Embolotherapy in Acute Arterial Gastrointestinal Hemorrhage · Embolotherapy in Acute Arterial...

Embolotherapy in Acute Arterial Gastrointestinal Hemorrhage

Josef Rösch* and Frederick S. KellerDotter Interventional Institute, Oregon Health & Science University, Portland, OR, USA

Abstract

After the presentation of the first patient treated by embolization 1970, the authors present potentialsources of gastrointestinal (GI) bleeding. The acutely bleeding patients need to have first endoscopicevaluation and eventual treatment. Diagnostic angiography is then described. Embolization withocclusion of the bleeding vessel is presently the preferred approach by most interventionalists.Depending on their preference and size of the bleeding vessel, interventionalists use particles ofGelfoam sponge or polyvinyl alcohol foam, coils, or liquid agents as N-butyl cyanoacrylate forembolization. Characteristics of agents are described, and examples are presented. In extra-alimentary sources of GI bleeding, hemobilia and bleeding from pancreas and fistulas with aortaand major arteries are discussed, and embolotherapy approaches are suggested.

Glossary of Terms

Angiodysplasia Structural vascular abnormality with small arterio-venouscommunications.

Autologous clot Clot from the patient’s own blood.Barrett Syndrome Chronic ulceration of the columnar epithelium lined lower esophagus.Coagulopathy Blood clotting abnormality.Embolization Therapeutic introduction of various substances into circulation to occlude

vessels.Empiricembolization

Guided by practical experience with no angiographic findings to indicateactive hemorrhage.

Fistula Abnormal connection between vessel to another vessel or epithelialsurface.

Iatrogenic Induced inadvertently by a physician during diagnosis or treatment.Intususception A problem with the intestine in which one portion of the bowel slides into

the next portion.Mallory-WeissSyndrome

Upper gastrointestinal bleeding resulting from a mucosal laceration at thegastroesophageal junction usually induced by retching or vomiting.

Meckel’sdiverticulum

A congenital diverticulum of the lower part of the small intestine.

N-butylcyanoacrylate

Fast-acting adhesive used for vascular occlusion.

*Email: [email protected]

PanVascular MedicineDOI 10.1007/978-3-642-37393-0_127-1# Springer-Verlag Berlin Heidelberg 2014

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Pseudoxanthomaelasticum

An inherited disorder of connective tissue.

TIPS procedure Transjugular intrahepatic portosystemic shunt – a percutaneous procedurefor creation of portosystemic shunt.

Introduction

Therapeutic vascular embolization for treatment of acute arterial gastrointestinal (GI) bleedingbegan on November 1, 1970. On that date we were asked to treat acute hematemesis froma bleeding gastric ulcer in a 43-year-old coagulopathic woman with cirrhosis. We first tried selectivevasoconstrictive infusion to control her acute GI bleeding; however, its effect was only temporary.Because the patient was not a surgical candidate, following consultation with her surgeon, wedecided to treat her with arterial embolization. First, we selectively catheterized the bleedinggastroepiploic artery and occluded it with an injection of 2 cm3 of autologous clot that was heldin place by selective epinephrine infusion. The embolization was successful and the bleeding ceased.A 14-h follow-up angiogram showed localized occlusion of the gastroduodenal artery with goodcollateral filling of the distal gastroepiploic artery (Fig. 1a–c). To explore this technique and thesafety of embolization, we did a series of canine experiments before our case was published early in1972 (Rösch et al. 1972). We found the combination of vasoconstrictive infusions and clotembolization was effective and did not cause infarction because of rich collateral circulation inthe upper gastrointestinal track. Publication of these studies led to rapid introduction of selectivearterial embolization for control of acute arterial bleeding. After several attempts to use modifiedautologous clots, surgical gelatin (Gelfoam) became the embolization material of choice. It wasmostly used as small pieces cut from surgical pads for more central embolization. During theintervening years, introduction and refinement of catheters, microcatheters, microguidewires, coilsand microcoils, and other embolic materials led to the rapid improvement in interventional treatmentof acute GI bleeding transforming it from a last-ditch procedure reserved for only desperate

