embolizacion

Embolization of Bleeding Duodenal
Ulcer Using Amplatzer Vascular Plug II
and Hydrogel Coils: Case Report
Vascular and Endovascular Surgery
45(3) 307-310
ª The Author(s) 2011
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DOI: 10.1177/1538574411399158
http://ves.sagepub.com
Ahmed K. Abdel-Aal, MD, MSc1, Sherif Osman, MD, MSc1,
Maysoon F. Hamed, MD, MSc2, Souheil Saddekni, MD, FSIR, FAHA1,
and Wael E. A. Saad, MD, FSIR3
Abstract
Purpose: To present a case of upper gastrointestinal bleeding (UGIB) that was treated with percutaneous endovascular
embolization using Amplatzer vascular plug and hydrogel coils after failed endoscopic treatment. Case Report: A 78-year-old
male was referred for endovascular treatment of massive recurrent UGIB from a duodenal ulcer. Attempts at endoscopic treatment were unsuccessful. Based on our knowledge of the site of the bleeder in the duodenum from prior endoscopy, we decided
to empirically embolize the gastroduodenal artery (GDA) and the right gastroepiploic artery using a combination of coils (Azur
peripheral hydrocoil; Terumo Medical Corporation, Somerset, New Jersey) and Amplatzer vascular plug II (AVP II; AGA Medical,
Plymouth, Minnesota). Conclusion: We present this case of UGIB where effective, rapid, precise, and controlled embolization of
the GDA was achieved using AVP II device in combination with coils. To our knowledge, the use of AVP II in embolization of GDA
for treatment of emergent UGIB has not been described in the literature.
Keywords
upper gastrointestinal bleeding, duodenal ulcer, Amplatzer Vascular Plug II, gastroduodenal artery, hydrogel coils
Introduction
Upper gastrointestinal bleeding (UGIB) is defined as gastrointestinal bleeding originating proximal to the ligament of Treitz.
The most common cause of acute nonvariceal UGIB is peptic
ulcer disease. Effective treatment requires resuscitation followed by endoscopic examination and treatment. Of the small
group of patients who fail endoscopic therapy, some are treated
surgically. Increasingly, the majority of patients who fail endoscopic treatment are referred for transcatheter embolization
which has been shown to be effective in controlling hemorrhage and decreasing mortality due to gastric or duodenal
ulcers. The Amplatzer vascular plug II (AVP-II) is a recently
developed embolization device. To our knowledge, its use in
embolization of gastroduodenal artery (GDA) for treatment
of emergent UGIB has not been described in the literature.
We present this case of UGIB where effective, rapid, precise,
and controlled embolization of the GDA was achieved using
a combination of coils and AVP II device.
Case Report
A 78-year-old male with duodenal ulcer presented to us with
recurrent massive UGIB causing hemodynamic instability and
necessitating volume replacement with 5 units of packed red
blood cell (RBC) transfusion. The patient had a history of acute
coronary syndrome, hypertension, and chronic kidney disease.
The patient had a similar episode of UGIB a week earlier which
was treated endoscopically using epinephrine injections, metal
clips, and heater probe applied to the bleeding area which was
located at the superior genu of the duodenum.
After resuscitation, repeat esophagogastroduodenoscopy
(EGD) was performed which identified the ulcer location at the
anterior portion of the superior duodenal genu and confirmed
the presence of a pulsating, intermittently bleeding vessel at the
superior margin of the ulcer that failed to compress with heater
probe. Attempts at metal clip placement were unsuccessful due
to firm consistency of the ulcer edge.
1
Division of Vascular and Interventional Radiology, Department of Radiology,
University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
2
Brookdale University Hospital and Medical Center, Brooklyn, New York,
USA
3
University of Virginia Health System, Charlottesville, Virginia, USA
Corresponding Author:
Ahmed K. Abdel Aal, Division of Vascular and Interventional Radiology,
Department of Radiology, University of Alabama at Birmingham (UAB), 619
19th Street South, Birmingham, AL 35249, USA
Email: [email protected]
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Vascular and Endovascular Surgery 45(3)
Figure 2. Coils placed in the right gastroepiploic artery distal to the
metal clips (presumed site of bleeding duodenal ulcer) to avoid back
bleeding.
