Superselective embolization of active jejunal bleeding

Clinical History

Patient presented with gastrointestinal bleeding two days after small bowel resection due to ileal obstruction.

Imaging Findings

Patient presented with gastrointestinal bleeding two days after small bowel resection due to ileal obstruction. The obstruction was due to strangulation caused by adhesions from previous abdominal surgery. Angiography was requested on an emergency basis since the patient was actively bleeding and hypotensive. Angiography was performed using a femoral approach and a 4Fr. Simmons 1 catheter. Superior mesenteric arteriography revealed active extravasation of contrast medium at the level of a jejunal loop (Fig. 1a), most likely consistent with acute bleeding from a small bowel ulcer (in the differential diagnosis one should consider a vascular malformation, or less likely a small tumour). Superselective catheterisation of the bleeding vessel was achieved with the 4Fr. Catheter and with a coaxial 2.3Fr. microcatheter (with an 1.9Fr. distal end) (Fig. 1b). The use of a microcatheter allowed for catheterisation of the terminal artery, beyond the jejunal arcades , exactly at the site of haemorrhage (Fig. 1c). A microcoil was delivered within the vessels (small piece of a 0.014 inches platinum coil) followed by injection of a 1 ml of gelfoam slurry injected by using a 1 cc syringe (Fig. 1d). The bleeding ceased immediately as showed by post-embolization runs (Fig. 1e). The patient had no other episodes of haemorrhage, and recovered from her surgery . At a follow-up of 8 months the patient is in good health, without clinical evidence intestinal malfunction.

Discussion

Diagnosis and catheter therapy of lower gastrointestinal bleeding is an important part of the interventional angiographers' work. Our patient was bleeding profusely. In this situation the embolization may be a life-saving procedure replacing emergency surgery, which has high morbidity and mortality, particularly in elderly and debilitated patients, such as patients who have had recent surgery. This procedure, however, has to be approached whit great caution in the small bowel. Ileal and jejunal loops have less collateral vasculature than the stomach or duodenum, therefore, embolization of the small bowel carries a higher risk of ischemic injury. To avoid this risk, we decided to use a coaxial catheter that allows for superselective injection of the bleeding artery or of its small feeders. During catheterisation, care has to be taken to minimize major spasm and avoid intimal dissection of vessels not supplying the hemorrhagic site. Embolization should spare the distal communicating arcades in the small intestine, so that development of collateral circulation is not impaired; possibly, only the distal intestinal braches (vasa recta) should be occluded. Occlusion of the proximal communicating arcades can be done, but is not very effective, since bleeding can continue due to collateral flow. The number of occluded vessels has to be kept to a minimum and optimally only the bleeding artery should be occluded. Choice of the proper occlusive material is critical for safety of embolization. In our patients we used a 0.014 inch microcoil. Microcoils can be easily and safely introduced through small coaxial catheters and stay at the point of placement in a small artery. When introduced in the vasa recta, they result in a localized occlusion and favour development of peripheral collateral circulation through the intramural vascular network. Since platinum microcoil have been shown to recanalize with time, we injected 1 ml of gelfoam slurry to increase the short- to mid-term efficacy of the embolization.

Differential Diagnosis List

Final Diagnosis

Gastrointestinal bleeding

URL:	https://eurorad.org/case/695
DOI:	10.1594/EURORAD/CASE.695
ISSN:	1563-4086