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Angiographic Embolization for Gastroduodenal Hemorrhage: Safety, Efficacy, and Predictors of Outcome
George A Poultsides1, Christine Kim1, Rocco Orlando, III1, Michael J Hallisey2, Paul V Vignati1
1Department of Surgery, Hartford Hospital, University of Connecticut School of Medicine, Hartford, CT;2Department of Radiology, Hartford Hospital, University of Connecticut School of Medicine, Hartford, CT
Objective: To examine the safety, efficacy, and predictors of outcome of angiographic embolization in the management of gastroduodenal hemorrhage.
Design: Retrospective chart review.
Setting: University-affiliated tertiary care center.
Patients: All patients were referred after endoscopic treatment failure. Surgery was not immediately considered because of poor surgical risk, refusal to consent, or endoscopist’s decision. Patients with coagulopathy, hemobilia, variceal or traumatic bleeding were excluded from the study.
Interventions: Between 1996 and 2006, seventy embolization procedures were performed in 57 patients.
Main Outcome Measures: Technical success rate (target vessel devascularization), clinical success rate (“in-hospital” cessation of bleeding without further endoscopic, radiologic or surgical intervention) and complications.
Results: Technical success rate was 94%. Clinical success rate was 53% and 57% after repeat embolization. Two factors were found to be independent predictors of poor outcome by multivariate analysis: recent duodenal ulcer surgery (p=0.038) and > 6-unit blood transfusion prior to procedure (p=0.043). There was no predictive value for angiographic failure based on age, gender, steroid use, prior coagulopathy, renal failure at presentation, multiple organ system failure, empiric (blind) embolization, and use of permanent vs. temporary embolic agents. Major ischemic complications requiring operation occurred in 6% of cases. | Diagnosis | Patients | Embolizations | Primary Clinical Success | Secondary Clinical Success (following repeat embolization) | | Duodenal ulcer | 14 | 17 | 57% | 57% | | Post-sphincterotomy bleeding | 10 | 13 | 50% | 70% | | Gastric ulcer | 7 | 7 | 43% | - | | Duodenal bleeding indeterminate by endoscopy | 7 | 10 | 57% | 71% | | Gastric cancer | 5 | 7 | 60% | 60% | | Duodenal ulcer post-plication | 5 | 7 | 20% | 20% | | Mallory-Weiss tear | 4 | 4 | 50% | - | | Dielafoy’s lesion | 3 | 3 | 33% | - | | Periampullary neoplasm | 2 | 2 | 50% | - | | Total | 57 | 70 | 53% | 57% |
Conclusions: Angiographic embolization for gastroduodenal hemorrhage was associated with “in-hospital” rebleeding in almost half of the patients. When entertained, it should be performed expeditiously, early in the course of bleeding. Repeat embolizations were not helpful except for post-sphincterotomy bleeding. Embolization to control reccurent hemorrhage after oversewing duodenal ulcers was rarely successful (20%).
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