Nonvariceal Upper Gastrointestinal Bleeding: the Usefulness of Rotational Angiography after Endoscopic Marking with a Metallic Clip

다국어 초록 (Multilingual Abstract)

Objective: We wanted to assess the usefulness of rotational angiography after endoscopic marking with a metallic clip in upper gastrointestinal bleeding patients with no extravasation of contrast medium on conventional angiography.
Materials and Methods: In 16 patients (mean age, 59.4 years) with acute bleeding ulcers (13 gastric ulcers, 2 duodenal ulcers, 1 malignant ulcer), a metallic clip was placed via gastroscopy and this had been preceded by routine endoscopic treatment. The metallic clip was placed in the fibrous edge of the ulcer adjacent to the bleeding point. All patients had negative results from their angiographic studies. To localize the bleeding focus, rotational angiography and high pressure angiography as close as possible to the clip were used.
Results: Of the 16 patients, seven (44%) had positive results after high pressure angiography as close as possible to the clip and they underwent transcatheter arterial embolization (TAE) with microcoils. Nine patients without extravasation of contrast medium underwent TAE with microcoils as close as possible to the clip. The bleeding was stopped initially in all patients after treatment of the feeding artery. Two patients experienced a repeat episode of bleeding two days later. Of the two patients, one had subtle oozing from the ulcer margin and that patient underwent endoscopic treatment. One patient with malignant ulcer died due to disseminated intravascular coagulation one month after embolization. Complete clinical success was achieved in 14 of 16 (88%) patients. Delayed bleeding or major/minor complications were not noted.
Conclusion: Rotational angiography after marking with a metallic clip helps to localize accurately the bleeding focus and thus to embolize the vessel correctly.

다국어 초록 (Multilingual Abstract)

Objective: We wanted to assess the usefulness of rotational angiography after endoscopic marking with a metallic clip in upper gastrointestinal bleeding patients with no extravasation of contrast medium on conventional angiography.
Materials and Methods: In 16 patients (mean age, 59.4 years) with acute bleeding ulcers (13 gastric ulcers, 2 duodenal ulcers, 1 malignant ulcer), a metallic clip was placed via gastroscopy and this had been preceded by routine endoscopic treatment. The metallic clip was placed in the fibrous edge of the ulcer adjacent to the bleeding point. All patients had negative results from their angiographic studies. To localize the bleeding focus, rotational angiography and high pressure angiography as close as possible to the clip were used.
Results: Of the 16 patients, seven (44%) had positive results after high pressure angiography as close as possible to the clip and they underwent transcatheter arterial embolization (TAE) with microcoils. Nine patients without extravasation of contrast medium underwent TAE with microcoils as close as possible to the clip. The bleeding was stopped initially in all patients after treatment of the feeding artery. Two patients experienced a repeat episode of bleeding two days later. Of the two patients, one had subtle oozing from the ulcer margin and that patient underwent endoscopic treatment. One patient with malignant ulcer died due to disseminated intravascular coagulation one month after embolization. Complete clinical success was achieved in 14 of 16 (88%) patients. Delayed bleeding or major/minor complications were not noted.
Conclusion: Rotational angiography after marking with a metallic clip helps to localize accurately the bleeding focus and thus to embolize the vessel correctly.

참고문헌 (Reference)

1 Kakeda S, "Usefulness of cone-beam volume CT with flat panel detectors in conjunction with catheter angiography for transcatheter arterial embolization" 18 : 1508-1516, 2007

2 Schenker MP, "Upper gastrointestinal hemorrhage and transcatheter embolotherapy: clinical and technical factors impacting success and survival" 12 : 1263-1271, 2001

3 Hwan Jun Jae, "Transcatheter Arterial Embolization of Nonvariceal Upper Gastrointestinal Bleeding with N-Butyl Cyanoacrylate" 대한영상의학회 8 (8): 48-56, 2007

