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Paper |

Angiographic Embolization for Gastroduodenal Hemorrhage:  Safety, Efficacy, and Predictors of Outcome FREE

George A. Poultsides, MD; Christine J. Kim, MD; Rocco Orlando III, MD; George Peros, MD; Michael J. Hallisey, MD; Paul V. Vignati, MD
[+] Author Affiliations

Author Affiliations: Departments of Surgery (Drs Poultsides, Orlando, and Vignati) and Radiology (Drs Kim and Hallisey), University of Connecticut School of Medicine, Farmington; Departments of Surgery (Drs Poultsides, Orlando, and Vignati) and Radiology (Drs Kim and Hallisey), Hartford Hospital, Hartford, Connecticut; and Fourth Department of Surgery, Attikon University Hospital and Department of Surgery, University of Athens School of Medicine, Athens, Greece (Dr Peros).


Arch Surg. 2008;143(5):457-461. doi:10.1001/archsurg.143.5.457.
Text Size: A A A
Published online

Objective  To examine the safety, efficacy, and predictors of outcome of angiographic embolization in the management of gastroduodenal hemorrhage.

Design  Retrospective record review.

Setting  University-affiliated tertiary care center.

Patients  All of the patients were referred after endoscopic treatment failure. Surgery was not immediately considered because of poor surgical risk, refusal to consent, or endoscopist's decision. Patients with coagulopathy, hemobilia, and variceal or traumatic upper gastrointestinal tract bleeding were excluded from review.

Interventions  Between January 1, 1996, and December 31, 2006, 70 embolization procedures were performed in 57 patients.

Main Outcome Measures  Technical success rate (target vessel devascularization), clinical success rate (in-hospital cessation of bleeding without further endoscopic, radiologic, or surgical intervention), and complications.

Results  The technical success rate was 94% (66 of 70 angiographies). The primary clinical success rate was 51% (29 of 57 patients), and the clinical success rate after repeat embolization was 56% (32 of 57 patients). Two factors were found to be independent predictors of poor outcome by multivariate analysis: recent duodenal ulcer suture ligation (P = .03) and blood transfusion of more than 6 units prior to the procedure (P = .04). There was no predictive value for angiographic failure based on age, sex, prior coagulopathy, renal failure at presentation, immunocompromised status, multiple organ system failure, empirical (blind) embolization, and use of permanent vs temporary embolic agents. Repeat embolizations were helpful for postsphincterotomy bleeding. Major ischemic complications (4 patients [7%]) were associated with previous foregut surgery.

Conclusions  Angiographic embolization for gastroduodenal hemorrhage was associated with in-hospital rebleeding in almost half of the patients. Angiographic failure can be predicted if embolization is performed late, following blood transfusion of more than 6 units, or for rehemorrhage from a previously suture-ligated duodenal ulcer.

Acute upper gastrointestinal (GI) tract bleeding will stop spontaneously in approximately 80% of patients. In patients with persistent bleeding, therapeutic endoscopy can achieve hemostasis in almost 80% of cases.1 Surgical intervention is usually an expeditious and gratifying endeavor required in fewer than 5% of patients with upper GI tract hemorrhage but can be associated with operative mortality rates of up to 30% in patients with severe comorbidity.2,3 Although angiographic embolization is now considered the first-line therapy for colonic hemorrhage4,5 and hemobilia,6 the safety and durability of this modality for upper GI tract bleeding remains unclear. This study will attempt to define the role of angiographic embolization for gastroduodenal hemorrhage and to identify factors that could predict angiographic failure so as not to delay operative intervention.

PATIENTS

All of the patients who underwent angiographic embolization for upper GI tract bleeding from January 1, 1996, to December 31, 2006, at Hartford Hospital, Hartford, Connecticut, were identified using a prospectively maintained interventional radiology database. Patients with persistent coagulopathy, hemobilia, and variceal or traumatic bleeding were excluded. Seventy angiographic embolization procedures in 57 consecutive patients were retrospectively reviewed. Data collection included patient demographics, diagnosis, comorbid conditions, steroid use or other immunosuppression, prior coagulopathy, renal failure at presentation, transfusion requirements, multiple organ system failure, vessel(s) embolized, type of embolic agent(s) used, incidence of empirical or blind embolizations, incidence of complications (gastric or duodenal ischemia, inadvertent spleen or liver embolization, superior mesenteric artery dissection, nephrotoxicity, groin hematoma), clinical outcome, and mortality.