Fig. 1 (a–c) The first patient embolized for gastrointestinal bleeding in November 1, 1970. (a) Selective gastroepiploicarteriogram shows extravasation in the gastric antrum (arrow). (b) Gastroduodenal arteriogram after selective epineph-rine infusion and blood clot embolization demonstrate extensive vasoconstriction of the gastroepiploic artery and bloodclots around the catheter in the gastroduodenal artery (arrowheads). (c) Selective gastroduodenal arteriogram 14 h afterclot injection shows occlusion of the distal portion of the gastroduodenal artery


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circumstances to a frontline therapy for acute GI bleeding (Baum 2006; Loffroy and Guin 2009;Mirsadraee et al. 2011; Navuluri et al. 2012).

Bleeding Sources

GI bleeding is caused in the majority of cases by well-known and expected lesions and diseases.Gastric and duodenal ulcers, gastritis, andMallory-Weiss tears are the most common causes of upperGI hemorrhage. Esophagitis, Barrett’s syndrome, benign and malignant tumors of the stomach,gastric and duodenal vascular malformations, pseudoxanthoma elasticum, vasculitis, and hemobiliaare among its rare sources. Lower GI hemorrhage is most often caused by hemorrhoids, colonicdiverticula, acquired angiodysplasias, congenital arteriovenous malformations, inflammatory orischemic bowel disease, benign or malignant tumors, and iatrogenic causes such as polypectomy.Intussusception, aortoduodenal fistula, small bowel diverticula including Meckel’s diverticulum,hemobilia, bleeding from the pancreas, and fecal disimpaction are some of the uncommon sources oflower GI bleeding. Both upper and lower GI hemorrhage can occur after surgery or trauma, withacetylsalicylic acid or anticoagulant medications, and in patients with coagulopathies, particularlywith coexisting bowel pathology. Finding the proper source of bleeding is important in the selectionof embolization technique, particularly in deciding whether a temporary or permanent embolicmaterial should be used.

Clinical Considerations

The needs of a patient undergoing interventional treatment for acute GI bleeding are best met bya hospital equipped with a well-trained interventional team consisting of interventional radiologists,interventional radiology technologists and nurses, and a modern interventional suite. The interven-tional teammust be available and ready to respond within a short time at any hour of the day or night.However, not every patient with acute GI bleeding requires interventional treatment or, for thatmatter, even diagnostic angiography. With aggressive medical treatment consisting of bloodreplacement, intravenous fluids, correction of coagulation defects, sedation, and bed rest, GIhemorrhage will cease in approximately 75–80 % of patients (Rösch et al. 1976).

Today, endoscopy is both the primary diagnostic and therapeutic methods for investigation ofacute upper GI track hemorrhage. Arterial bleeding can be treated through the endoscope withepinephrine injection, heater probe application, and electrocoagulation. Bleeding varices can bedifferentiated from arterial bleeding, and when discovered the patient can be treated with eitherendoscopic sclerosis or banding or referred for TIPS. Angiographic treatment is reserved for thosepatients who continue to bleed from lesions in the upper GI tract that fail attempts at endoscopiccontrol. In these patients, the endoscopist can place clips adjacent to the bleeding lesion to provideguidance for the interventional radiologist. Endoscopy is less useful for acute lower GI bleeding.Since blood travels both proximally and distally to a bleeding colonic or small bowl lesion, often thesite of bleeding gets obscured. Radionuclide scanning has been, therefore, often used for determin-ing activity of lower GI bleeding. Extravasation of radionuclide in the bowel at rates as low as 0.1mil/s was detected with the use of 99/TC sulfur colloid. At present, multi-detector CT (MDCT)enterography is often used for determining the activity and location of the bleeding lesions (Yoonet al. 2006; Wu et al. 2010).


