., JR., D., MIXTER, G., JR., SECOY, C. F., and HINTON, J. W. Gradations of pancreatitis, edematous through hemorrhagic, experimentally produced by controlled injection of
abdominal
13.
REFERENCES
T., munication.
therapy 1973,
21 1-213.
ation
ALMEN,
Embolic Radiol.,
288.
hemorrhage by selective of the bleeding artery in 17 of In patients with bleeding from
i.
selective Gynec. &
RUDE,
10.
and one gastritis. trolled immediately further bleeding
embolization 22 patients.
by Surg.,
715-720.
E.
Invest.
microspheres Surgery,
upper
hemorrhage by left gastric in seven additional pagastric ulcers; two, duode-
Thus, gastrointestinal
140,
F.
function artery.
R. E., and ALLEN, of E-aminocaproic acid with ting and fibrinolytic systems.
7.
gastrointestinal artery embolization tients. Two had
pressin
Radiology,
SAFADI,
to
two
of splenic of splenic
MADDISON,
encouraging.
submission
ulcers;
vasopressin.
BOOKSTEIN,
splenism.
48132
attempted
of
497-505.
diminution embolization Obst., 1975,
ADDENDUM
have
2975
SEPTEMBER,
J. J., CHLOSTA, E., WALTERS, J., and FOLEY, D. Trans-catheter hemostasis of gastrointestinal bleeding using modified autogenous clot. Radiology, 1974, 113, 277-285. 5. CHUANG, V. P., and REUTER, S. R. Experimental 4.
Stewart R. Reuter, M.D. Department of Radiology Wayne
Bree
infusion 98,
1971,
large
receive
R. L.
and
GIRARGIANA,
duodenal
embolization
clot. 7.A.M.A.,
al.
Fibrinolytic Brit. M.
activity Bull.,
F. A., JR., ulcer control: with
#{182}974, 229,
autogenous 546-548.
of 1964,
and BELL, selective blood
No.
125,
i
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SELECTIVE
ARTERIAL CONTROL OF GASTROINTESTINAL
STEWART
By
EMBOLIZATION MASSIVE UPPER BLEEDING*
R. REUTER, M.D., ROBERT L. BREE,
and
ELOISE,
MICHIGAN
AND
VINCENT MAJOR,
KEESLER
FOR
P. CHUANG, M.C., USAF
AFB,
M.D.,
MISSISSIPPI
ABSTRACT:
Massive upper gastrointestinal bleeding was controlled in i of i 5 patients by the use of selectively injected arterial emboli. Embolization is most successful in the treatment of patients with demonstrated arterial bleeding sites at angiography. This group of patients generally has ulcers and it is this group in whom vasopressin infusion has the lowest success rate. At the same time we were successful in controlling only i of 4 patients who were bleeding from diffuse hemorrhagic gastritis, those patients in whom vasopressin infusion is very successful. We, therefore, now embolize only patients in whom arterial bleeding
has
sites
failed
to
are
demonstrated
control
the
at
bleeding
indicates that with aminocaproic
short
manent
types
of embolic
material.
HE
generally
accepted
method
T
arterial
reported,
be
problems.
left
hours
in
the
to days
with
in the
per cent however, artery
the
thrombus formation. tion has been observed sions because of the present
bleeding
potential
we
from
peptic
We
tive *
24-27,
ulcers
than
gastrointestinal
must of
hormone
other
forms
method to
the
Seventy-Fifth
Meeting
of the
embolization
AND
METHOD
1973,
and
patients
July, for
1974,
massive
of several
units
of blood.
After demonstration of the bleeding site by selective angiography in each patient, the catheter was advanced into the orifice of
of the
bleeding.’2
Annual
selective
artery.