Coagulopathy was defined as an international normalized ratio higher than 1.5, a partial thromboplastin time longer than 45 seconds, or a platelet count of less than 50 000/mL.7 The technical success rate was defined as target vessel devascularization. The clinical success rate was defined as in-hospital cessation of bleeding without further endoscopic, radiologic, or surgical intervention. The secondary clinical success rate after repeat angiographic embolization was also analyzed.

INTERVENTIONS

All of the patients had persistent or recurrent bleeding despite initial therapy consisting of volume replacement, correction of coagulopathy, intravenous administration of H2 receptor blockers or proton pump inhibitors, and at least 1 previous attempt to control the bleeding by endoscopic means. Reasons for interventional radiology referral before surgical intervention were poor surgical risk, patient or family refusal to consent to surgery, nondiagnostic previous upper endoscopy, or endoscopist's decision prior to surgical consultation. Sodium bicarbonate infusion was instituted in patients at high risk for contrast nephrotoxicity.8

Angiographic procedures were performed with standard percutaneous transfemoral catheterization using a 5- or 6-French sheath. All of the patients had selective opacification of the celiac trunk and superior mesenteric artery, followed by superselective arteriography of the left gastric artery or gastroduodenal artery as necessary. Images were obtained with the digital subtraction technique. When extravasation of contrast material was demonstrated at angiography, embolic therapy was performed as selectively as possible, with a 3-French Tracker microcatheter (Target Therapeutics, Fremont, California) coaxially inserted through the 5-French catheter into the target vessel. The embolic agents used were temporary, such as cellulose sponge plugs (Gelfoam; Pharmacia and Upjohn, Kalamazoo, Michigan); permanent, such as vascular coils ranging from 2 to 7 mm (Gianturco; Cook, Bloomington, Indiana), platinum microcoils (Target Therapeutics), and 355- to 500-mm or 500- to 710-mm polyvinyl alcohol particles (Contour; Target Therapeutics); or a combination of both. If direct entry into the bleeding artery was not possible, occlusion was attempted by means of a flow-directed injection of the embolic agent. When a dual blood supply existed, contrast injection through the alternate route was performed to exclude extravasation by retrograde filling. If this was demonstrated, embolization through the second limb was carried out until cessation of extravasation was achieved.

In certain patients without angiographic evidence of contrast extravasation into the gastroduodenal lumen or other vascular anomaly, such as a pseudoaneurysm, neovascularity, or arteriovenous malformation, empirical or blind embolization was achieved based on conclusive endoscopic identification of the source of bleeding. Pharmacoarteriography with the use of anticoagulants, vasodilators, or fibrinolytic agents to provoke contrast medium extravasation was not performed.

STATISTICAL ANALYSIS

The χ2 test and Fisher exact test, where appropriate, were used for univariate comparisons. Binary logistic regression was used to incorporate all of the explanatory variables in a model predicting clinical success. Statistical analysis was performed using SPSS version 11.0 statistical software (SPSS, Inc, Chicago, Illinois) for Windows (Microsoft Corp, Redmond, Washington). P < .05 was considered statistically significant.

PATIENT CHARACTERISTICS

A total of 70 consecutive embolization procedures were reviewed in 57 patients. There were 38 men (67%). The mean age was 65 years (range, 22-93 years).

Diagnoses were duodenal ulcer (n = 13), postsphincterotomy bleeding (n = 10), gastric ulcer (n = 8), gastric cancer (n = 5), duodenal ulcer previously suture ligated (n = 5), Mallory-Weiss tear (n = 4), Dieulafoy lesion (n = 3), duodenal arteriovenous malformation (n = 2), periampullary neoplasm (n = 2), arterial-duodenal fistulas (inferior pancreaticoduodenal artery pseudoaneurysm secondary to pancreatitis [n = 2] and aberrant right hepatic artery pseudoaneurysm following hepatic artery infusion pump placement [n = 1]), duodenal vasculitis (n = 1), and cytomegalovirus duodenitis (n = 1).