Figure 1. A 78-year-old male with massive recurrent upper gastrointestinal bleeding. Celiac arteriogram shows no evidence of active contrast extravasation or any signs of active bleeding. Metallic clips from
prior endoscopic intervention are seen along the course of the right
gastroepiploic artery (arrows). Other metallic clips are from prior
cholecystectomy.
Due to failure of endoscopic treatment twice, the patient was
referred for endovascular treatment of his UGIB. Access was
obtained through the right femoral artery and aortic angiogram
using 4-French omniflush catheter (Angiodynamics, Queensbury, New York) was performed showing no arterial anatomical variants. Selective angiography of the celiac trunk was then
performed using a 5F RC2 catheter (Cook, Bloomington, Indiana), showing no evidence of active bleeding (Figure 1). The
GDA was then catheterized and angiogram also failed to show
any active arterial bleeder. The metal clips that were previously
placed by endoscopy were seen superimposed over the course
of the right gastroepiploic artery. Based on our knowledge of
the site of the bleeder in the duodenum from prior EGD results,
and the location of the metal clips seen on angiograms, we
decided to empirically embolize the GDA and the right gastroepiploic artery. A 6-French sheath (Destination; Terumo Medical Corporation, Somerset, New Jersey) was then placed in the
common hepatic artery over a 0.035 inch Glidewire Advantage
(Terumo Medical Corporation, Somerset, New Jersey). A 5French RC2 catheter was then placed through the sheath and
used to catheterize the GDA. Subselective catheterization of
the right gastroepiploic artery was then performed using a
2.8-French Progreat microcatheter (Terumo Medical Corporation, Somerset, New Jersey) which was advanced beyond the
location of the visualized metal clips in order to embolize distal
to the suspected bleeding site to avoid ‘‘backbleeding.’’ Embolization was performed using hydrogel coils (Azur peripheral
hydrocoil; Terumo Medical Corporation, Somerset, New Jersey;
Figure 2). Angiogram was performed after each coil deployment
to assess for contrast stasis. Following deployment of several
Figure 3. Subselective gastroduodenal arteriogram showing active
contrast extravasation between duodenal folds giving ‘‘pseudo-vein sign’’
(arrow).
coils, and during postdeployment angiogram, we noticed
contrast extravasation from the right gastroepiploic artery at the
site of the visualized metal clips denoting active bleeding. The
extravasated contrast pooled between the duodenal folds giving
the pseudovein sign (Figure 3). We continued coil deployment
proximal to the bleeding site using the same coil type till the distal GDA was embolized. Due to its large size measuring about
5.0 mm, we decided to embolize the proximal GDA using AVP
II. The RC2 catheter was removed and the Destination sheath
was advanced into the patent GDA over the Glidewire Advantage. We then placed an 8-mm AVP II into the GDA. A single
nonsubtracted image was obtained immediately after device
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Abdel-Aal et al
309
Figure 4. A single nonsubtracted image demonstrating satisfactory
position of the Amplatzer vascular plug II (AVP-II) in the gastroduodenal artery (GDA) prior to its release (arrows).
placement, demonstrating satisfactory position of the device
(Figure 4), which was then released from the delivery cable. The
sheath was then retracted into the common hepatic artery and
another angiogram was performed showing complete occlusion
of the GDA (Figure 5). The occlusion time for the AVP II was 1
minute and 35 seconds, which was determined by subtracting the
reference time recorded on the single nonsubtracted image
obtained after the placement of the device from the reference
time recorded on the common hepatic angiogram that showed
total occlusion of the GDA. The procedure was then terminated
and there were no immediate or late adverse events related to the
procedure.
