Gastrointestinal Intervention 2018; 7(3): 155-157
Outcomes and complications of embolization for gastrointestinal bleeding
In Joon Lee
Department of Radiology, Center for Liver Cancer, National Cancer Center, Goyang, Korea
*Department of Radiology, Center for Liver Cancer, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang 10408, Korea. E-mail address: (I.J. Lee). ORCID:
Received: June 18, 2018; Revised: July 7, 2018; Accepted: July 7, 2018; Published online: October 31, 2018.
© Society of Gastrointestinal Intervention. All rights reserved.

cc This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gastrointestinal bleeding is a common medical emergency with significant morbidity and mortality. Although endoscopic treatment was recommended as the first-line approach, it is often limited in real clinical practice. Over the past few decades, transcatheter arterial embolization has become a major treatment modality for the management of gastrointestinal bleeding that is refractory to endoscopic management. This review aims to describe the outcomes and complications of transcatheter arterial embolization for gastrointestinal bleeding.

Keywords: Gastrointestinal bleeding, Transcatheter arterial embolization

Since the introduction of transcatheter arterial embolization (TAE) in the 1970s, it has been widely used for the management of acute gastrointestinal bleeding (GIB).1,2 GIB is categorized as upper GIB (UGIB) and lower GIB (LGIB), with the Treitz ligament used as an anatomical landmark to differentiate between the two. Outcomes and complications of TAE differ somewhat between the two. The vascular supply to the stomach and duodenum is quite rich, which can make successful embolization more challenging but decrease the incidence of post-embolization ischemia.3 In TAE for LGIB, post-embolization ischemia is a major concern and intermittent bleeding often causes management difficulties.


In a review published in 2010 that identified 15 studies (including a total of 829 patients), TAE of UGIB showed a technical success rate of 93% (range, 62%–100%), a clinical success rate of 67% (range, 52%–94%), a rebleeding rate of 33% (range, 9%–66%), and a 30-day mortality rate of 28% (range, 4%–46%).4 A wide range of these outcomes is probably due to different etiologies. A recent multicenter study also reported high technical and clinical success rates of TAE for peptic ulcer bleeding.5 In a systemic review of TAE versus surgery, there were no significant differences in the mortality rates; however, TAE had higher rebleeding rates than surgery.6 Coagulopathy is a representative clinical predictor of rebleeding, and increases the odds ratio up to 19.5 for clinical failure.7,8 Other possible causes are shock, low hemoglobin concentration, massive transfusion, and longer time to angiography.7,911 In the technical predictors, using only coils can increase the rebleeding rate.8 Although coil embolization is precise, it is limited to embolizing the distal branch of the small target artery due to its profile and can be just proximal embolization; bleeding can resume through collateral channels.

Theoretically, N-butyl cyanoacrylate (NBCA) might be a good solution to overcome the clinical and technical predictors of rebleeding. Because NBCA is a liquid embolic agent, it can not only reach the distal branches of the small target artery but also embolize the collateral channels that cannot be embolized using coils. NBCA can polymerize and occlude a vessel immediately after contact with ions in the blood or tissue despite the presence of any underlying coagulopathy. Recently, two large studies and a meta-analysis were published, which introduced that TAE for UGIB with NBCA was safe and effective.1214 In UGIB, duodenal bleeding had a worse outcome than gastric bleeding probably due to rich collateral channels, and superselective embolization using a smaller microcatheter could improve the outcome of TAE for duodenal bleeding because NBCA can be delivered through a smaller microcatheter.12

Because it is a fundamentally endovascular procedure, access site hematoma, vessel injury related to catheter manipulation, contrast-related problems, and nephrotoxicity can occur in TAE for UGIB.4,11 Although TAE for UGIB is generally considered safe due to a rich collateral blood supply to the stomach and duodenum, significant ischemia can occur when collateral channels were damaged from previous surgery or radiotherapy within the same area or when very small particles or liquid agents such as NBCA extensively penetrate too deeply into the vascular bed, overflowing the collateral vessels and leading to extensive or nontarget embolization.10,15 Moreover, Lang reported 25% incidence rate of duodenal stricture when NBCA was infused at the muscular branch level of duodenum probably because of the ischemic injury of the muscle layer.16