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Diagnostic Angiography

Before diagnostic angiography and intervention treatment are undertaken, the patient should bevisited by the interventional radiologist for an explanation of the procedure, its risks, and potentialcomplications. Informed consent is obtained at this time. A limited physical examination withnotation of the femoral and peripheral pulses should be done. The patient’s chart and all pertinentlaboratory results, imaging exams, and endoscopic reports need to be reviewed. Factors that mayincrease the procedural risk such as renal insufficiency, hypertension, and severe atheroscleroticdisease of the peripheral arteries or coagulopathy should be recorded along with the rationale forproceeding with the examination in the presence of increased risk.

The femoral artery approach is used in most cases for catheter introduction. If the bleeding lesionhas been localized by endoscopy or noninvasive imaging, the interventional radiologist can focusattention to that area. Otherwise, GI bleeding should be categorized as “upper” or “lower.” If thepatient has hematemesis, upper GI bleeding is present, and study should start with selective celiacangiogram. With “lower” GI bleeding, the inferior and superior mesenteric angiograms are donefirst. The celiac angiogram must follow if these are negative. If an arterioenteric or aortoentericfistula is a consideration, a midstream aortogram or distal aortogram with imaging over the pelvisneeds to be performed first. It is important that imaging covers the entire GI tract. In patients withupper GI bleeding, this extends from the distal esophagus to the ligament of Treitz. For lower GIbleeding, the entire small bowel and colon to the level of the anus should be imaged.

The pathognomonic angiographic sign of acute arterial hemorrhage is extravasation of contrastmaterial into the GI lumen. The patient must be bleeding actively at a rate equal to or greater than0.5 ml per minute when the angiographic contrast material is injected to visualize the extravasation.If bleeding is intermittent, minute-to-minute in nature, provocative measures such as use ofvasodilators, anticoagulants, or fibrinolytics can be used to reactivate the bleeding (Röschet al. 1986). This aggressive measure, however, should be reserved for patients who are diagnosticproblems and for whom the risk of prolonging or reactivating bleeding is outweighed by thepotential benefit and for whom replacement blood is immediately available.

Embolotherapy

Initially, embolotherapy was reserved for patients with life-threatening hemorrhage who failed a trialvasopressin infusion. Today, however, most interventional radiologists prefer to use embolization asthe initial approach. The goal of embolization is to reduce the blood pressure at the bleeding site andallow a stable clot to form without causing tissue ischemia or necrosis. Embolotherapy has theadvantages of rapid control of bleeding without the problems of maintaining long-term arterialcatheterization needed for vasopressin infusion. However, embolization is not without its risks,embolic particles and most embolic devices cannot be retrieved once they are released. Therefore, itis essential that the arterial embolization catheter is in a fixed position as close as possible to the siteof extravasation. A coaxial microcatheter often can be advanced to the bleeding lesion (Fig. 2a–c).The embolic material is than carefully injected to block the artery. The rich collateral arterial supplyto the gastrointestinal track usually protects these organs from significant ischemia and infarctionafter embolization of the bleeding vessel. If there is a dual blood supply to the bleeding site, it is oftennecessary to embolize both sides of the arcade. Duodenal bleeding can be supplied by both thegastroduodenal artery and the inferior pancreaticoduodenal artery. A bleeding colonic lesion in the“watershed” area of the splenic flexure can be supplied by branches of both the superior and inferior


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mesenteric arteries. Distal rectal or anal bleeding may also have a dual supply consisting of superiorhemorrhoidal branches from the inferior mesenteric artery and/or middle hemorrhoidal branchesfrom the internal iliac artery. In instances of dual blood supply, successful embolization of both sidesof the arterial arcades as close as possible to the bleeding lesion is frequently necessary.