Comorbid conditions noted were steroid use or other immunosuppression (n = 14 [25%]), prior coagulopathy (n = 15 [26%]), renal failure at presentation (n = 15 [26%]), transfusion requirement of more than 6 units of packed red blood cells prior to the procedure (n = 27 [47%]), and multiple organ system failure (n = 15 [26%]).

PROCEDURAL OUTCOMES

Embolization was technically possible in 66 of 70 angiographies, reaching a technical success rate of 94%. Technical failures were mainly associated with stenosis of the celiac trunk, which precluded superselective catheterization, or inability to safely occlude the targeted vessel without inadvertent splenic, hepatic, or superior mesenteric artery embolization.

Arteries primarily embolized were the gastroduodenal artery (n = 30), the left gastric artery (n = 18), the inferior pancreaticoduodenal artery (n = 10), an aberrant right hepatic artery (n = 4), the right gastroepiploic artery (n = 2), the splenic artery (n = 1), and the superior pancreaticoduodenal artery (n = 1). In 3 duodenal ulcer cases, the gastroduodenal artery was successfully embolized but superior mesenteric arteriography revealed back bleeding from the inferior pancreaticoduodenal artery; the inferior pancreaticoduodenal artery was subsequently embolized, achieving angiographic hemostasis. In 1 case of bleeding gastroesophageal junction carcinoma, left gastric artery occlusion was supplemented with embolization of a left inferior phrenic perforator to the tumor to accomplish cessation of contrast extravasation.

Empirical embolizations were performed in 22 patients (39%), and permanent embolic agents were used in 33 of the 66 technically successful embolization procedures.

CLINICAL OUTCOMES

In-hospital cessation of bleeding without further endoscopic, radiologic, or surgical intervention was accomplished in 29 of 57 patients (51%). The primary clinical success rate was higher for duodenal ulcer (8 of 13 patients [62%]) and gastric cancer (3 of 5 patients [60%]). The mean interval to rebleeding in the 28 primary failures was 3.8 days (range, 1-22 days). Thirteen patients underwent repeat embolization. Three of them eventually achieved hemostasis, with a secondary clinical success rate of 56% (32 of 57 patients). Repeat embolization was successful in 2 cases of postsphincterotomy bleeding and 1 case of duodenal arteriovenous malformation.

Rebleeding occurred in 25 patients (44%) despite initial or repeat embolization. Eleven of those patients underwent surgery, and 8 recovered well. Three patients died in the postoperative period, 2 from duodenal stump blowout following salvage antrectomy after failed gastroduodenal artery embolization for a bleeding duodenal ulcer and 1 secondary to gastric remnant necrosis following salvage distal subtotal gastrectomy after unsuccessful left gastric artery embolization for a bleeding gastric ulcer. Of the remaining 14 patients with angiographic failures, 8 were salvaged with repeat endoscopy and 6 died secondary to bleeding or underlying terminal disease. Mortality was 36% (9 of 25 patients) when embolization failed and 9% (3 of 32 patients) when embolization was successful. Overall mortality was 21% (12 of 57 patients).

Seven angiographic embolizations were performed in 5 patients with recurrent bleeding from a previously suture-ligated duodenal ulcer. Bleeding recurred in all but 1 case of an embolized gastroduodenal artery pseudoaneurysm. Of the remaining 4 cases of angiographic failure, 2 patients were salvaged with antrectomy and 2 patients died as described earlier.

COMPLICATIONS

Four patients (7%) experienced major ischemic complications. Three of them resulted in postoperative deaths as described previously. The fourth complication was a liver abscess in an immunosuppressed patient after gastroduodenal artery embolization for postsphincterotomy bleeding. Eight patients (14%) experienced minor complications, including inadvertent spleen or liver embolization without clinical sequelae (n = 3), groin hematoma (n = 1), and transient periprocedural renal insufficiency (n = 4).

PREDICTORS OF OUTCOME

Eight patient variables and 2 procedural variables were subjected to univariate and multivariate analysis to identify predictors of outcome (Table 1). By univariate analysis, a transfusion requirement of more than 6 units of blood prior to the procedure was the only variable found to be associated with clinical failure (P = .02). Two factors were found to be independent predictors of embolization failure by multivariate analysis. Patients with recurrent bleeding from a previously suture-ligated duodenal ulcer had only a 24% likelihood of achieving long-term hemostasis with embolization (odds ratio = 0.24; 95% confidence interval, 0.07-0.78; P = .03) compared with patients with other diagnoses. Similarly, patients who received fewer than 6 units of blood prior to the procedure were 4 times more likely to have a clinically successful embolization (odds ratio = 0.25; 95% confidence interval, 0.06-0.95; P = .04). There was no predictive value for angiographic failure based on age, sex, prior coagulopathy, immunocompromised status, renal failure at presentation, multiple organ system failure, use of permanent vs temporary embolic agents, and empirical (blind) embolization.

