Int J Gastrointest Interv 2022; 11(4): 179-185
Published online October 31, 2022 https://doi.org/10.18528/ijgii220047
Copyright © International Journal of Gastrointestinal Intervention.
Yozo Sato1,* , Kiyoshi Matsueda1 , Marie Osawa2 , Yoshitaka Inaba3 , Yu Takahashi4 , Yosuke Inoue4 , Atsushi Oba4 , Yosuke Fukunaga5 , and Yasuhiro Shimizu6
1Department of Diagnostic Ultrasound & Interventional Radiology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
2Department of Radiology, NTT Medical Center Tokyo, Tokyo, Japan
3Department of Diagnostic and Interventional Radiology, Aichi Cancer Center, Nagoya, Japan
4Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
5Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
6Department of Gastroenterological Surgery, Aichi Cancer Center, Nagoya, Japan
Correspondence to:*Department of Diagnostic Ultrasound & Interventional Radiology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan.
E-mail address: firstname.lastname@example.org (Y. Sato).
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/bync/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Postoperative arterial bleeding after gastrointestinal surgery is a potentially fatal complication. Transcatheter arterial embolization is considered the first-line treatment because of efficacy and less invasiveness despite the risk of organ infarction. With the recent advances in endovascular devices, stent-graft placement, which can preserve arterial flow, has been an alternative treatment option in patients with extrahepatic artery hemorrhage. Moreover, clinical outcomes of stent-graft placement for pseudoaneurysms in relative long term have been reported recently. Herein, we review the techniques and clinical outcomes for interventional management for postoperative arterial bleeding.
Keywords: Embolization, therapeutic, Hemorrhage, Radiology, interventional, Surgical procedures, operative
Postoperative arterial bleeding after gastrointestinal surgery is a potentially fatal complication. The reported incidence of arterial bleeding after gastrointestinal surgery, which depends on the surgical site, varies from 0.9% to 15%.1–4
Traditionally, surgical repair is performed as a standard treatment option. However, the bleeding site is difficult to establish because of local inflammatory response after surgery.5 In addition, patients with postoperative gastrointestinal bleeding are reported to be poor candidates for emergency surgery because of cicatrization and the friability of postoperative tissues.5,6 Therefore, transcatheter arterial embolization (TAE) has been considered a less invasive alternative treatment option despite the risk of organ infarction.7 Furthermore, with the recent advances in endovascular devices, stent-graft placement, which can preserve arterial flow, is recommended as a first-line treatment option in patients with suitable anatomy.8 However, according to recent reports of stent-graft placement for pseudoaneurysm of hepatic arteries, stent-graft patency rates decreased over time.9 This review discusses the techniques and clinical outcomes of interventional management for postoperative arterial bleeding in gastrointestinal surgery.
Enhanced computed tomography (CT) using multi-detector row CT is a standard imaging modality for postoperative arterial bleeding.10 Enhanced CT has greater availability, speed, and noninvasiveness. Pre-contrast scan is obtained to evaluate hemorrhage. Hemorrhage with high-attenuation mass may be masked after contrast administration; therefore, pre-contrast scan is essential.2 Contrast scans of early and late phases using intravenous bolus injection of contrast medium are performed to evaluate arterial abnormalities including extravasation, pseudoaneurysm, and irregularity. Moreover, contrast scans can provide information on portal flow and vascular anatomy for pre-interventional planning.11 In an animal model, CT angiography was shown to detect bleeding rates as low as 0.3 mL/min more successfully than conventional angiography.12
The typical angiographic findings of arterial bleeding are visualization of the extravasation of contrast medium and pseudoaneurysm. Chatani et al4 reported extravasation and pseudoaneurysm in 12 of 28 (42.9%) and 12 of 28 (42.9%) procedures for bleeding after abdominal surgery, respectively. Other indirect signs of bleeding on angiography include irregular arterial wall, vessel spasm, and cut-off.10 With reference to clinical information and enhanced CT findings, areas with other indirect signs should be selected even in the absence of typical findings (Fig. 1). Moreover, contact with the surgical clip and surgical drain tube may cause arterial bleeding (Fig. 2).
