To assess the value of recently developed aggressive pharmacologic angiographic techniques for the diagnosis of acute lower gastrointestinal hemorrhage, we reviewed our experience with 63 consecutive patients referred for angiography. Hemorrhage was severe as indicated by a mean blood transfusion requirement of 9.4 units. Extravasation of contrast (46%), or an obvious vascular abnormality suggestive of a bleeding site (32%), was identified in 78% of patients. Extravasation was seen more frequently in patients with greater than or equal to 3 units of transfusion (66%) than in those with less than 3 units of transfusion (17%, P less than 0.001). After the introduction of pharmacologic techniques using heparin, tolazoline, streptokinase, and indwelling arterial catheters, the percentage of studies with extravasation of contrast increased from 32 to 65% (P less than 0.01). Application of aggressive angiographic techniques increases the diagnostic yield of angiography in acute severe lower gastrointestinal hemorrhage while exposing the patient to modest increased procedure-related risks which can be accepted in selected patients.
Gelfoam (gelatin foam) powder was used for embolization therapy of massive gastric bleeding from small vessels in 14 patients with severe underlying medical problems. Bleeding was controlled in 10 patients with lesions localized in areas supplied by the embolized left gastric artery. In four patients with concurrent lesions in other portions of the stomach, bleeding decreased only (3 patients) or did not respond to embolization (1 patient). Complications developed in 2 patients with compromised vascular supply of the stomach: superficial ischemic ulcers that healed, and a large ulcer that perforated and required surgery. Microscopic studies demonstrated Gelfoam powder penetration mostly into vessels 100 to 200 microns in diameter and only occasionally into smaller vessels 50 to 60 microns, with occlusion of approximately 10 to 15% of the vasculature. It is concluded that Gelfoam fragments are the primary embolic material to be used for occlusion of the left gastric artery. Use of Gelfoam powder should be limited to occasional patients who have only little chance of responding to Gelfoam fragment embolization. Potential candidates for Gelfoam powder embolization include patients with major coagulopathies and/or uremia who massively hemorrhage from small-vessel lesions localized in upper portions of the stomach, exhibit significant mucosal hypervascularity, and do not respond to selective vasopressin treatment. An uncompromised vascular supply of the stomach is a precondition of a safe left gastric artery embolization.
To improve visualization of the small vessels for distal bypass grafting, arteriograms of the lower extremity were obtained in 187 patients by use of active warming of the extremities, selective distal positioning of the catheter for contrast agent injections, and intraarterial administration of tolazoline. With these techniques, satisfactory visualization was obtained for planning of operation, and in only one patient was an intraoperative arteriogram necessary before bypass grafts were placed.
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