Particle Embolization

Today, the choice of embolic material varies with the preference of the interventional radiologist andthe anatomy and size of the vessels to be embolized. Many lesions causing acute GI bleeding arebenign and self-limiting and will heal with medical treatment. The use of temporary embolic agentslike Gelfoam sponge is preferred. Recanalization of arteries occluded with Gelfoam usually occurswithin one to three weeks. The Gelfoam sponge is cut into small pledgets, mixed with contrastmaterial, and carefully injected into the bleeding artery to avoid reflux. If deeper penetration ofGelfoam is desired, the pledgets can be mixed with contrast material and passed between twosyringes with a three-way stopcock interposed. This will result in a fine mixture of Gelfoam that canbe injected through microcatheters. Gelfoam powder, on the other hand, penetrates too far distallyoccluding arteries as small as 50–60 m in diameter making it unacceptable as an embolic material forinterventional management of GI bleeding. Both acute and chronic superficial and perforatinggastric ulcers occurred in swine whose left gastric arteries were embolized with Gelfoam powder.

Polyvinyl alcohol foam or calibrated acrylic particles are preferred by some interventionalists.The diameters of these particles range in size from 100 m to 1,000 m. Interventionalists can choosethe appropriate diameter particle depending upon the desired depth of penetration. These agentscause permanent occlusion and are especially indicated when GI hemorrhage is caused by invasionof the GI tract by primary or secondary malignancies. The particles are suspended in a syringecontaining dilute contrast material and carefully delivered under fluoroscopic monitoring. Sincethey are soft and comfortable, they can easily pass through microcatheters.

Fig. 2 (a–c) Bleeding from the ascending colon diverticulum embolized by straight coils with the use ofa microcatheter. (a) Superior mesenteric arteriogram shows extravasation in the ascending colon (arrow). (b) Arterio-gram of the vasa recta with use of a microcatheter (arrowhead) shows massive extravasation in the ascending colon andstraight metal coils in two previously occluded vasa recta. The catheterized vasa recta were also occluded. (c) Follow-upsuperior mesenteric arteriogram does not demonstrate any bleeding. Residual contrast medium in the ascending colon


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Coil Embolization

Occlusion coils are mechanical devices that are also very effective in controlling GI hemorrhage(Fig. 3). They are used for bleeding from large vessels for which Gelfoam or other particles may beineffective (Padia et al. 2009). Unlike particles that embolize distally from the catheter, coils remainwhere they are deployed at or close to the site of the lesion. Occlusion coils are indicated when pepticerosion has caused a large arterial defect frequently seen in the gastroduodenal artery in a patientwith an acutely bleeding duodenal ulcer. With this situation, the particulate embolics will likely passdirectly through the hole in the artery into the lumen of the duodenum. To function as intended,occlusion coils require an intact coagulation system. In patients with a focal bleeding site originatingfrom a large artery, the interventional strategy is to “bracket” the lesion by placing coils just proximaland distal to it, or the entire length of the artery can be occluded (Fig. 4a–e). In order to accomplishthis with bleeding duodenal ulcers, both sides of the pancreaticoduodenal arcade may requirecatheterization and occlusion (Keller and Rösch 1988). Advancements in occlusion coil technologyresulted in the development of detachable coils, microcoils capable of being delivered througha microcatheter and metallic coils that do not degrade MR images (Loffroy et al. 2011).

Liquid Embolic Agents

Liquid embolic agents also have a role in interventional therapy of acute GI bleeding. N-butylcyanoacrylate (Trufill) is a type of glue that is mixed with Ethiodol and polymerizes upon contactwith ions in the blood (Morishita et al. 2013). The rapidity of polymerization depends upon the ratioof the mixture. This material is useful when a permanent occlusion is desired, but the angiographiccatheter cannot be advanced close enough to the pathologic lesion for placement of a coil and forwhich particulate embolization has decreased chances of success (Yata et al. 2013). The use ofN-butyl cyanoacrylate is not intuitive. Because proper usage requires training either in an animal labor on a model, it is not an embolic material that can be pulled off the shelf and used for the first timeto embolize an acutely bleeding patient. Absolute alcohol is another liquid embolic agent that hasbeen used in interventional radiology for specifically limited indications. However, since absoluteethanol denatures protein and infarcts tissue, it absolutely has no role in the interventional therapy ofacute GI bleeding.

