Procedure Guides
Arterial

GI Bleed

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Procedure Guide

Indications

  • Arterial gastrointestinal (GI) bleeding with failure of conservative management and/or endoscopic therapy.

    • Helpful if gastroenterology can leave clip as target if unsuccessful

  • Unstable patient with massive hematochezia (received >5U pRBCs) per ACR appropriateness criteria and gastroenterology guidelines.

Contraindications

No absolute contraindication. However, 85% GI bleeds resolve spontaneously [56-88% (UGIB), 84-92% (LGIB, only 15% for diverticulosis)] and most coagulopathic bleeds resolve spontaneously with correction of the coagulopathy.

For example, in this small study, spontaneous coagulopathic retroperitoneal bleeds had better clinical outcomes with conservative management rather than embolization, even in those who were hemodynamically unstable.

Efficacy and alternatives

CTA is often helpful to localize, plan, and assess for other etiologies of GI bleeding (e.g. variceal bleeding) if not a massive lower GI bleed or already identified endoscopically.

  • Consider TIPS for esophageal variceal bleeding with failure of endoscopic management (see separate lesion).

  • Consider transvenous obliteration for isolated gastric and other variceal bleeding with failure of endoscopic management (see separate lesion). Alternatively, partial splenic embolization can also help gastric variceal bleeding if transvenous obliteration is not feasible.

Diagnostic imaging sensitivity (common misconception among referrers):

  • Tagged RBC scan - most sensitive (detects bleeding at >0.1 mL/s) and able to detect intermittent bleeding but poor anatomic information and localization

  • CTA - best anatomic information and localization and moderate sensitivity (detects bleeding at >0.1-0.5 mL/s)

  • Catheter-based angiography - moderate localization and worst sensitivity (detects bleeding at >0.5-1.0 mL/s)

Most GI bleeds resolve with conservative management [56-88% (UGIB), 84-92% (LGIB, only 15% for diverticulosis)] and most coagulopathic bleeds resolve spontaneously with correction of the coagulopathy.

Prophylactic UGI embolization is as effective as embolization with extravasation for duodenal bleeding but not gastric

Angiodysplasia embolization rarely prevents re-bleeding. Often needs surgery.

Pre-procedure care

Stabilize and optimize patient, often with assistance of ICU team, e.g., pressors, balanced transfusion, IV albumin for hypoalbuminemic cirrhotics, hold and reserve anticoagulation, and correct coagulopathies.

Labs: CBC, PT/INR, heparin activity level and anti-Xa if reversing anticoagulation, CMP, Type & screen

CTA to characterize and locate bleed (“catheter angio is a bad fishing expedition”)

  • *Exception* ACR appropriateness criteria recommends catheter angiography over CTA for unstable patient with massive hematochezia (received >5U pRBCs)

GI +/- surgery multidisciplinary discussion up front can improve outcomes 

Anesthesia support as needed, particularly for unstable patients

procedure

  • Arterial access, often CFA with 5 Fr sheath but can do radial or others as needed.

  • Select catheter for selecting target vessel. Examples below.

    • Celiac/SMA - C2, Sim, Sos

    • Left gastric - Mickaelson, Sim 1

    • IMA - Mickaelson

    • Internal iliac - RUC

    • Thoracic branches - Vert

  • DSA +/- Cone-beam CT to localize bleed and interrogate vessels. Some recommend interrogating IMA first if being done to interrogate rectum before bladder fills with contrast.

  • If bleed identified (or prophylactic embo), advance catheter to target. Often requires microwire/microcatheter with examples below.

    • Large 2.8 Fr (ProGreat, Renegade Hiflow, Direxion Hiflow) - better angio but less selective and trackable

    • Small 2.3 Fr (Prowler plus, Direxion, Merit Maestro) - nice in between

    • Tiny 1.7-1.9 Fr (Excelsior SL10, Proler LP-ES, Echelon) - poor angio but more selective

  • DSA to confirm positioning followed by embolization.

    • Embolize cautiously if prior GI surgery as the target vessel may be the only source of perfusion to a section of bowel and require more selective embolization

    • Coils - common and effective but requires functional clotting cascade to form clot

    • GelFoam -  less permanent, can be good if suspicious but no bleed identified

    • Liquid (e.g., glue) - less controlled but good for coagulopathy, can save time and radiation; Onyx has no reported ischemic complications but less data

    • Particles - less common beyond bleeding tumors (e.g. HCC), BAE, UAE  due to increased ischemia

    • Gelfoam + Coils - effective but may increase risk of ischemia

    • Vasopressin - old school and less effective, 0.2U/min x 20 min -> repeat angio -> 0.4U/min x 20 min if still bleeding -> angio -> embo or surgery if still bleeding

    • Autologous blood clot - can be effective but higher re-bleeding rate

  • Post-embolization DSA of target vessel plus potential collateral flow channels, e.g., SMA after GDA embo due to inferior pancreaticoduodenal artery

    • Celiac - GDA - SMA: pancreaticoduodenal arteries and  Arc of Buhler (4, arising proximal to inferior pancreaticoduodenal, a/w aneurysm to the setting of celiac stenosis)

    • SMA - IMA: marginal artery of Drummond (along mesenteric border of colon) and Arc of Riolan (“meandering mesenteric artery”, viable but usually more central)

    • Winslow pathway: aorto-iliac occlusive dx; subclavian - internal thoracic - superior epigastric - inferior epigastric - external iliac

    • Corona mortis: obturator to external iliac coursing in front of superior pubic rim that can cause death in pelvic trauma or type 2 endoleak

    • Persistent sciatic artery: continuation of internal iliac, passes posterior to femur; pathway for external iliac occlusion; prone to injury, aneurysms, early atherosclerosis

  • Access closure

Provocative angiography

Good option for recurrent GI bleeds which are occult on angiography/CTA with some evidence of a likely area of bowel to target. Despite initial safety concerns, available data suggest it is safe and can identify and treat the occult bleed in ~31-49% of cases. Review of 27 articles with 230 patients had a single case of intestinal hemorrhage requiring transfusion. Another study of 36 cases had a single episode of ischemic bowel from embolization and another study of 36 cases had no complications.

  • Initial infusion to suspected supplying vasculature: heparin 5000 IU, nitroglycerin 100-200 mcg, and t-PA 4 mg

  • Repeat angio in 5-10 min

  • Can serial escalate t-PA doses, e.g., 8 -> 12 -> 20 -> 25 mg. Some go up to 20 mg and others up to 50 mg. First pass metabolism of the t-PA through the liver results in only a small fraction reaching the systemic vasculature likely accounting for the low complication rate reported in prior studies.

Complications

Varies widely based on specific anatomy and site of bleeding. Major adverse events for GI bleed embolization estimated at ~12%, primarily bowel ischemia, nontarget embolization, vascular injury (e.g. dissection), or access site complications.

Post-procedure care & Follow Up

Often return care to primary ICU team for continued close hemodynamic monitoring. Risk factors for poor outcomes include comorbidities such as HTN, PAD, ESRD, and severe atherosclerotic disease.