In patients with LGIB who are hemodynamically stable, colonoscopy is recommended as the first-line approach because it can be used for diagnosis and treatment.17 However, it is often limited by inadequate bowel preparation or active bleeding that can interfere with detecting the bleeding focus. The frequency of small bowel bleeding cannot be understated, which is approximately 5% to 10% of all patients presenting with GIB.18 Bookstein et al2 first described TAE for LGIB in 1974. Although high rates of bleeding control were achieved, it carried an unacceptably high rate of bowel infarction and postembolization ischemia because of a weaker anastomotic blood supply to the lower gastrointestinal tract compared to the upper gastrointestinal tract.19,20 In 1990s, technical advances in microcatheter and embolic agents facilitated superselective embolization for LGIB. Kuo et al21 introduced superselective microcoil embolization for LGIB in 2003, reporting a complete clinical success rate of 86% but a minor ischemic complication rate of 4.5%.

NBCA also has advantages as a primary embolic agent for the selective embolization of LGIB as well as UGIB (Fig. 1).22 It can be delivered through a smaller microcatheter for selective embolization and more distally than the point of a microcatheter tip. This enables the occlusion of a bleeding focus distal to the small arteries through which a microcatheter cannot pass. Referring to an animal study, ischemic bowel injury was relatively tolerable in superselective NBCA embolization involving three or fewer vasa recta.23 In a systematic review and meta-analysis, superselective NBCA embolization of LGIB showed a technical success rate of 97.8%, a clinical success rate of 86.1%, and a major complication rate of 6.1%.14

Conflicts of Interest

No potential conflict of interest relevant to this article was reported.