February, treated
transfusions
vaso-
depending gastric
therefore evaluated an alternaof controlling massive gastro-
have
Presented
in
Between have
also
blood clot mixed as the more per-
gastrointestinal bleeding by emof the bleeding artery (Table i). To date, only gastric and duodenal bleeders have been treated with this method. Of the 15 patients, #{182}4 were not candidates for operation because of coexisting heart, lung, liver or renal disease; all had required
pressin. Finally, vasopressin in fusions have been less successful in controlling bleeding massive
bleeding: bleeding
infusion
experience
bolization
several
available
Our
upper
fluid retenlong infu-
anti-diuretic
commercially
vasopressin
MATERIAL
has
problem
Second, following
whom
gastritis.
intestinal of the
of pais not
for
in
such as autogenous controlling bleeding
into that
First, the catheter
bleeding
an-
gastrovasocon-
vasopressin, various series
been controlled in 6o-8o tients.2’3-’2-’7 The method, without
for
of massive infusion of
strictive drugs, generally the bleeding artery. In been
or
hemorrhagic
acting occlusive agents, acid, are as successful in
giographic control intestinal bleeding is
have
angiography
from
mixed American
Roentgen
left
gastric
or gastroduodenal
on
whether
duodenal. with epsilon
or
Ray
Society,
the Autogenous
artery, bleeding
was
blood
aminocaproic
San
Francisco,
California,
clot acid
September
5974.
From the Departments of Radiology, Medical Center, Keesler (ATC), Keesler The opinions or asert ions contained reflecting the views
of the Department
University of Michigan AFB, Mississippi. herein are the private of the United
States
and
Wayne
County
General
of the
authors
and
views
Air Force
“9
or the Department
Hospital, are
not
Eloise,
to be construed
of Defense.
Michigan,
and
as official
USAF nor
as
S. R.
120
Reuter,
V. P. Chuang
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Age
Success
Sex
-
Left i.
62
Diagnosis gastric aneurysm
OF
Angiographic Findings Left gastric aneurysm
R. L.
Bree
SEPTEMBER,
CASES
Treatment Fat globules
Result
Follow-up
Control
M
No rebleed up to si Died of pneumonia
(angiography) 2.
48
M
Gastric
ulcer
3.
6
M
Gastric
ulcer
4-
47
M
Hemorrhagic (endoscopy)
(upper
months
Active
bleeding
in fundus
o.
cc. Amicar
clot
Immediate
control
No
rebleed
up to 54 months
(endoscopy)
Active
bleeding
in fundus
o.
cc. Amicar
clot
Immediate
control
No
rebleed
up to i
gastritis
Gastritis bleeding
o.
cc. Amicar
clot
Immediate
control
No rebleed for 2 weeks Subsequent variceal and portacaval shunt
.
52
M
Gastric
6.
62
F
No diagnosis too much clot
.
62
M
Hemorrhagic a superficial (endoscopy)
8.
4!
M
Duodenal ulcer and angiography)
9.
22
M
Gastric ulcer
so.
64
M
Gastric phy)
is.
7
M
Pseudoaneurysm duodenal artery phy)
ulcer
GI)
1975
I
TABLE SUMMARY
and
(endoscopy)
Active lesser bleeding
established(endoscopy)
Active
gastritis fundal
with ulcer
(history
(endoscopy)
ulcer
with active in fundus
(angiogra-
of gastro(angiogra-
Active
curvature
bleeding
in fundus
bleeding
x.
cc. Amicar
clot
Immediate
s.
cc. Amicar
clot
Control
in body
pc
Gelfoam
control
months
bleed
No rebleed
up to 9 months
No
rebleed
up to 6 months
Immediate
control
No
rebleed up to 6 months
Active bleeding nal bulb
in duode-
z.s cc. Amicar
clot
lmmediate
control
No
rebleed
up to 2 months
Active bleeding
curvature
x.
clot
Immediate
control
No
rebleed
up to s8 months
Immediate
control
Bled 2 weeks later from gasIritis; expired i month later from hepatic failure
Active
Actively duodenal
lesser
bleeding
in fundus
bleeding gastroaneurysm
cc. Amicar
6 pc. Gelfoam
0.5
CC. Oxycel
Immediate
control
No rebleed up to 3 months
2.5
cc. Oxycel
Continuous bleed
slow
Vagotomy at days; later
o.
cc. Amicar
clot
Continuous ing
,.
cc. Amicar
clot
Continuous bleed
slow
Continuous bleed
slow
Failure 12.
