Liquid Embolization with Onyx in a Technically Challenging Case of Acute Upper GI Bleeding

Abstract

Conventional embolization such as coiling of acute upper gastrointestinal bleeding may be rendered impossible or unsuitable due to anatomical and technical factors. Liquid (Onyx) embolization in such situations may prove valuable and life saving, though literature on the subject, particularly of acute upper gastrointestinal bleeding due to duodenal ulcer, is sparse. We present a technically challenging case of acutely rebleeding duodenal ulcer embolized successfully using ethylene polyvinyl alcohol polymer (Onyx).

Ethylene Vinyl Alcohol Copolymer (Onyx) Embolization for Acute Hemorrhage: A Systematic Review of Peripheral Applications

“…In a case of iliac artery aneurysm causing enteroarterial fistula, extravasation persisted after the placement of 18 coils into the aneurysm sac, finally arresting after Onyx was added (17). In a case of bleeding duodenal ulcer, embolization of superior and inferior pancreaticoduodenal arteries was unsuccessful with coils (as a result of vessel tortuosity) and microspheres (which extravasated into the duodenum) before Onyx was successfully used (20). In 12 cases (9.2%), EVOH copolymer was used to treat rebleeding after a procedure following initial treatment with other agents (coils, microspheres, or both).…”

“…Several studies described persistent hemorrhage or rebleeding with use of microspheres and coils (13,17,19,20). Microspheres may be shunted through large-diameter collaterals or acquired fistulae, and multiple coils may be difficult to deploy throughout tortuous vessels (13,19,32,33).…”

“…There were 19 articles detailing 131 patient cases identified to meet the inclusion criteria (Fig), comprising 150 treated lesions. There were 11 case series (2,4,9,(10)(11)(12)(13)(14)(15)(16)(17) and 8 case reports (18)(19)(20)(21)(22)(23)(24)(25). One published conference abstract was included among the case series (11).…”

Upper Gastrointestinal Bleed Embolization with Onyx®: The “Tattoo Effect”

“…[ 6 ] In our case, the bleeding arose from the distal branches of the RGA with a suggested Dieulafoy/vascular lesion on angiography, so Onyx ® was selected as the embolic agent for its ability to provide deep occlusion of distal branches and obliterate anomalous vessels. [ 7 ]…”

“…Onyx has shown positive outcomes in controlling acute v bleeding in selected patients with good results in long-term follow-up. [ 7 ] Onyx is intrinsically black, and it is known to cause staining of the overlying skin when used in peripheral applications. [ 7 9 ] A similar “tattoo effect” finding was incidentally observed in our patient's gastric mucosa during follow-up endoscopy the next day [ Figure 4 ].…”