Fig. 1. A 67-year-old man who underwent pylorus-preserving pancreaticoduodenectomy 6 years prior presented with massive hematemesis. (A) Computed tomography image shows contrast media extravasation in the efferent jejunal loop around the gastrojejunostomy (arrow). (B) Endoscopy failed to control active arterial bleeding at the jejunal ulcer. (C) Angiography shows pseudoaneurysm (arrow) around the endoscopic clips (arrowhead). (D) Superselective N-butyl cyanoacrylate embolization is performed through the tortuous jejunal branch and glue cast (arrow) is demonstrated on a fluoroscopic image.
  1. Rösch, J, Dotter, CT, and Brown, MJ (1972). Selective arterial embolization. A new method for control of acute gastrointestinal bleeding. Radiology. 102, 303-6.
    Pubmed CrossRef
  2. Bookstein, JJ, Chlosta, EM, Foley, D, and Walter, JF (1974). Transcatheter hemostasis of gastrointestinal bleeding using modified autogenous clot. Radiology. 113, 277-85.
    Pubmed CrossRef
  3. Frisoli, JK, Sze, DY, and Kee, S (2004). Transcatheter embolization for the treatment of upper gastrointestinal bleeding. Tech Vasc Interv Radiol. 7, 136-42.
    Pubmed CrossRef
  4. Loffroy, R, Rao, P, Ota, S, De Lin, M, Kwak, BK, and Geschwind, JF (2010). Embolization of acute nonvariceal upper gastrointestinal hemorrhage resistant to endoscopic treatment: results and predictors of recurrent bleeding. Cardiovasc Intervent Radiol. 33, 1088-100.
    Pubmed CrossRef
  5. Spiliopoulos, S, Inchingolo, R, Lucatelli, P, Iezzi, R, Diamantopoulos, A, and Posa, A (2018). Transcatheter arterial embolization for bleeding peptic ulcers: a multicenter study. Cardiovasc Intervent Radiol. 41, 1333-9.
    Pubmed CrossRef
  6. Beggs, AD, Dilworth, MP, Powell, SL, Atherton, H, and Griffiths, EA (2014). A systematic review of transarterial embolization versus emergency surgery in treatment of major non-variceal upper gastrointestinal bleeding. Clin Exp Gastroenterol. 7, 93-104.
    Pubmed KoreaMed CrossRef
  7. Schenker, MP, Duszak, R, Soulen, MC, Smith, KP, Baum, RA, and Cope, C (2001). Upper gastrointestinal hemorrhage and transcatheter embolotherapy: clinical and technical factors impacting success and survival. J Vasc Interv Radiol. 12, 1263-71.
    Pubmed CrossRef
  8. Loffroy, R, Guiu, B, D’Athis, P, Mezzetta, L, Gagnaire, A, and Jouve, JL (2009). Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol. 7, 515-23.
    Pubmed CrossRef
  9. Defreyne, L, Vanlangenhove, P, De Vos, M, Pattyn, P, Van Maele, G, and Decruyenaere, J (2001). Embolization as a first approach with endoscopically unmanageable acute nonvariceal gastrointestinal hemorrhage. Radiology. 218, 739-48.
    Pubmed CrossRef
  10. Walsh, RM, Anain, P, Geisinger, M, Vogt, D, Mayes, J, and Grundfest-Broniatowski, S (1999). Role of angiography and embolization for massive gastroduodenal hemorrhage. J Gastrointest Surg. 3, 61-5.
    Pubmed CrossRef
  11. Shin, JH (2012). Recent update of embolization of upper gastrointestinal tract bleeding. Korean J Radiol. 13, S31-9.
    Pubmed KoreaMed CrossRef
  12. Hur, S, Jae, HJ, Lee, H, Lee, M, Kim, HC, and Chung, JW (2017). Superselective embolization for arterial upper gastrointestinal bleeding using N-butyl cyanoacrylate: a single-center experience in 152 patients. J Vasc Interv Radiol. 28, 1673-80.
    Pubmed CrossRef
  13. Koo, HJ, Shin, JH, Kim, HJ, Kim, J, Yoon, HK, and Ko, GY (2015). Clinical outcome of transcatheter arterial embolization with N-butyl-2-cyanoacrylate for control of acute gastrointestinal tract bleeding. AJR Am J Roentgenol. 204, 662-8.
    Pubmed CrossRef
  14. Kim, PH, Tsauo, J, Shin, JH, and Yun, SC (2017). Transcatheter arterial embolization of gastrointestinal bleeding with N-butyl cyanoacrylate: a systematic review and meta-analysis of safety and efficacy. J Vasc Interv Radiol. 28, 522-31.e5.
    Pubmed CrossRef
  15. Loffroy, R, Guiu, B, Cercueil, JP, and Krausé, D (2009). Endovascular therapeutic embolisation: an overview of occluding agents and their effects on embolised tissues. Curr Vasc Pharmacol. 7, 250-63.
    Pubmed CrossRef
  16. Lang, EK (1992). Transcatheter embolization in management of hemorrhage from duodenal ulcer: long-term results and complications. Radiology. 182, 703-7.
    Pubmed CrossRef
  17. Strate, LL, and Gralnek, IM (2016). ACG clinical guideline: management of patients with acute lower gastrointestinal bleeding. Am J Gastroenterol. 111, 459-74.
    Pubmed KoreaMed CrossRef
  18. Strate, LL (2005). Lower GI bleeding: epidemiology and diagnosis. Gastroenterol Clin North Am. 34, 643-64.
    Pubmed CrossRef
  19. Rosenkrantz, H, Bookstein, JJ, Rosen, RJ, Goff, WB, and Healy, JF (1982). Postembolic colonic infarction. Radiology. 142, 47-51.
    Pubmed CrossRef
  20. Zuckerman, DA, Bocchini, TP, and Birnbaum, EH (1993). Massive hemorrhage in the lower gastrointestinal tract in adults: diagnostic imaging and intervention. AJR Am J Roentgenol. 161, 703-11.
    Pubmed CrossRef
  21. Kuo, WT, Lee, DE, Saad, WE, Patel, N, Sahler, LG, and Waldman, DL (2003). Superselective microcoil embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol. 14, 1503-9.
    Pubmed CrossRef
  22. Hur, S, Jae, HJ, Lee, M, Kim, HC, and Chung, JW (2014). Safety and efficacy of transcatheter arterial embolization for lower gastrointestinal bleeding: a single-center experience with 112 patients. J Vasc Interv Radiol. 25, 10-9.
  23. Jae, HJ, Chung, JW, Kim, HC, So, YH, Lim, HG, and Lee, W (2008). Experimental study on acute ischemic small bowel changes induced by superselective embolization of superior mesenteric artery branches with N-butyl cyanoacrylate. J Vasc Interv Radiol. 19, 755-63.
    Pubmed CrossRef

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