7
M
Hemorrhagic (endoscopy)
gastritis
Gastritis
53.
84
F
Gastric
(autopsy)
Active lesser bleeding
14.
5
F
Hemorrhagic (operation)
gastritis
Gastritis
Hemorrhagic (endoscopy)
gastritis
i.
24
M
ulcer
curvature
Gastritis
(Amicar,
Lederle) was then injected in 9 patients, Gelfoam (Upjohn, Inc.) in 2, OxyCe! (Upjohn, Inc.) in 3 and fat emboli in (Table i). The Amicar-mixed autogenous blood clot was prepared by drawing io cc. of the patient’s blood into a glass syringe containing 0.5 to i cc. Amicar. ately after insertion patient’s abdominal
first
flush
with
This was done immediof the catheter into the aorta and prior to the
heparinized
saline. The time required for demonstration of the bleeding, usually about 30 minutes, allowed the blood to form a firm clot. The clot was removed from the back end of the syringe, cut into
5.0
Oxycel
cc.
cc.
0.5
pieces,
selective Gelfoam strip
bleed-
and
catheter emboli of Gelfoam
then
into
Oxycel
forced
cubes
fibers
cutting
small
pieces
them
with
with of
ter. Fat emboli were adipose tissue adjacent site. Following
repeat the
angiogram completeness
through
the
2
the
to 4 mm.
injected were
saline
injection was of the
i
Vagotomy and antrectomy at 24 hours; gastrectomy at 48 hours; expired at imonth
with a tuberculin syringe. were prepared by cutting
jecting
ture
at 20 hours
Vagotomy with pyloroplasty at 24 hours; expired at month
side. These cubes were saline. Oxycel emboli mixing
Expired
and pyloroplasty expired s month
0.2
to
on
along prepared
blood 0.3
through
then and
the
a
with by
and cc.
a
in-
cathe-
obtained from the to the femoral puncof obtained occlusion.
the
emboli, to
observe If bleed-
a
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Arterial
VoL.
125,
No.
ing
persisted,
Embolization
additional
of Upper
emboli
were
in-
jected in o. cc. increments until the bleeding was successfully controlled. The catheter was then generally left in place from I to 6 additional hours in case bleeding recurred and further embolization was required. RESULTS
Gastrointestinal
Bleeding
most
of
were
again
the
patent
a few
branches
previously
occluded but no active was seen (Fig. i). In the patients Gelfoam and Oxycel, however, left gastric artery was thrombosed second examination, indicating had propagated proximally from the occlusion (Fig. 2). The patient fat emboli fell between the two
Successful control of the bleeding was achieved in I I of the i patients (Table i). Success could be evaluated easily since all patients had nasogastric tubes in place and changes in the rate of bleeding could be
with
judged rinses.
In 7 though
there was patients
gastritis
which
by changes In 9 patients,
in the color in whom
of the control
saline was
immediate, the nasogastric return changed from bright red to pink to almost clear over a 5 to I 5 minute period. In 2 additional patients, who were also considered to be controlled, the bleeding slowed immediately but the nasogastric return did not become clear for I to 3 hours. Follow-up of the I I successfully
treated
patients
bleeding problem i i months tion. Further bleeding had The
other
after embolizanot occurred
patient
ther bleeding for 2 weeks, repeat massive hemorrhage endoscopy to be caused gastritis. an 18
The hour
bleeding infusion
died a month later The 4 patients by who
major
embolization had
a large
branch
sanguinated had diffuse complications i month
Follow-up to 36 hours the
patients
of hepatic who were continued
of the
had
in 20 hours. hemorrhagic
following receiving
no
fur-
with
he
but
to bleed. eroding
gastric
In 8 of the observed
autopsy
I
bolization. ing
5 days
to
most
remain-
gastric mucosa operation, or
following
embolization.
no mucosal necrosis, frequently had changes probably
antedated
patient,
I
who
in an attempt
from
diffuse
later
gastric
mucosa,
a!of
the
em-
received
to control
hemorrhagic
5 days
eration sloughed was
#{231} patients the by endoscopy,
In
cc. ofOxycel
but
2.5
bleed-
gastritis, revealed
but
op-
areas
no
of
bleeding
seen.