Fig. 3 Various types and sizes of embolization microcoils and coils


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Empiric Embolization

In most instances, embolization for acute GI bleeding occurs following the demonstration ofextravasation of contrast material from the offending lesion on the initial angiogram. Empiricembolization is the practice of performing embolization based on either the endoscopic or MDCTangiography findings in the absence of extravasation (Ichiro et al. 2011; Dixon et al. 2013). Theendoscopist may place a clip next to the bleeding site to help guide the interventional radiologist.Used almost exclusively in patients with upper GI bleeding, empiric embolization has essentially thesame overall good results as embolization performed in the presence of extravasation. One largestudy concluded that stopping upper GI hemorrhage with embolization had a significantly positiveeffect on survival independent of demonstrable extravasation at the time of embolization (Ichiroet al. 2011).

For patients with endoscopically identified gastric bleeding who do not have active extravasationat angiography, the left gastric artery is embolized empirically. If the endoscopic exam revealsduodenal bleeding and no angiographic extravasation is present, the gastroduodenal artery is

Fig. 4 (a–e) Duodenal bleeding embolized by microcoils. (a) Celiac arteriogram demonstrates extravasation in lowerportion of the descending duodenum. (b) Selective arteriogram of the bleeding artery with a microcatheter shows largeextravasation (arrow). (c) Follow-up gastroduodenal arteriogram after its embolization with microcoils shows occlusionof the gastroduodenal artery. (d, e). Follow-up celiac and mesenteric arteriograms show gastroduodenal artery occlusionwith no bleeding


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empirically embolized in its entirety. Furthermore, depending upon the endoscopic findings, theanterior or posterior superior pancreaticoduodenal arteries and sometimes the inferior pancreatico-duodenal artery are also empirically embolized.

Extra-Alimentary Tract Sources of GI Bleeding

HemobiliaAlthough blunt trauma with liver lacerations and penetrating trauma from stab wounds are well-known causes of hemobilia, invasive diagnostic and therapeutic procedures such as percutaneousliver biopsies and transhepatic biliary drainages are the greatest causes of hemobilia today. Tradi-tional therapy for hemobilia is either surgical resection of the hepatic lobe or segment containing theinvolved lesion or hepatic artery ligation. Today, however, both surgeons and interventionalradiologists agree that superselective transcatheter occlusion of the intrahepatic artery (or portalvein branch) that supplies the pathologic lesion responsible for hemobilia is the current therapy ofchoice (Fig. 5a–c). For peripheral hepatic lesions causing hemobilia, simple placement of occlusioncoils as close as possible to the lesion is the best approach (Vaughan et al. 1984). Ifa pseudoaneurysm in a large central hepatic artery is present, the interventional radiologist shouldtry to isolate it by bracketing it with occlusion coils placed both distally and proximally to it. Thispractice eliminates the chance of rebleeding from perfusion of the pseudoaneurysm in a retrogradefashion from intrahepatic collaterals.

GI Hemorrhage of Pancreatic OriginDigestion of the arterial walls by enzymes released during an episode of acute pancreatitis can causeformation of pseudoaneurysms that may communicate with the lumen of various segments of thealimentary tract, the pancreatic duct (hemosuccus pancreaticus), or pseudocysts. Patients maypresent with massive GI hemorrhage. In these patients, CT often demonstrates a pseudoaneurysmfilled with blood and may show extravasation of contrast material into the GI track if the patient is

Fig. 5 (a–c) Embolization treatment of hemobilia with Gelfoam in a 9-year-old girl who had six episodes of uppergastrointestinal bleeding after liver injury and surgery. (a) Celiac arteriogram shows intrahepatic arterialpseudoaneurysm (arrow). (b) The catheter is introduced close to the pseudoaneurysm for injection of several piecesof Gelfoam. Study was done prior to coil introduction. (c) Follow-up hepatic arteriogram two months after embolizationdoes not demonstrate the pseudoaneurysm. The patient did not have any bleeding recurrence


