Multicenter retrospective study of transcatheter arterial embolisation for life-threatening haemorrhage in patients with uncorrected bleeding diathesis

Abstract

Background We retrospectively investigated outcomes of emergency TAE for the management of life-threatening haemorrhage in patients with uncorrected bleeding diathesis. Materials and methods This multicenter, retrospective, study, was designed to investigate the safety and efficacy of percutaneous TAE for the management of life-threatening haemorrhage in patients with uncorrected bleeding disorder at the time of embolization. All consecutive patients with uncorrected coagulation who underwent TAE for the treatment of haemorrhage, between January 1st and December 31th 2019 in three European centers were included. Inclusion criteria were thrombocytopenia (platelet count < 50,000/mL) and/or International Normalized Ratio (INR) ≥2.0, and/or activated partial thromboplastin time (aPTT) > 45 s, and/or a pre-existing underlying blood-clotting disorder such as factor VIII, Von Willebrand disease, hepatic cirrhosis with abnormal liver function tests. Primary outcome measures were technical success, rebleeding rate and clinical success. Secondary outcome measures included patients’ 30-day survival rate, and procedure-related complications. Results In total, 134 patients underwent TAE for bleeding control. A subgroup of 17 patients with 18 procedures [11 female, mean age 70.5 ± 15 years] which represent 12.7% of the total number of patients, presented with pathological coagulation parameters at the time of TAE (haemophilia n = 3, thrombocytopenia n = 1, cirrhosis n = 5, anticoagulants n = 7, secondary to bleeding n = 1) and were analyzed. Technical success was 100%, as in all procedures the bleeding site was detected and successfully embolised. Clinical success was 100%, as none of the patients died of bleeding during hospitalization, nor was surgically treated for bleeding relapse. Only one rebleeding case was noted (5.9%) that was successfully treated with a second TAE. No procedure-related complications were noted. According to Kaplan-Meier analysis the estimated 30-day survival rate was 84.2%. Conclusion TAE in selected patients with uncorrected bleeding diathesis should be considered as a suitable individualized management approach. Emergency TAE for life threatening haemorrhage in patients with coagulation cascade disorders should be used as an aid in realistic clinical decision making.

A Multicenter Retrospective Cohort Study Evaluating the Clinical Outcomes of Patients with Coagulopathy Undergoing Transcatheter Arterial Embolization (TAE) for Acute Non-Neurovascular Bleeding

“…Transcatheter arterial embolization (TAE) is the mainstay of treatment for acute major hemorrhage [ 1 , 2 , 3 ]. A multitude of conditions, including trauma, tumors, iatrogenic injuries, and coagulation disorders, can cause major acute bleeding and may benefit from TAE [ 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 ].…”

“…Despite TAE in patients with coagulation disorders being a well-known area of endovascular therapy, the definition of coagulopathy differs among authors [ 4 , 19 , 31 , 32 ]. The Cardiovascular and Interventional Radiological Society of Europe (CIRSE) and the Society of Interventional Radiology (SIR) issued some documents on peri-operative anticoagulation management in patients undergoing interventional radiology procedures [ 33 , 34 , 35 ].…”

“…The Cardiovascular and Interventional Radiological Society of Europe (CIRSE) and the Society of Interventional Radiology (SIR) issued some documents on peri-operative anticoagulation management in patients undergoing interventional radiology procedures [ 33 , 34 , 35 ]. Interestingly, some authors have defined the condition of coagulopathy by choosing some cut-off values that previous guidelines or investigations have used to recommend the correction of coagulation function in order to safely perform an endovascular procedure [ 19 , 32 ]. However, the coagulopathy condition in patients undergoing TAE is a separate clinical setting and goes beyond the safety issues related to the endovascular treatment in itself and vascular access site management, as it results in a number of well-known consequences: (1) worsening of the severity of bleeding [ 36 , 37 ], (2) predicting mortality [ 37 ] and rebleeding [ 24 , 38 ], (3) higher risk of clinical failure after TAE [ 39 ], and (4) high clinical failure rates with embolic agents that act by clot formation, such as gelatin sponge and coils [ 4 , 32 , 40 , 41 , 42 , 43 , 44 ].…”

“…Coagulopathies recognize congenital or acquired causes. Among the acquired causes, some conditions, such as COVID-19-related coagulopathy, thromboprophylaxis with anticoagulants, and trauma-induced coagulopathy, are of particular interest, as they are frequent causes of acute major bleeding requiring TAE [ 19 , 50 , 51 , 52 ].…”

“…Unfortunately, the existing evidence on the safety and efficacy of TAE in patients with coagulopathy is inconsistent; often limited to small populations, retrospective-based case series [ 19 ], or subgroup analyses; and performed in a single-center fashion [ 31 , 32 , 39 , 44 , 53 , 54 ]. Our study aims to assess the efficacy and safety of TAE for spontaneous non-neurovascular acute bleeds in patients with coagulopathy via a multicenter, retrospective, large cohort evaluation.…”