The other gastritis,
were
3, who of
emas
short
and
many
12
in clot,
2
5 of re-
ceiving Gelfoam, i receiving Oxycel, and the patient receiving fat emboli. In all patients receiving Amicar-mixed blood clot,
of intermediate
small
emboli
duration,
as it passes
catheter.
Fragmentation
important
advantage
sion, supply Also,
of because
through emboli the
the is
an
many
the branches peripheral the occlu-
the
less likely that collateral blood will develop around the occlusion. the small emboli hopefully are flow
directed sults
performed
acting,
permanent. In the first group, the most commonly used is autogenous blood clot, which has the advantage of being an endogenous material. Also, it fragments into
which
surgery
embolization Amicar
a
ex-
died
Several materials may be used for bolic occlusion. These can be grouped
small embolic fragments shower of the bleeding artery, causing occlusions. The more peripheral
One, into
artery,
secondary to gastric following embolization.
angiograms
in
failure. not controlled
ulcer
left
was
open
DISCUSSION
at which time a was shown by by hemorrhagic
was controlled of epinephrine
gastric
occluded.
that 8 months
were still alive and well 2 to I following embolization. One patient died of pneumonia unrelated to his original
interval.
ing
branches bleeding receiving the entire at the that clot the site of receiving extremes,
revealed
9
this
121
the in an
toward lack increased
the bleeding of peripheral
blood
artery,
resistance flow. Most
in reautog-
enous blood clot emboli are absorbed within a few hours.’3 For this reason, we have mixed the blood clot with epsilon aminocaproic acid (Amicar) to prolong its duration of occlusion. Amicar reacts with plasmm to form a fibrin which has an increased
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122
S. R. Reuter, V. P. Chuang
#{149} .
#{149} ,..
I
and R. L. Bree SEPTEMBER,
#{182}975
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VOL.
Arterial
No.
125,
resistance
to
periments, lyses within
most
up
to An
Embolization
fibrinolysis.7
24
In
animal
Amicar-mixed hours,
weeks.5 interesting
of Upper
clot have
some
but
2
observation
accompany-
ing the use of Amicar-mixed clot bleeding artery appears to remain while most of the surrounding, teries
become
patent
only explanation sistence is the
by
we
work
can
that the the intima
is decreased. activator
However, in arterial
mm
portance
to
circulating of
this
24
find
is that the occluded, normal ar-
hours.’#{176}
The
this peret al.,’6 who
for
of Warren
have found activator in
pared
ex-
emboli lasted
amount
of
of damaged
plasmin
vessels
the amount of plaswalls is small comactivator,
observation
and
is not
the
certain.
im-
Gastrointestinal
Bleeding
It is apparent, from
however, vessels
normal
that while
terial branch appears A more controlled type sion might be produced spheres sion.’
123
clot
the
does
lyse
bleeding
ar-
to remain occluded. of temporary occluby gelatin micro-
of known Such emboli autogenous blood
size and duration of occluhave the advantages of clot but have a more con-
trollable
of occlusion.
duration
Occlusion
manentlv
lasting
can
from
able, non-autogenous Oxvcel4 or Gelfoam. not absorbed for up periments peripherally pulsation.’
have and Therefore,
by
that
compressed an
to
using
materials, Although to 2 weeks,
shown
perabsorb-
weeks
be obtained
such Gelfoam animal it
by occluded
is
pushed arterial artery
as is ex-
S. R.
124
Reuter,
V.
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may appear to open and branches contrast medium over a period hours. However, in the patients series
occlusions
appear
to
with
have
propagation
Oxycel
become
back
gastric
to
or
the
Chuang
fill with to 24 in this
Gelfoam
permanent,
of thrombus
occlusion
up
P.
with
from
the
point
orifice
of
the
of
left
artery.