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bleeding acutely at the time of the CT. The CT serves as a guide for the interventional treatment ofthese lesions. Surgical intervention is often required to manage the complications of pancreatitis.Preoperative embolization in patients needing surgery reduces the chances of serious hemorrhageduring the operation and frequently obviates the need for surgery altogether. Interventional treatmentof pseudoaneurysms from pancreatitis that cause acute GI bleeding consists of isolating thepseudoaneurysm by placing occlusion coils both distally and proximally to it.N-butyl cyanoacrylateis also a useful embolic agent for the management of hemorrhagic complications of pancreatitis.

Aortoenteric and Arterioenteric FistulasVascular graft anastomoses, aneurysms, and pseudoaneurysms that lie near a portion of the alimen-tary tract and eventually erode into it as a result of continuous pulsations against it are rare causes ofacute GI bleeding. Often these problems are diagnosed by CT, and the patient goes directly tosurgery. If the patient is bleeding actively at the time of angiography, extravasation of contrastmaterial is present on an aortogram. The interventional radiologist, however, must have a high indexof suspicion for an aortoenteric or iliac artery enteric fistula because of a history of aneurysms ofthese vessels or aortic or iliac artery surgery. In these cases the first contrast injection should be anaortogram. The typical finding of arterial (aortic) enteric fistulas when active bleeding is not presentis either a pseudoaneurysm or defect in the arterial wall at the site of the fistula. The traditionaltherapy for these lesions is vascular surgery. If the patient is bleeding actively, an occlusion ballooncan be placed in the aorta or iliac artery at the site of the fistula and inflated to tamponade thehemorrhage prior to operation. If, however, the patient is a poor operative candidate, eitherembolization or interventional placement of an aortic or iliac artery endograft has successfullymanaged hemorrhage from these lesions.

Conclusion

Embolotherapy of acute arterial GI bleeding grew enormously since 1970. Starting with a simpleidea to prevent exsanguination of a patient, the concept of using embolization to control acute GIhemorrhage without causing tissue infarction was validated in animal experiments. The use ofembolization to treat acute gastrointestinal bleeding is now a technique adopted worldwide. Manysmart and inventive interventional radiologists contributed to the growth of embolotherapy withtheir new ideas and their excellent experimental and clinical work. Today, experienced interven-tional radiologists using careful techniques can occlude practically all the bleeding arteries and canstop most cases of GI bleeding. However, the words “experienced interventionalists” and “carefultechniques” must be emphasized in order to prevent complications. With the rapid improvement inboth embolization techniques and embolic materials, further improvement in embolotherapy isinevitable.

References

Baum S (2006) Arteriographic diagnosis and treatment of gastrointestinal bleeding. In: Baum J,Pentacoast MJ (eds) Abrams’ angiography. Interventional radiology. Lippincott/Williams &Wilkins, Philadelphia, pp 487–515


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Dixon S, Chan V, Shrivastava V, Anthony S, Uberio R, Bratby M (2013) Is there a role for empiricgastroduodenal artery embolization in the management of patients with active upper GI hemor-rhage? Cardiovasc Intervent Radiol 36:970–977

Ichiro I, Shushi H, Akihiko I, Yasuhiko I, Yasuyuki Y (2011) Empiric transcatheter arterialembolization for massive bleeding from duodenal ulcers: efficacy and complications. J VascInterv Radiol 22:911–916

Keller FS, Rösch J (1988) Embolization for acute duodenal hemorrhage. Semin Interv Radiol5:32–38

Loffroy R, Guin B (2009) Role of transcatherter arterial embolization for massive bleeding fromgastroduodenal ulcers. World J Gastroenterol 15(47):5889–5897

Loffroy RF, Abualsaud BA, Lin MD, Rao PP (2011) Recent advances in endovascular techniquesfor management of acute nonvariceal upper gastrointestinal bleeding. World J Gastrointest Surg3:89–100

