What is the role of Interventional Radiology (IR) embolization in managing Gastrointestinal (GI) bleeding?

From the Guidelines

IR embolization is a highly effective treatment for gastrointestinal bleeding, with technical success rates ranging from 73% to 100% and clinical success rates ranging from 63% to 96% 1.

Key Considerations

• The procedure involves identifying the bleeding vessel through angiography and selectively embolizing it using various agents such as coils, N-Butyl cyanoacrylate (NBCA), or ethylene-vinyl alcohol copolymer.
• For acute lower GI bleeds, branches of the superior or inferior mesenteric arteries are commonly targeted.
• The choice of embolic agent depends on the presence of coagulopathy, with NBCA being a good option in such cases due to its ability to polymerize rapidly and achieve hemostasis independently of the coagulation cascade 1.

Clinical Success and Complications

• Clinical success rates are generally lower than technical success rates due to the risk of rebleeding, which can occur in 11.1% to 50% of cases 1.
• Potential complications include bowel ischemia, non-target embolization, access site hematomas, and contrast-induced nephropathy.
• Patients should be monitored post-procedure for signs of rebleeding, abdominal pain, or fever.

Recommendations

• IR embolization should be considered for patients with gastrointestinal bleeding who are poor surgical candidates or have bleeding from difficult-to-access locations 1.
• The procedure is particularly valuable for patients with lower GI bleeding, where endoscopic management may not be feasible or has failed.
• In cases of recurrent bleeding, provocative transcatheter arteriography can be used to identify the location of the bleeding, allowing for targeted treatment 1.

From the Research

IR Embolization for GI Bleed

• IR embolization is a minimally invasive procedure used to control gastrointestinal (GI) bleeding when medical management and endoscopic therapy are inadequate 2, 3.
• The procedure involves the use of angiographic techniques to locate the source of bleeding and embolization to stop the bleeding 2.
• IR embolization is a lifesaving option in emergent situations, highlighting the importance of immediate competence of the interventional radiologist in preangiographic evaluation and endovascular treatment of GI bleeding 2.

Indications and Techniques

• IR embolization is indicated for non-variceal upper and lower GI bleeding that is not controllable by endoscopic means 3, 4.
• The technique involves the use of transcatheter arterial embolization (TAE) to stop the bleeding, and is considered a safe and effective minimally invasive alternative to surgery 4.
• The updated S2k guideline "gastrointestinal bleeding" recommends interventional radiology with its minimally invasive endovascular techniques for the treatment of non-variceal GI bleeding 3.

Results and Complications

• IR embolization has good technical and clinical success rates, with a low rate of complications 3.
• Adequate periinterventional management is essential to increase the success rate of endovascular therapy 3.
• Solid knowledge of vascular anatomy is also essential to acquire adequate hemostasis 3.

Guidelines and Recommendations

• The European Society of Gastrointestinal Endoscopy (ESGE) recommends that patients with hemodynamic instability and suspected ongoing bleeding undergo computed tomography angiography before endoscopic or radiologic treatment to locate the site of bleeding 5.
• The ESGE also recommends withholding vitamin K antagonists in patients with major lower GI bleeding and correcting their coagulopathy according to the severity of bleeding and their thrombotic risk 5.
• The use of IR embolization is supported by various guidelines and recommendations, including the S2k guideline "gastrointestinal bleeding" and the ESGE guideline on acute lower GI bleeding 3, 5.