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Provocative Angiography, Followed by Therapeutic Interventions, in the Management of Hard-To-Diagnose Gastrointestinal Bleeding

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Abstract

Background

Despite significant advances in imaging and endoscopic diagnostic techniques, adequate localization of gastrointestinal bleeding (GIB) can be challenging. Provocative angiography (PROVANGIO) has not been part of the standard diagnostic algorithms yet. We sought to examine the ability of PROVANGIO to identify the bleeding source when conventional radiography fails.

Methods

Patients undergoing PROVANGIO for GIB during 2008–2014 were retrospectively included. Demographics and periprocedural patient characteristics were recorded. PROVANGIO was performed in a multidisciplinary setting, involving interventional radiology, surgery and anesthesiology teams, ready to intervene in case of uncontrolled bleeding. The procedure included conventional angiography of the celiac, superior and inferior mesenteric arteries (SMA, IMA) followed by a stepwise bleeding provocation with anticoagulating, vasodilating and/or thrombolytic agent administration, combined with angiography.

Results

Twenty-three PROVANGIO were performed. Patients were predominantly male (15, 65.2%), and hematochezia was the most common presenting symptom (12, 52.2%). Patients with a positive PROVANGIO had lower Charlson comorbidity index (1 vs. 7, p = 0.009) and were less likely to have a prior history of GIB (14.3% vs. 87.5%, p = 0.001). PROVANGIO localized bleeding in 7 (30%) patients. In 6 out of 7 patients, the bleeding source was identified in the SMA and, in one case, in the IMA distribution. The bleeding was controlled angiographically in four cases, endoscopically in one case and surgically in the remaining two. No complications related to PROVANGIO were detected.

Conclusions

In our series, PROVANGIO safely identified the bleeding source, and provided that necessary safeguards are put into place, we recommend incorporating it in the diagnostic algorithms for GIB management.

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Authors and Affiliations

  1. Division of Trauma, Department of Surgery, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA

    Nikolaos Kokoroskos, Leon Naar, Thomas Peponis, Myriam Martinez, Mohamad El Moheb, Majed El Hechi, Osaid Alser, Eva Fuentes & George Velmahos

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  1. Nikolaos Kokoroskos
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  2. Leon Naar
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  3. Thomas Peponis
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  4. Myriam Martinez
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  5. Mohamad El Moheb
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  6. Majed El Hechi
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  7. Osaid Alser
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  8. Eva Fuentes
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  9. George Velmahos
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Corresponding author

Correspondence to Nikolaos Kokoroskos.

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The authors declare that they have no conflict of interest.

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As a retrospective chart review analysis, no informed consent was required from the individual participants. No individual participants’ identifying information is included in this article.

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This study protocol was reviewed and approved by the Institutional Review Board (IRB) at the Massachusetts General Hospital.

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Kokoroskos, N., Naar, L., Peponis, T. et al. Provocative Angiography, Followed by Therapeutic Interventions, in the Management of Hard-To-Diagnose Gastrointestinal Bleeding. World J Surg 44, 2944–2949 (2020). https://doi.org/10.1007/s00268-020-05545-8

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  • DOI: https://doi.org/10.1007/s00268-020-05545-8

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