Despite the possibility of organ infarction, TAE has been widely performed for arterial bleeding after gastrointestinal surgery.4,5,7 In most cases, TAE is performed using a 4-Fr or 5-Fr angiographic catheter with a coaxial 1.7- to 2.4-Fr micro-catheter. When the micro-catheter could not be advanced to the bleeding portion because of tortuous vessel, a triple coaxial system may be useful.13 In the case of embolization of the hepatic artery, portal vein (PV) patency should be confirmed through superior mesenteric angiography.8
Embolization techniques are classified into isolation, packing, and selective techniques.4 Isolation is defined as the embolization of both distal and proximal arteries, packing as the occlusion of the pseudoaneurysm, and selective embolization as the occlusion of the end artery. Basically, the isolation technique should be performed.4,7 The micro-catheter is advanced to the distal part of the bleeding portion, and metallic coils were deployed from the distal to the proximal part of the bleeding portion, which is also known as the sandwich or trapping technique.7,14 When navigation to the distal portion was difficult because of a tortuous vessel or spasm, a 20% to 50% mixture of
With the recent advancements in endovascular devices, embolic agents such as pushable and detachable metallic coils, NBCA, gelatin sponge, particulate embolic materials, and vascular plug are available.4,18 The choice of embolic agents depends on the combination of the vascular anatomy, angiographic findings, achievable catheter position, and operator’s preference.18 Detachable coil and vascular plug can reduce the risk of distal migration.19 NBCA is a liquid embolic material with a non-radiopaque nature; thus, it should be mixed with lipiodol to provide radiopacity and control viscosity.15 Moreover, adjusting the NBCA–lipiodol mixing ratio is necessary depending on the situation. Usually, the NBCA–lipiodol ratio ranges from 1:1 to 1:4.20,21 Operators should decrease the amount of lipiodol when attempting to embolize short segments and should increase for long segments. It is advantageous for massive bleeding that requires urgent hemostasis, especially in patients with coagulopathy caused by rapid polymerization with blood.10,15
Stent-graft placement for pseudoaneurysms can preserve the arterial flow and thereby decrease the risk of organ ischemia, such as hepatic failure.9 Previously, no stent-grafts for visceral arteries were commercially available; hence, covered biliary metallic stent as an alternative device was off-label used owing to the risk of organ ischemia.22 Recently, polytetrafluoroethylene covered stent-graft (GORE® VIABAHN®; Gore & Associates Inc., Flagstaff, AZ, USA) was commercially available for bleeding visceral arteries in Japan. Stent-graft placement is indicated for pseudoaneurysms common to the lobar hepatic artery, superior mesenteric artery, and splenic artery.9,23 In the procedure using VIABAHN®, a 6 to 7-Fr guiding sheath is inserted to the target artery as distal as possible, and the stent delivery system is advanced distal to the pseudoaneurysm along with a stiff 0.018-inch guidewire. Then, a stent-graft is deployed across the neck of the pseudoaneurysm, and balloon dilation is performed from the distal to the proximal portion of the stent-graft to prevent endoleak (Fig. 6).9 Stent-graft placement is not feasible because of potential technical difficulties, such as a tortuous vessel, celiac artery stenosis, or small-caliber target artery.8
Technical success is defined as the elimination of active bleeding and pseudoaneurysm as detected by angiography after the initial intervention. Clinical success is generally defined as the absence of active rebleeding and no further management is necessary, such as repeated angiography or surgery, during the same admission.8 According to previous reports, the technical and clinical success rates of interventional management including TAE and stent-graft placement ranged from 78% to 100% and 60% to 100%, respectively.4,7,8,24-30 Moreover, the technical and clinical success rates of stent-graft placement ranged from 83% to 100% and from 71% to 100%, respectively.8,9,23,29
Despite the relatively high success rates, the packing technique is frequently associated with rebleeding with respect to the embolization techniques.7,25 Hur et al7 investigated two techniques of TAE of pseudoaneurysms after pancreaticoduodenectomy (PD). No rebleeding occurred after TAE using isolation techniques (
However, TAE using the isolation technique can cause post-embolization ischemia. Specifically, hepatic infarction caused by TAE for extrahepatic artery hemorrhage after PD may lead to fatal outcomes. The incidence of hepatic infarction of these TAE procedures ranged from 8.3% to 45.5%.7,8,31 These incidences were possibly different because of hepatic artery variations. In patients with hepatic artery variations, intrahepatic collateral vessels via replaced hepatic arteries were exclusively evident on angiograms obtained immediately after TAE. Therefore, TAE of hepatic artery using the isolation technique was found to be safe in patients with replaced hepatic arteries.27
Generally, the dual blood supply from the hepatic artery and PV and the extensive collateral pathways including the inferior phrenic arteries, intercostal arteries, and gastric arteries provide protection against hepatic infarction.8 In the case of poor hepatic collaterals in TAE after PD, PV flow was important for determining hepatic infarction because PV stenosis is a common complication of PD.32 In a recent study, transhepatic PV stent placement was performed immediately after hepatic artery embolization in patients with PV obstruction after PD, and it led to successful PV flow restoration and crucial rescue.27
Stent-graft placement can overcome hepatic infarction after TAE. In a recent study of stent-graft placement for pseudoaneurysms of the hepatic artery, the technical success rate was 92% in pseudoaneurysm exclusion, with the maintenance of the hepatic arterial flow in 88% of the cases.9 High stent patency rates (81%) were observed at short-term (< 6 weeks) follow-up, but with decreased to 40% at mid- (> 6 weeks to 1 year) to long- (> 1 year) term follow-up. However, stent occlusion was mainly asymptomatic because of the development of collateral vessels that provided sufficient hepatic blood supply in most patients (86%) (Fig. 7). To prevent stent occlusion, anticoagulation and antiplatelet regimens after stent-graft placement are generally administered.33,34 According to the guidelines of the European Societies of Cardiology and for Vascular Surgery, no recommendations were provided regarding single- or dual-antiplatelet therapy after endovascular treatments in visceral arteries.35 Most centers empirically prescribe a combination of daily clopidogrel (75 mg) and aspirin (low dose) from 1 month to 1 year.35 However, considering the rebleeding risk, these antithrombotic treatments may be contraindicated in the perioperative period. Other major complications of stent-graft placement, such as arterial dissection and stent-graft infection, were reported.8,23
With the recent advancements in endovascular devices, interventional management including TAE and stent-graft placement has been considered a first-line treatment for arterial bleeding after gastrointestinal surgery. Stent-graft placement, which can preserve the hepatic arterial flow, is better than TAE in patients with extrahepatic artery hemorrhage. However, in patients with anatomical changes such as a tortuous vessel, celiac artery stenosis, or small-caliber target artery, stent-graft placement is technically difficult; therefore, TAE should be initially performed. Moreover, TAE can be performed in patients with replaced hepatic arteries because of the low risk of hepatic infarction.
We thank the members of Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital.
No potential conflict of interest relevant to this article was reported.
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