Table Graphic Jump LocationTable 1. Univariate and Multivariate Predictors of Embolization Failure

The first transcatheter embolization for upper GI tract bleeding was of the right gastroepiploic artery using autologous clot and was described by Rösch et al9 in 1972. Embolotherapy for lower GI tract bleeding was reported at almost the same time but had an unacceptably high bowel ischemic rate and quickly fell out of favor.10 Most believe such high rates were due to the availability of only large catheters and primitive embolic agents by today's standards. However, since the advent of microcatheters (≤ 3 French) and associated embolics, superselective transcatheter embolization has become first-line therapy for colonic hemorrhage with rebleeding rates between 10% and 40%.4,5 In contrast, angiographic embolization for upper GI tract bleeding has been largely limited to these rare situations where endoscopy is unsuccessful and surgery is not considered. Since 1984, there have been 11 articles on angiographic embolization for nonvariceal upper GI tract hemorrhage, consisting of 549 patients (Table 2).1121 There is a need to clearly define the efficacy, safety, and durability of this modality as well as the clinical criteria for the selection of patients who may benefit from it.

Table Graphic Jump LocationTable 2. Published Series of Angiographic Embolization for Upper Gastrointestinal Tract Bleeding

Unlike lower GI tract bleeding, angiographic confirmation of a bleeding site is not a prerequisite for transcatheter therapy in the upper GI tract. Although an early study by Dempsey et al12 did not find empirical embolizations based on surgical or endoscopic guidance (without evidence of contrast extravasation) to be helpful in controlling hemorrhage, 3 succeeding studies showed no difference between patients with empirical embolization and patients with positive angiography results.1517 Lang et al,22 describing 13 patients with massive upper GI tract hemorrhage and normal angiogram results, concluded that prophylactic embolization of the left gastric artery appears warranted when there is definite prior identification of a lesion in the left gastric artery territory or there is no prior localization of a lesion but the patient is at risk for multiple organ failure if bleeding recurs. In our series, empirical embolization was performed in 22 patients (39%) and was not found to independently predict angiographic failure, confirming the current practice of almost all centers to empirically embolize the most likely offending vessel based on endoscopic guidance.

Although not as worrisome as with lower GI tract embolotherapy, ischemia does occur following upper GI tract embolization. Despite the foregut's rich collateral blood supply, reported rates of major ischemic complications range from 0% to 16% (Table 2). Late ischemic complications can be more frequent with terminal vessel embolization, which has been associated with a 25% incidence of late duodenal stricture in 1 study.14 Our study did not have the long-term endoscopic follow-up to confirm the incidence of this late complication. However, we did have 3 major ischemic complications, 2 involving the proximal stomach and 1 involving the duodenal stump, in the setting of previous distal gastrectomy. Lieberman et al11 reported 3 ischemic complications in their series of 32 patients embolized for upper GI tract bleeding, all of whom had surgically altered anatomy. This finding concurs with our observation that postembolization intestinal ischemia can be aggravated by previous gastric resection.

Predictors of clinical failure to control upper GI tract bleeding seem to agree that coagulopathy and multiple organ failure result in a reduced likelihood of clinical success. Schenker et al17 found a 17.5-fold increased mortality rate in patients with multiple organ failure and upper GI tract bleeding. However, patients with multiple organ failure and successful embolization had a 69% rate of survival compared with a 4% rate of survival when embolization failed, prompting the investigators to conclude that embolization should be attempted in these patients despite their higher mortality rate. Coagulopathy has been shown to adversely affect the success rate for embolotherapy with an increase in the odds ratio for clinical failure, which ranges from 2.9 to 19.6.13,16,17 Therefore, aggressive correction of coagulation parameters is our recommended institutional policy before embolization for GI tract bleeding. Walsh et al15 found longer time to angiography (P = .01), more total units of packed red blood cells (P = .003), and prior surgery for bleeding (P = .02) to be predictors of embolization failure by multivariate analysis. Our study agrees with the earlier findings, indicating that recent duodenal ulcer surgery (P = .03) and blood transfusion of more than 6 units prior to the procedure (P = .04) are independent predictors of poor embolization outcome.

