New advances in lower gastrointestinal bleeding management with embolotherapy

Abstract

Lower gastrointestinal bleeding (LGIB) is associated with high morbidity and mortality. Embolization is currently proposed as the first step in the treatment of acute, life-threatening LGIB, when endoscopic approach is not possible or is unsuccessful. Like most procedures performed in emergency setting, time represents a significant factor influencing outcome. Modern tools permit identifying and reaching the bleeding site faster than two-dimensional angiography. Nonselective cone-beam CT arteriography can identify a damaged vessel. Moreover, sophisticated software able to detect the vessel may facilitate direct placement of a microcatheter into the culprit vessel without the need for sequential angiography. A further important aspect is the use of an appropriate technique of embolization and a safe and effective embolic agent. Current evidence shows the use of detachable coils (with or without a triaxial system) and liquid embolics has proven advantages compared with other embolic agents. The present article analyses these modern tools, making embolization of acute LGIB safer and more effective.

Endoscopic hemostasis makes the difference: Angiographic treatment in patients with lower gastrointestinal bleeding

“…We used this approach in about 90% of our patients. The choice of embolization material[ 31 ] is not important; it depends on the investigator’s preference. We used coils in the large majority of cases.…”

Current trends and perspectives in interventional radiology for gastrointestinal cancers

“…Although its major complication is ischemia, it should be preferred as a first-line approached in these selected patients[ 63 ]. A new frontier for the treatment of LGIB is CBCT embolization, which allowed a fast identification of the bleeding site and simplifying the placement of the microcrater in the vessel, without requiring sequential angiography[ 64 ]. The indications and possible complications of these techniques are the same as the traditional AE, with the theoretical advantage of greater safety and efficacy due to the modern and accurate tools[ 64 ].…”

Acute Lower Gastrointestinal Hemorrhage

“…Unlike in upper GI hemorrhage, where the gastroduodenal artery and left gastric artery trunks may be empirically embolized, [33][34][35] proximal or empiric embolization is usually avoided in lower GI hemorrhage due to the increased risk of bowel ischemia and infarction. As a rule, lower GI embolization is performed as selectively as possible, preferably at the level of the vasa recta, [36][37][38] and after the source of hemorrhage is confirmed.…”

“…Other embolic agents that have been explored include particles, 39 n-butyl cyanoacrylate (nBCA) glue, [40][41][42] and ethylene vinyl alcohol copolymer (Onyx; ev3, Plymouth, MN). 38,43 Glue and Onyx have a potential advantage of achieving immediate occlusion of the embolized vessel regardless of any underlying coagulopathy or thrombocytopenia. 38,40 However, there are fewer long-term data describing the safety and efficacy of liquid agents, and some experts cite potential concerns regarding increased ischemic complications.…”

“…38,43 Glue and Onyx have a potential advantage of achieving immediate occlusion of the embolized vessel regardless of any underlying coagulopathy or thrombocytopenia. 38,40 However, there are fewer long-term data describing the safety and efficacy of liquid agents, and some experts cite potential concerns regarding increased ischemic complications. 44 After successful deployment of embolic agents in the target vessel(s), repeat angiography is performed less selectively to confirm resolution of hemorrhage.…”