Mirsadraee S, Tirukonda P, Nicholson A, Everett SM, McPherson SJ (2011) Embolization fornon-variceal upper gastrointestinal tract hemorrhage: a systematic review. Clin Radiol66:500–509

Morishita H, Yamagami T, Matsumoto T, Asai S, Masui K, Sato H, Majima A, Sato O (2013)Transcatheter arterial embolization with N-butyl cyanoacrylate for acute life-threatening gastro-duodenal bleeding uncontrolled by endoscopic hemostasis. J Vasc Interv Radiol 24:432–438

Navuluri R, Patel J, Kang L (2012) Role of interventional radiology in the emergent management ofacute upper gastrointestinal bleeding. Semin Interv Radiol 29:169–177

Padia SA, Geisinger MA, Newman JS, Pierce G, Obuchowski NA, Sands MJ (2009) Effectivenessof coil embolization in angiographically detectable versus non-detectable sources of uppergastrointestinal hemorrhage. J Vasc Interv Radiol 20:461–466

Rösch J, Dotter CT, Brown MJ (1972) Selective arterial embolization, a new method for control ofacute gastrointestinal bleeding. Radiology 102:303–306

Rösch J, Antonovic R, Dotter CT (1976) Current angiographic approach to diagnosis and therapy ofacute gastrointestinal bleeding. Rofo 125:301–310

Rösch J, Kozak BE, Keller FS, Dotter CT (1986) Interventional angiography in diagnosis of acutelower gastrointestinal bleeding. Europ J Radiol 6:136–141

Vaughan R, Rösch J, Keller FS, Antonovic R (1984) Treatment of hemobilia by transcathetervascular occlusion. Eur J Radiol 4:183–189

Wu L, Xu J, Yin Y, Qu X (2010) Usefulness of CT angiography in diagnosing acute gastrointestinalbleeding: A meta-analysis. World J Gastroenterol 16(31):3957–3963

Yata S, Ihaya T, Kaminou T, Hashimoto M, Ohuchi Y, Umekita Y, Ogawa T (2013) Transcatheterarterial embolization of acute arterial bleeding in the upper and lower gastrointestinal tract withN-butyl-2-cyanoacrylate. J Vasc Interv Radiol 24:422–431

YoonW, Jeong YY, Shin SS, Lim HS, Song SG, Jang NG, Kim JK, Kang HK (2006) Acute massivegastrointestinal bleeding: Detection and localization with arterial phase multi-detector row helicalCT. Radiology 239:160–167

Further ReadingArrayeh E, Fidelman N, Gordon RL, LaBerge JM, Kerlan RK Jr, Klimov A, Bloom AI

(2012) Transcatheter arterial embolization for upper gastrointestinal nonvariceal hemorrhage: isempiric embolization warranted? Cardiovasc Intervent Radiol 35:1346–1354


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Loffroy R, Rao P, Ota S, Lin MD, Kwak B, Geschwind J (2010) Embolization of acute nonvaricealupper gastrointestinal hemorrhage resistant to endoscopic treatment: Results and predictors ofrecurrent bleeding. Cardiovasc Intervent Radiol 33:1088–1100

Mirsadraee S, Tirukonda P, Nicholson A, Everett SM, McPherson SJ (2011) Embolization fornon-variceal upper gastrointestinal tract hemorrhage: a systematic review. Clin Radiol66:500–509

Yap FY, Omene BO, Patel MN, Yohannan T, Minocha J, Knuttinen MG, Owens CA, Bui JT, GabaRC (2013) Transcatheter embolotherapy for gastrointestinal bleeding: a single center review ofsafety, efficacy and clinical outcomes. Dig Dis Sci 58:1976–1984


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Index Terms:

Aortoenteric and arterioenteric fistulas 9Coil embolization 6Embolotherapy 8Empiric embolization 8Gastrointestinal (GI) bleeding 4, 9Hemobilia 8Liquid embolic agents 6Particle embolization 5


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