To our knowledge, no studies have prospectively compared transcatheter therapy with other modalities in the management of gastroduodenal hemorrhage. Ripoll et al20 attempted to retrospectively compare transcatheter embolotherapy for the treatment of bleeding peptic ulcers refractory to endoscopic intervention vs surgery. Although there was no difference between the embolotherapy and surgery groups in the incidence of recurrent bleeding (29% vs 23.1%, respectively), need for additional surgery (16.1% vs 30.8%, respectively), or mortality (25.8% vs 20.5%, respectively), the embolotherapy group included significantly older patients with more comorbidities, such as heart disease and prior anticoagulation therapy. There is clearly a great need for prospective, randomized, controlled studies comparing surgical and endovascular management of massive GI tract bleeding after endoscopic failure, although this task would be intrinsically difficult to perform in the emergency setting.

In summary, angiographic embolization for nonvariceal upper GI tract hemorrhage is a viable option in poor candidates for surgery. When used, it should be performed with the understanding that despite initial technical success, bleeding can recur in almost half of the patients. Previous foregut surgery can exacerbate ischemic complications. Failure to achieve long-term hemostasis can be predicted if embolization is performed late in the course of bleeding following transfusion of more than 6 units of blood or in the setting of recurrent bleeding from a previously suture-ligated duodenal ulcer.

Correspondence: Paul V. Vignati, Department of Surgery, Hartford Hospital, 85 Seymour St, Ste 715, Hartford, CT 06106 (pvignati@ctsurgical.com).

Accepted for Publication: December 14, 2007.

Author Contributions:Study concept and design: Poultsides, Kim, Orlando, Hallisey, and Vignati. Acquisition of data: Poultsides and Kim. Analysis and interpretation of data: Poultsides, Kim, Orlando, Peros, Hallisey, and Vignati. Drafting of the manuscript: Poultsides. Critical revision of the manuscript for important intellectual content: Kim, Orlando, Peros, Hallisey, and Vignati. Statistical analysis: Poultsides. Administrative, technical, and material support: Kim, Orlando, Peros, Hallisey, and Vignati. Study supervision: Orlando, Peros, Hallisey, and Vignati.

Financial Disclosure: None reported.

Previous Presentation: This paper was presented at the 88th Annual Meeting of the New England Surgical Society; September 29, 2007; Burlington, Vermont; and is published after peer review and revision.

