Refractory bladder haemorrhage represents a major clinical problem treated on an emergency bases. According to the literature, various conservative measures available result in a response rate ranging from 50% to 100% (Ghahestani and Shakhssalim 2009; Choong et al. 2000). Surgical treatment is associated with high morbidity and mortality since most of these patients suffer from serious comorbidities. Percutaneous, trans-catheter, arterial, embolization (TAE) is an alternative, minimally invasive therapeutic option with good results and a lower complication rate compared to conventional surgical approach. (Loffroy et al. 2014)
Review of the literature reveals only few small case series or sporadic case reports reporting results from endovascular embolization for severe haematuria. [Table 3] Most of these studies support the safety and efficacy of the technique in short and mid-term follow up and present a low complication rate. (Loffroy et al. 2014) The herein presented outcomes indicate that super-selective, vesical artery TAE is feasible in the majority of the cases and achieves very satisfactory long-term clinical success rates of 85%.
Rebleeding represents the weak point of the method and in our series rebleeding was encountered in 3/18 (16%) of the patients. This is in keeping with the lower reported rates which range between 10 to 28%. (Delgal et al. 2010) Earlier studies describe mainly nonselective unilateral internal artery embolization, associated with high complication and re-bleeding rate (Liguori et al. 2010; Hietala 1978; Pisco et al. 1989). Overall we treated 10 patients (55.5%) with bilateral super-selective embolization of the vesical arteries and only one of these patients (10%) suffered bleeding recurrence, 5 h later following initial TAE. As a result, the patient underwent second bilateral super-selective TAE using microspheres with successful clinical outcome. On the contrary 8 patients underwent unilateral embolization and rebleeding was noticed in 2 patients (25%), at 35 and 43 days respectively, following initial treatment. One managed conservative and one with further unilateral embolization of the same vessel. Bilateral approach seems to decrease the rate of early re-bleeding which is attributed to the rich collateral blood supply to the internal iliac artery. (Liguori et al. 2010; Hietala 1978; Rastinehad et al. 2008; Ozono et al. 1988; Prasad et al. 2009) We do argue that bilateral embolization may lead to more durable response although is hard to support it due to lack of technique standardization and the small number of patients treated.
Super-selective embolization seems to have fewer complications. (Hietala 1978; Pisco et al. 1989) Delgal et al. reports the safety and efficacy of super-selective embolization with particles in 11 patients. (Delgal et al. 2010) We also performed super-selective embolization with particles or glue or a combination of both without complications. The sole major complication in this series was encountered following TAE from the orifice IIA anterior division using microspheres after coil blockage of the posterior division. Selective distal catheterization of the anterior division was not feasible due to severe stenosis in its proximity. Few hours later the patient developed severe pain from gluteal and anterior abdominal wall necrosis. He died ten days later due to myocardial infarction. On a retrospect, this patient had a history of peripheral arterial disease, previous endovascular aortic aneurysm repair and fem-fem bypass, with a rich collateral network due to the underlying severe atherosclerosis that was over looked. Moreover small sized particles of 40 μm were used aiming in better penetration. All the above contributed to this disastrous complication could definitely be prevented if the angiographic findings were cautiously evaluated. The use of 300- to 500 μm particles would have certainly been a better choice, as it has been reported to decrease the complication rate given a lower risk of non-targeted embolization and/or tissue devascularisation. Surgery was not an option for this patient due to severe comorbidities.
The use of different embolization materials has been reported like coils, glue, particles, alcohol and gelfoam without any actual benefit of a specific agent over another. Most of the authors used particles regardless the selectivity of embolization. (Delgal et al. 2010; Liguori et al. 2010) In the majority of the cases we used particles, glue or a combination of both. There are only few reports of embolization with the use of cyanoacrylate glue in the literature. Delgal, et al., reported cyanoacrylate glue embolization of the feeding branch in patients with angiographic evidence of contrast extravasation. In this study, n-butyl-2-cyanocrylate glue mixed with ultra-fluid lipiodol (1:3 ratio) was used, alone or in combination with other embolic agents in 7 patients, regardless of the angiographic findings. There were no complications observed associated with the use of glue.
According to the literature and the author’s opinion, bilateral superselective approach when possible seems to be the desired treatment option when no site of active bleeding is identified. However definite conclusions about the best technique and embolization agent to optimize the technique efficiency cannot be drawn yet. Unilateral embolization can be efficient in selected cases, especially when angiography depicts bleeding from a terminal arteriole or a focalized hypervascularity rather than diffuse disease. (Delgal et al. 2010) An attempt to embolize one of the vesical arteries or even branches of the IIA should be made, as flow reduction could sometimes suffice as to stop the bleeding or incite clinical improvement.
Limitations of the present study include an inherent external validity bias, the small number of patients investigated due to the single-centre design and the lack of technique standardization. Moreover, the limited number of subjects included did not enable sub-group analysis as to identify possible factors influencing outcomes such as clinical presentation, embolic material, bilateral versus unilateral embolization etc. Finally, as this was a retrospective study some cases might have not been identified.