13th Annual Global Embolization Symposium & Technologies
Purpose : Failure to detect the lower gastrointestinal bleeding (LGIB) site during catheter angiography is a major concern precluding superselective-targeted embolization. We have been using empiric cone-beam CT (CBCT)-guided embolization at our institution since 2014 for those patients with a positive CT angiography (CTA) but subsequent negative digital substraction angiography (DSA). The purpose of this study is to assess the clinical usefulness and safety of empiric CBCT guided embolization in the treatment of acute LGIB.
Material and Methods : Retrospective study of all patients with acute LGIB who received a catheter angiography at our institution between 2008 and 2018 (n=109). Only patients with an active contrast extravasation on pre-procedural CTA (< 24h) were included (n=88). Patients with active contrast extravasation during DSA were treated with superselective embolization (targeted embolization group). If DSA was negative, patients underwent an empiric CBCT-guided embolization of the assumed ruptured vas rectum (empiric embolization group) or no embolization (conservative treated group). Hemodynamic instability was defined as systolic pressure ≤ 100 mmHg and heart rate of ≥ 100/min or vasopressor need secondary to blood loss.
Results : Mesenteric DSA performed after positive CTA demonstrated active contrast extravasation in 43 of 88 (48.9%) cases. Superselective empiric CBCT-guided embolization was done in twenty consecutive patients with PVA (n=14), glue (n=3), microcoils (n=2) and PVA + microcoils (n=1). In four patients with initial negative DSA, extravasation was observed during attempted empiric CBCT-guided superselective catheterization and subsequently treated targeted. In two patients CBCT was not used for guidance. Two patients were lost to follow-up. Overall 30-day recurrent bleeding rates in the targeted (n = 45), empiric (n=20) and conservatively (n=19) treated group were 15.6%, 20.0%, and 47.6% respectively (p=0.024). If hemodynamic unstable, rebleeding rates were 15.2%, 25.0%, and 81.8% respectively (p=0.000). Rebleeding was significantly higher in the empiric treated group compared to the conservative group if hemodynamic unstable (p=0.012). Rebleeding was not significantly different between the empiric and targeted embolization group. There were no major ischemic or other complications attributed to embolization in this study cohort.
Conclusions : If acute LGIB is localized by extravastion on CTA, but subsequent catheter angiography is negative, empiric Cone-Beam CT-guided empiric embolization of the suspected vas rectum is safe and superior to a conservative wait-and-see management.