Ferguson  CBMitchell  RM Nonvariceal upper gastrointestinal bleeding: standard and new treatment. Gastroenterol Clin North Am 2005;34 (4) 607- 621
PubMed Link to Article
McConnell  DBBaba  GCDeveney  CW Changes in surgical treatment of peptic ulcer disease within a veterans hospital in the 1970s and the 1980s. Arch Surg 1989;124 (10) 1164- 1167
PubMed Link to Article
Larson  GSchmidt  TGott  JBond  SO'Connor  CARichardson  JD Upper gastrointestinal bleeding: predictors of outcome. Surgery 1986;100 (4) 765- 773
PubMed
Miller  M  JrSmith  TP Angiographic diagnosis and endovascular management of nonvariceal gastrointestinal hemorrhage. Gastroenterol Clin North Am 2005;34 (4) 735- 752
PubMed Link to Article
DeBarros  JRosas  LCohen  JVignati  PSardella  WHallisey  M The changing paradigm for the treatment of colonic hemorrhage: superselective angiographic embolization. Dis Colon Rectum 2002;45 (6) 802- 808
PubMed Link to Article
Green  MHDuell  RMJohnson  CDJamieson  NV Haemobilia. Br J Surg 2001;88 (6) 773- 786
PubMed Link to Article
Cook  DJFuller  HDGuyatt  GH  et al.  Risk factors for gastrointestinal bleeding in critically ill patients. N Engl J Med 1994;330 (6) 377- 381
PubMed Link to Article
Morcos  SK Prevention of contrast media-induced nephrotoxicity after angiographic procedures. J Vasc Interv Radiol 2005;16 (1) 13- 23
PubMed Link to Article
Rösch  JDotter  CTBrown  MJ Selective arterial embolization: a new method for control of acute gastrointestinal bleeding. Radiology 1972;102 (2) 303- 306
PubMed Link to Article
Bookstein  JJChlosta  EMFoley  DWalter  JF Transcatheter hemostasis of gastrointestinal bleeding using modified autogenous clot. Radiology 1974;113 (2) 277- 285
PubMed Link to Article
Lieberman  DAKeller  FSKaton  RMRosch  J Arterial embolization for massive upper gastrointestinal tract bleeding in poor surgical candidates. Gastroenterology 1984;86 (5, pt 1) 876- 885
PubMed
Dempsey  DTBurke  DRReilly  RSMcLean  GKRosato  EF Angiography in poor-risk patients with massive nonvariceal upper gastrointestinal bleeding. Am J Surg 1990;159 (3) 282- 286
PubMed Link to Article
Encarnacion  CEKadir  SBeam  CAPayne  CS Gastrointestinal bleeding: treatment with gastrointestinal arterial embolization. Radiology 1992;183 (2) 505- 508
PubMed Link to Article
Lang  EK Transcatheter embolization in management of hemorrhage from duodenal ulcer: long-term results and complications. Radiology 1992;182 (3) 703- 707
PubMed Link to Article
Walsh  RMAnain  PGeisinger  M  et al.  Role of angiography and embolization for massive gastroduodenal hemorrhage. J Gastrointest Surg 1999;3 (1) 61- 66
PubMed Link to Article
Aina  ROliva  VLTherasse  E  et al.  Arterial embolotherapy for upper gastrointestinal hemorrhage: outcome assessment. J Vasc Interv Radiol 2001;12 (2) 195- 200
PubMed Link to Article
Schenker  MPDuszak  R  JrSoulen  MC  et al.  Upper gastrointestinal hemorrhage and transcatheter embolotherapy: clinical and technical factors impacting success and survival. J Vasc Interv Radiol 2001;12 (11) 1263- 1271
PubMed Link to Article
Defreyne  LVanlangenhove  PDe Vos  M  et al.  Embolization as a first approach with endoscopically unmanageable acute nonvariceal gastrointestinal hemorrhage. Radiology 2001;218 (3) 739- 748
PubMed Link to Article
Ljungdahl  MEriksson  LGNyman  RGustavsson  S Arterial embolisation in management of massive bleeding from gastric and duodenal ulcers. Eur J Surg 2002;168 (7) 384- 390
PubMed Link to Article
Ripoll  CBañares  RBeceiro  I  et al.  Comparison of transcatheter arterial embolization and surgery for treatment of bleeding peptic ulcer after endoscopic treatment failure. J Vasc Interv Radiol 2004;15 (5) 447- 450
PubMed Link to Article
Holme  JBNielsen  DTFunch-Jensen  PMortensen  FV Transcatheter arterial embolization in patients with bleeding duodenal ulcer: an alternative to surgery. Acta Radiol 2006;47 (3) 244- 247
PubMed Link to Article
Lang  EVPicus  DMarx  MVHicks  MEFriedland  GW Massive upper gastrointestinal hemorrhage with normal findings on arteriography: value of prophylactic embolization of the left gastric artery. AJR Am J Roentgenol 1992;158 (3) 547- 549
PubMed Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. Univariate and Multivariate Predictors of Embolization Failure
Table Graphic Jump LocationTable 2. Published Series of Angiographic Embolization for Upper Gastrointestinal Tract Bleeding

