What is the approach to duodenal embolization for hemostasis in cases of severe duodenal bleeding where the bleeding site cannot be detected?

Prophylactic Duodenal Embolization Without Detected Bleeding Site

Prophylactic embolization of the gastroduodenal artery territory should be considered when severe duodenal bleeding is documented by endoscopy or CTA but no active extravasation is visible on angiography, as empiric embolization achieves comparable clinical success rates (72-83%) to targeted embolization with acceptable safety profiles. 1, 2

Evidence-Based Approach to Empiric Embolization

When to Proceed with Empiric Embolization

Proceed with prophylactic embolization when:

• Endoscopy has documented severe duodenal ulcer bleeding but failed to achieve hemostasis 1
• CTA demonstrates contrast extravasation in the duodenal region 1
• Angiography shows no active bleeding but clinical suspicion remains high based on endoscopic findings 1
• Patient has high-risk features: hemodynamic instability, ulcer >2cm, or ongoing transfusion requirements 1

Technical Execution

The embolization technique must address the rich collateral blood supply:

• Perform selective catheterization of both celiac axis and superior mesenteric artery with high-volume contrast (20 mL at 5 mL/sec) and prolonged imaging (30-40 seconds) 1
• Embolize a long stretch of the gastroduodenal artery (GDA) including both anterior and posterior superior pancreaticoduodenal arteries (ASPD and PSPD) 3
• Use superselective distal-to-proximal embolization to prevent "back door" rebleeding through collaterals 1
• Microcoils are the preferred embolic agent, though glue may reduce rebleeding rates 1

Critical pitfall: Embolizing only one side of the bleeding point leads to treatment failure—both arterial approaches to the duodenum must be addressed due to extensive collateralization 1, 3

Expected Outcomes

Clinical success rates for empiric embolization:

• Technical success: 92-100% 2, 4
• Clinical success (no rebleeding within 30 days): 72-83% 2, 4
• Rebleeding rate: 17-28% 2, 4
• 30-day mortality: 17-20% (comparable to surgery) 4, 5

Importantly, empiric TAE shows no significant difference in outcomes compared to embolization with identified bleeding sites 2

Safety Considerations

Complication rates are acceptably low:

• Bowel ischemia risk: 1-10%, though most cases are asymptomatic and managed conservatively 1
• Duodenal stenosis: no significant increase with empiric approach 2
• Access site complications: standard for arterial procedures 1
• Overall post-procedural complications significantly lower than surgery 1

The risk of bowel ischemia is minimized by:

• Using microcoils rather than particles (0% vs 5.3% severe ischemia) 1
• Avoiding glue when possible in duodenal territory 1
• Performing superselective rather than proximal embolization 1

Alternative Considerations

When empiric embolization may not be appropriate:

• Hemodynamically unstable patients despite resuscitation should proceed directly to surgery 1
• Patients with ulcers >2cm and hypotension at first endoscopy may benefit from surgery without repeated endoscopy 1
• Free perforation or other surgical indications are present 1

The 2024 ACG/SAR consensus specifically states that in the absence of visualized extravasation but documented bleeding at endoscopy or CTA, prophylactic embolization of the suspected vessel should be considered 1

Guidance from Endoscopic Findings

Use endoscopic information to guide empiric embolization:

• Endoscopic clip placement at the ulcer site helps direct angiographic targeting 1
• Location of ulcer on endoscopy determines which pancreaticoduodenal branches to prioritize 1
• High-risk stigmata (visible vessel, adherent clot) support proceeding with empiric approach 1

Limitations of Current Evidence

The 2020 WSES guidelines note that while several retrospective studies support empiric embolization with outcomes similar to targeted embolization, no recommendation can be made for routine prophylactic embolization due to insufficient high-level data 1. However, the more recent 2024 ACG/SAR consensus provides stronger support for this approach when bleeding is documented by other modalities 1.

In high-risk elderly patients (APACHE II ≥16.5), empiric TAE appears safer than surgery with lower mortality trends (23.1% vs 50.0%) 5