Finally, achieved
permanent with the use
acrylate,’4
lead
occlusions can of isobutyl-2-cyano-
shot,”
Ivalon,”
or
be
Although massive arterial bleeding can be controlled with any of these embolic materials, our experience indicates that adequate control can be achieved with that
the
autogenous
more
materials
blood
permanent
are
types
and
of occlusive
tritis
bleeding
site
ting
factors.
Occasionally
such
blood
can
preferred
in
this
type
ing
is
with
localized,
bleeding
Of
site
giograms, (91 per without tive
such
ulcers.
the
was
we
artery shown in all
One,
by
3 and
was
3
had
endoscopy; they
occurs in whom a on the an-
bleeding in io embolized
patients were demonstration
aneurysm, other
generally
the
controlled
cent). Four angiographic
extravasation.
The
as
patients demonstrated
died
with treated
of ac-
a left
successfully.
hemorrhagic the
gastric
treatment
following
failed
gastric
sur-
gery. Probably the same rich anastomotic circulation which prevents gastric necrosis also hinders the control of diffusely bleeding lesions
such
tions.
We
tients
with
as
gastritis
therefore hemorrhagic
or
multiple
recommend
patient embolized
and
it is not
occurred
gastritis
vertent creas. painful, result
be treated
clot
that
Also,
the
animal
this
ischemia
pancreatic
or pan-
artery during false aneu-
be
The
have
embolized
effects
of
shown
without pancreatic
are less certain. It is known of small pancreatic arteries 8-20 microns in diameter
had
in
occurred.
gastroduodenal branches
severe of
symptoms
had with
mad-
is
infarction may be do not appear to of the spleen.
None
pancreatitis patients
would
spleen
experiments
results
series
However,
a spleen in a paand Tadavarthy
can
effects.’
embolization that occlusion with microspheres
a
was
alone.
of the
spleen
in
of vasopresembolization
complication
has infarcted hyperspienism,
consistently
pa-
the
the
con-
artery
clot.
that
and be
Prochaska
et al.” have occluded a splenic the embolization of a bleeding rysm.
organ
necrosis
gastric
Although splenic serious sequelae from embolization
Maddison6 tient with
amounts
must
hours to the
embolization
as pa-
bleeding
autogenous
potential
used
small
gastric
with
for
other
embolization.
clear
used
ischemic,
left
in
quantity
not
that
also had in addition
have
occurred bleeding
the
with
the
with
this patient sin infusion
in
injections left gastric
have in
of the
reported
in whom
of
or
was
temporarily
each
have
experimentally.8
ulcerathat
even
with
et al.9
adverse
gastritis
made
is a possibility
sidered
reserved localized
large
clot
repeated until the
a segment
Another
I I
and
at least
cent
be a
not
The
mixed
However,
of patient.
Our experience also indicates that embolic control of upper gastrointestinal bleeding is more successful when the bleed-
areas.
tients.
infarction
be made to clot by the addition of a few drops of thrombin. However, the resulting clot is not particularly firm or easy to cut, and an artificial embolic material may be
of mucosa he was
much
of material,
per
angiography
was occluded. We embolic material
artery
some patients, particularly those who have received several transfusions, or who have a coagulopathy, the blood will not clot because of the depletion of platelets or clot-
to
at
Athgas-
to control the bleeding. in whom observation of was possible following
slough and
the embolization, of emboli were
84
should whom
in
from the denuded of 2.5 cc. of Oxycel
1975
According to from diffuse
in
is seen
whom infusion fails Of the 8 patients the gastric mucosa
becomes
made
SEPTEMBER,
controlled
Embolization patients
In
be
be
can
clot.
cannot
unless
Bree
patients. for those
pa-
blood
necessary
L.
by vasopressin infusion. anasoulis et al.,2 bleeding
the
tient’s
not
clot,
R.
embolization, only I patient
plastic
microspheres.
Amicar-mixed
and
were
pancreatitis
the to
patients
in
suggest
In
both
that
of
the
embolization, occjuded
by
em-
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VOL.
