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Empiric cone-beam CT-guided embolization in acute lower gastrointestinal bleeding

European Radiology volume 31, pages 2161–2172 (2021)Cite this article

Abstract

Objectives

To evaluate the clinical effect and safety of cone-beam CT (CBCT)-guided empirical embolization for acute lower gastrointestinal bleeding (LGIB) in patients with a positive CT angiography (CTA) but subsequent negative digital subtraction angiography (DSA).

Methods

A retrospective study of consecutive LGIB patients with a positive CTA who received a DSA within 24 h from January 2008 to July 2019. Patients with a positive DSA were treated with targeted embolization (TE group). Patients with a negative DSA underwent an empiric CBCT-guided embolization of the assumed ruptured vas rectum (EE group) or no embolization (NE group). Recurrent bleeding, major ischemic complications, and in-hospital mortality were compared by means of Fisher’s exact test. Further subgroup analysis was performed on hemodynamic instability.

Results

Eighty-five patients (67.6 years ± 15.7, 52 men) were included (TE group, n = 47; EE group, n = 19; NE group, n = 19). If DSA was positive, technical success of targeted embolization was 100% (47/47). If DSA was negative and the intention to treat by empiric CBCT-guided embolization, technical success was 100% (19/19). Recurrent bleeding rates in the TE group, EE group, and NE group were 17.0% (8/47), 21.1% (4/19), and 52.6% (10/19) respectively. Empiric CBCT-guided embolization reduced rebleeding significantly in patients with a negative DSA and hemodynamic instability (EE group, 3/10 vs NE group, 10/12, p = .027). Major ischemic complications occurred in one patient (TE group). Overall, the in-hospital mortality rate was 7.1% (6/85).

Conclusion

Empiric cone-beam CT-guided embolization proved to be a feasible, effective, and safe treatment strategy to reduce rebleeding and improve clinical success in hemodynamically unstable patients with acute LGIB, positive CTA but negative DSA.

Key Points

• A novel transarterial embolization technique guided by cone-beam CT could be developed extending the “empiric” embolization strategy to lower gastrointestinal bleeding.

• By implementing the empiric treatment strategy, nearly all patients with an active lower gastrointestinal bleeding on CTA will be eligible for a superselective empiric embolization, even if subsequent catheter angiography is negative.

• In patients with a negative catheter angiography, empiric embolization reduces the rebleeding rate and, particularly in hemodynamically unstable patients, improves clinical success compared with a conservative “wait-and-see” management.

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Abbreviations

AKI:

Acute kidney injury

CBCT:

Cone-beam CT

CTA:

Computer tomography angiography

DSA:

Digital subtraction angiography

LGIB:

Lower gastroinstestinal bleeding

NBCA:

N-Butyl cyanoacrylate

pRBC:

Packed red blood cells

PVA:

Polyvinyl alcohol

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Funding

The authors state that this work has not received any funding.

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Affiliations

  1. Department of Vascular and Interventional Radiology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium

    Laurens Hermie, Elisabeth Dhondt, Peter Vanlangenhove & Luc Defreyne

  2. Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium

    Jan De Waele

  3. Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium

    Helena Degroote

Authors
  1. Laurens Hermie
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  2. Elisabeth Dhondt
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  3. Peter Vanlangenhove
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  4. Jan De Waele
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  5. Helena Degroote
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  6. Luc Defreyne
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Corresponding author

Correspondence to Laurens Hermie.

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Guarantor

The scientific guarantor of this publication is Luc Defreyne, Head of Department of Vascular and Interventional Radiology, University Hospital Ghent.

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The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors has significant statistical expertise.

No complex statistical methods were necessary for this paper.

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Written informed consent was not required for this study because it comprises a retrospective observational study without inclusion of patient details or images that could lead to patient identification.

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Methodology

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• observational

• performed at one institution

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Hermie, L., Dhondt, E., Vanlangenhove, P. et al. Empiric cone-beam CT-guided embolization in acute lower gastrointestinal bleeding. Eur Radiol 31, 2161–2172 (2021). https://doi.org/10.1007/s00330-020-07232-7

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  • DOI: https://doi.org/10.1007/s00330-020-07232-7

Keywords

  • Gastrointestinal hemorrhage
  • Lower gastrointestinal tract
  • Embolization, therapeutic
  • Cone-beam computed tomography
  • Endovascular procedures