References

Ferguson  CBMitchell  RM Nonvariceal upper gastrointestinal bleeding: standard and new treatment. Gastroenterol Clin North Am 2005;34 (4) 607- 621
PubMed Link to Article
McConnell  DBBaba  GCDeveney  CW Changes in surgical treatment of peptic ulcer disease within a veterans hospital in the 1970s and the 1980s. Arch Surg 1989;124 (10) 1164- 1167
PubMed Link to Article
Larson  GSchmidt  TGott  JBond  SO'Connor  CARichardson  JD Upper gastrointestinal bleeding: predictors of outcome. Surgery 1986;100 (4) 765- 773
PubMed
Miller  M  JrSmith  TP Angiographic diagnosis and endovascular management of nonvariceal gastrointestinal hemorrhage. Gastroenterol Clin North Am 2005;34 (4) 735- 752
PubMed Link to Article
DeBarros  JRosas  LCohen  JVignati  PSardella  WHallisey  M The changing paradigm for the treatment of colonic hemorrhage: superselective angiographic embolization. Dis Colon Rectum 2002;45 (6) 802- 808
PubMed Link to Article
Green  MHDuell  RMJohnson  CDJamieson  NV Haemobilia. Br J Surg 2001;88 (6) 773- 786
PubMed Link to Article
Cook  DJFuller  HDGuyatt  GH  et al.  Risk factors for gastrointestinal bleeding in critically ill patients. N Engl J Med 1994;330 (6) 377- 381
PubMed Link to Article
Morcos  SK Prevention of contrast media-induced nephrotoxicity after angiographic procedures. J Vasc Interv Radiol 2005;16 (1) 13- 23
PubMed Link to Article
Rösch  JDotter  CTBrown  MJ Selective arterial embolization: a new method for control of acute gastrointestinal bleeding. Radiology 1972;102 (2) 303- 306
PubMed Link to Article
Bookstein  JJChlosta  EMFoley  DWalter  JF Transcatheter hemostasis of gastrointestinal bleeding using modified autogenous clot. Radiology 1974;113 (2) 277- 285
PubMed Link to Article
Lieberman  DAKeller  FSKaton  RMRosch  J Arterial embolization for massive upper gastrointestinal tract bleeding in poor surgical candidates. Gastroenterology 1984;86 (5, pt 1) 876- 885
PubMed
Dempsey  DTBurke  DRReilly  RSMcLean  GKRosato  EF Angiography in poor-risk patients with massive nonvariceal upper gastrointestinal bleeding. Am J Surg 1990;159 (3) 282- 286
PubMed Link to Article
Encarnacion  CEKadir  SBeam  CAPayne  CS Gastrointestinal bleeding: treatment with gastrointestinal arterial embolization. Radiology 1992;183 (2) 505- 508
PubMed Link to Article
Lang  EK Transcatheter embolization in management of hemorrhage from duodenal ulcer: long-term results and complications. Radiology 1992;182 (3) 703- 707
PubMed Link to Article
Walsh  RMAnain  PGeisinger  M  et al.  Role of angiography and embolization for massive gastroduodenal hemorrhage. J Gastrointest Surg 1999;3 (1) 61- 66
PubMed Link to Article
Aina  ROliva  VLTherasse  E  et al.  Arterial embolotherapy for upper gastrointestinal hemorrhage: outcome assessment. J Vasc Interv Radiol 2001;12 (2) 195- 200
PubMed Link to Article
Schenker  MPDuszak  R  JrSoulen  MC  et al.  Upper gastrointestinal hemorrhage and transcatheter embolotherapy: clinical and technical factors impacting success and survival. J Vasc Interv Radiol 2001;12 (11) 1263- 1271
PubMed Link to Article
Defreyne  LVanlangenhove  PDe Vos  M  et al.  Embolization as a first approach with endoscopically unmanageable acute nonvariceal gastrointestinal hemorrhage. Radiology 2001;218 (3) 739- 748
PubMed Link to Article
Ljungdahl  MEriksson  LGNyman  RGustavsson  S Arterial embolisation in management of massive bleeding from gastric and duodenal ulcers. Eur J Surg 2002;168 (7) 384- 390
PubMed Link to Article
Ripoll  CBañares  RBeceiro  I  et al.  Comparison of transcatheter arterial embolization and surgery for treatment of bleeding peptic ulcer after endoscopic treatment failure. J Vasc Interv Radiol 2004;15 (5) 447- 450
PubMed Link to Article
Holme  JBNielsen  DTFunch-Jensen  PMortensen  FV Transcatheter arterial embolization in patients with bleeding duodenal ulcer: an alternative to surgery. Acta Radiol 2006;47 (3) 244- 247
PubMed Link to Article
Lang  EVPicus  DMarx  MVHicks  MEFriedland  GW Massive upper gastrointestinal hemorrhage with normal findings on arteriography: value of prophylactic embolization of the left gastric artery. AJR Am J Roentgenol 1992;158 (3) 547- 549
PubMed Link to Article

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