125,
No.
Embolization
Arterial
i
3. Control
of massive bleeding coma. (A) Gastroduodenal angiogram. of the posterior pancreaticoduodenal
FIG.
from
of Upper
a duodenal
Gastrointestinal
ulcer
with
Bleeding
Amicar-mixed
clot in a
125
41
old man with
year
hepatic
Arterial
phase.
Contrast
medium
extravasates
from
a proximal
branch
arcade (arrow). (B) Capillary phase. The extravasated contrast medium layers in the duodenal bulb (arrow). (C) Gastroduodenal angiogram following embolization of the gastroduodenal artery with 1.5 cc. of Amicar-mixed autogenous blood clot. Both posterior and anterior pancreaticoduodenal arcades are occluded. No extravaSation is seen in the region of the duodenal bulb. (D) Gastroduodenal angiogram 24 hours after embolization. The pancreaticoduodenal arcades and gastroepiploic artery are again patent, although some residual thrombus remains. No extravasation of contrast medium is seen. The apparent occlusion of the transverse pancreatic artery (arrow) is caused by reversal of blood flow in this vessel; the contrast medium washed out toward the gastroduodenal artery.
boli
3). However,
(Fig.
are large
relative
pancreatic occlusions mally. This should an
extensive
velop
The
from
though potential
pancreatitis complication
have
had
It
should
no
probably allow the
several
indication
be
stressed
we and
i
the
though
to de-
is probably
the
use
occur proxiformation of
circulation
pancreas
body with circulation,
supply
emboli
microspheres,
collateral
distally.
organ in the for collateral
the
to
the
best possibilities receiving its blood
different must of that
that
arteries. be the
considered method,
we
most
of
these
terminal
bleeders.
were
bleeding
massively,
refused
existing
to
heart,
no
91
per
cent
the
because
kidney,
of
or
extravasation
excluded,
(io
Al-
of
the
u
tion
appears
to
over
infusion
as a method
have
sive
bleeding.
First,
at success
patients). 2 major for
co-
liver
dis-
success rate in these patients was 73 per If the 4 patients
localized are
operate
lung,
ease. Our over-all tremely difficult (ii of #{182}5 patients). raphy
a
were they
surgeons
had
Al-
it occurs.
patients
excent who
angiograte
was
Embolizaadvantages treating
it is extremely
mas-
simple
126
S. R. Reuter,
and
the
results
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Second,
can
the patient
be assessed does not
V. P. Chuang
arterial
immediately.
many for of the drugs and checking that the catheter tip does not come out of the bleeding artery, therefore, are not necessary. Although much further experience will be necessary before embolization can be considered as safe and effective as it is simple, our predoses hours
drugs. The side effects
of vasoconstrictive of monitoring
liminary
results
are
County
General
Eloise,
Michigan
Since
6.
the
MAXWELL,
Hospital
8.
PFEFFER,
209,
of control
this
paper
massive
we
nal
Mallory-Weiss
lacerations;
The bleeding was conin the first six and no has occurred up to six months of follow-up. The bleeding in the patient with gastritis was controlled for 24 hours, when further bleeding necessitated a gastrotomy with ligation of several bleeding sites. A repeat bleed one month later was successfully controlled by vasoinfusion. we have
ulcers
or
#{182}7 (94
per
9.
controlled
Mallory-Weiss cent)
massive
upper
2.
ATHANASOULIS,
were
3.
of hyper280.
D. Interactions thrombin clotNature, 1966,
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PROCHASKA,
Radiology, 1973, 107, 521-522. S. R., and CHUANG,
V. P.
REUTER,
lized II.
bleeding
material.
with
1974,
N.
K.,
86-91.
G. I. by cath-
BRIDI,
treated
7.
Brit.
of
embo-
14,
and
fistula
embolization.
Control
autogenous
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G. K., ATALLAH, Renal arteriovenous
RIZK,
eter
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R#{246}SCH,
&
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SNYDER,
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method bleeding.
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May8-II,
com-
: new
GOLDMAN,
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