SIR 2024
Embolization
Kavish Gupta, MD
Resident Physician
Cedars-Sinai Medical Center
Financial relationships: Full list of relationships is listed on the CME information page.
Richard Van Allan, MD
Interventional Radiologist, Associate Professor Imaging
Cedars-Sinai Medical Center
Disclosure information not submitted.
Jonathan Steinberger, MD
Vascular and Interventional Radiologist
Cedars-Sinai Medical Center Imaging Group
Financial relationships: Full list of relationships is listed on the CME information page.
Kevin F. Seals, MD
Interventional Radiologist
Cedars-Sinai Medical Center
Disclosure information not submitted.
Marc L. Friedman, MD
Chief of Interventional and Vascular Radiology
Cedars-Sinai Medical Center
Disclosure information not submitted.
Gabriel Lipshutz, MD
Disclosure information not submitted.
To evaluate the safety, efficacy and clinical utility of provocative mesenteric angiography (PMA), including the use of catheter directed tissue plasminogen activator (tPA), in the diagnosis and management of patients presenting with occult lower gastrointestinal bleeding (LGIB).
Materials and Methods:
Retrospective analysis of mesenteric angiography with tPA provocation for patients with suspected LGIB who had undergone prior studies without identification of an exact bleeding source was performed. Cases were performed at a large tertiary care medical center over a 6 year period (2015 – 2021). The primary outcome was a composite of successful provocation and identification of hemorrhage followed by successful treatment. Secondary outcomes included procedure related complications and mortality.
Results:
A total of 42 provocative angiograms among 38 patients, met inclusion criteria. Among all patients an average of 6.6 diagnostic studies were performed prior to PMA. Negative PMA cases were associated with a greater number of previous gastrointestinal studies (5.8 vs. 3.9, p = 0.04). Following initial negative conventional mesenteric angiography, contrast extravasation was successfully induced and identified in 15 out of 42 (36%) cases. Of positive cases, 12/15 (80%) successfully underwent embolization, thereby meeting criteria for technical success. 1/15 (7%) underwent endoscopic banding and in the remaining 2/15 cases (13%) bleeding self-resolved with supportive management. Of the 12 cases in which embolization was performed 10 of 12 (83%) met criteria for clinical success, with the remainder (2/12, 17%) requiring subsequent surgical resection. Neither periprocedural complications, including bleeding-related, nor procedure-attributable mortality occurred. There was no statistically significant difference between positive and negative cases with respect to length of hospital stay. In successful cases of provocation of hemorrhage, an average of 16.8 mg of tPA, 3700 units of heparin IV, and 270 mcg of nitroglycerin were used.
Conclusion:
Provocative mesenteric angiography with tPA is safe and effective in both diagnosing and facilitating the definitive treatment of occult LGIB. Further investigation is required to refine provocative angiographic techniques and the clinical management of patient with occult LGIB.