4 Hagen G, "Three-dimensional rotational angiography of transplanted renal arteries: influence of an extended angle of rotation on beam-hardening artifacts" 46 : 170-176, 2005

5 Bucek RA, "Three-dimensional digital rotation angiography for embolization therapy of uterine leiomyomas: first results" 176 : 1001-1004, 2004

6 Tanigawa N, "Three-dimensional angiography using rotational digital subtraction angiography: usefulness in transarterial embolization of hepatic tumors" 45 : 602-607, 2004

7 Malden ES, "Recurrent gastrointestinal bleeding: use of thrombolysis with anticoagulation in diagnosis" 207 : 147-151, 1998

8 Drooz AT, "Quality improvement guidelines for percutaneous transcatheter embolization. SCVIR Standards of Practice Committee. Society of Cardiovascular & Interventional Radiology" 8 : 889-895, 1997

9 Kim CY, "Provocative mesenteric angiography for lower gastrointestinal hemorrhage: results from a single-institution study" 21 : 477-483, 2010

10 Bloomfeld RS, "Provocative angiography in patients with gastrointestinal hemorrhage of obscure origin" 95 : 2807-2812, 2000

11 Saltzman JR, "Prospective trial of endoscopic clips versus combination therapy in upper GI bleeding (PROTECCT-UGI bleeding)" 100 : 1503-1508, 2005

12 Burke SJ, "Nonvariceal upper gastrointestinal bleeding" 17 : 1714-1726, 2007

13 Ryan JM, "Nonlocalized lower gastrointestinal bleeding: provocative bleeding studies with intraarterial tPA, heparin, and tolazoline" 12 : 1273-1277, 2001

14 "Non-variceal upper gastrointestinal haemorrhage: guidelines" 51 (51): iv1-6, 2002

15 Rockall TA, "Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Steering Committee and members of the National Audit of Acute Upper Gastrointestinal Haemorrhage" 311 : 222-226, 1995

16 Rupp T, "Gastrointestinal hemorrhage: The prehospital recognition, assessment & management of patients with a GI bleed" 29 : 80-96, 2004

17 Longstreth GF, "Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population-based study" 90 : 206-210, 1995

18 Eriksson LG, "Endoscopic marking with a metallic clip facilitates transcatheter arterial embolization in upper peptic ulcer bleeding" 17 : 959-964, 2006

19 Binmoeller KF, "Endoscopic hemoclip treatment for gastrointestinal bleeding" 25 : 167-170, 1993

20 Cipolletta L, "Endoclips versus heater probe in preventing early recurrent bleeding from peptic ulcer: a prospective and randomized trial" 53 : 147-151, 2001

21 Loffroy R, "Embolization of acute nonvariceal upper gastrointestinal hemorrhage resistant to endoscopic treatment: results and predictors of recurrent bleeding" 33 : 1088-1100, 2010

22 Virmani S, "Effect of C-arm angiographic CT on transcatheter arterial chemoembolization of liver tumors" 18 : 1305-1309, 2007

23 Chung IK, "Comparison of the hemostatic efficacy of the endoscopic hemoclip method with hypertonic saline-epinephrine injection and a combination of the two for the management of bleeding peptic ulcers" 49 : 13-18, 1999

24 Aina R, "Arterial embolotherapy for upper gastrointestinal hemorrhage: outcome assessment" 12 : 195-200, 2001

25 김진형, "Angiographically Negative Acute Arterial Upper and Lower Gastrointestinal Bleeding: Incidence, Predictive Factors, and Clinical Outcomes" 대한영상의학회 10 (10): 384-390, 2009

26 Hastings GS, "Angiographic localization and transcatheter treatment of gastrointestinal bleeding" 20 : 1160-1168, 2000

27 Hung CF, "A novel bidirectional expression system for simultaneous expression of both the protein-coding genes and short hairpin RNAs in mammalian cells" 339 : 1035-1042, 2006