The patient was discharged from the hospital 3 days after the
procedure. The patient was administered Pantoprazole intravenous infusion at a rate of 10 mg/h until he was discharged, and
continued on Omeprazole 20 mg capsules, twice per day after
discharge. The patient was placed on oxygen therapy through a
nasal cannula at a rate of 2 L/min during the day of the procedure. The patient received 2 units of intravenous packed red
blood cells (RBCs) immediately after the procedure. His hematocrit was 21.5% before the procedure and gradually increased to
29.2% when he was discharged. He remained alert and oriented
and his blood pressure remained stable until discharged. The
patient had no other episodes of UGIB up to 6 months following
the procedure.
Discussion
Acute UGIB is the most common complication of peptic ulcer
disease and about 50% of the cases of UGIB are due to gastric
or duodenal ulcers. The mortality rate in patients with bleeding
peptic ulcers remains as high as 10%.1
Recent development in a variety of endoscopic hemostatic
therapies has been considered to be the main reason for a
Figure 5. Common hepatic arteriogram showing total occlusion of
the gastroduodenal artery (GDA) with no flow distal to the Amplatzer
vascular plug II (AVP II) device.
substantial decline in urgent surgery as well as decline in mortality. Nevertheless, about 10% of patients with UGIB still
require urgent surgery. In another 10%, urgent endoscopy fails
or is severely impaired due to excessive bleeding in the gastroduodenal tract that hampers diagnosis. When surgical intervention is warranted, the mortality rate is about 15% to 20% and
rises up to 40% in high-risk patients.1-3
Endovascular embolization has been proposed as an alternative to open surgical approach, especially for high-risk patients.
The obvious advantage to this approach is avoidance of laparotomy in critically ill patients.3
As the advent of microcatheters technology and associated
embolic agents, transcatheter embolization of UGIB has been
performed expeditiously and safely with outcomes that have
been more favorable compared with surgical interventions.3
In several cases, a bleeding artery cannot be identified on
angiography and a target vessel is usually empirically embolized based on the prior knowledge of location of the bleeding
ulcer from prior imaging or endoscopic studies.4
Currently, microcoils are used by many institutions for
endovascular embolization of the GDA in cases of UGIB, as
they are easy to use and pose a lesser threat of ischemia than
other embolic agents such as polyvinyl alcohol, microspheres,
tris-acryl gelatin microspheres or gelfoam pledgets.5
The AVP-II is a recently developed occlusive device. To our
knowledge, its use in treatment of UGIB has not been described
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Vascular and Endovascular Surgery 45(3)
in literature. It is composed of a self-expanding cylindrical
nitinol basket that is compressed inside a delivery catheter and
expanded to its intended shape to occlude the target vessel.6,7
The AVP is available in diameters ranging from 3 to 22 mm.
It is preloaded and delivered through 4 to 7 French guiding
sheaths or 5 to 9 French guiding catheters.8
Amplatzer vascular plug has many advantages in GDA
embolization in the emergency UGIB setting. First, it allows
rapid precise placement within the artery and the position of the
device can be easily verified with a test injection through the
guiding catheter prior to its release. If device position is unsatisfactory, it can be repositioned or removed. Second, the risk
of migration appears to be lower compared to coils, if an appropriately sized device is used. Third, only single device is used
in most cases and the device has an acceptable occlusion time
which is advantageous in this emergency setting when rapid
occlusion of the target vessel is required. Fourth, less metallic
artifacts are encountered compared to coils on CTA studies,
which allows this modality to be used for precise assessment
of the results of treatment.
In a prospective randomized study comparing AVP-II with
platinum-fibered microcoils in prophylactic GDA embolization
prior to Y90 administration, Pech et al showed efficient embolization induced by AVP II, shorter duration of the procedure,
shorter embolization time, and less exposure of the medical
personnel to radiation.8
Disadvantages of AVP II include the need to place a 4 to 7
French delivery sheath in the GDA, which is sometimes hard to
achieve in tortuous anatomy. In our case, we used the Glidewire
advantage which we found useful in this particular situation.
This wire combines Glidewire construction on the distal
25 cm, with a PTFE coating on the proximal stiff end. The result
is a guidewire that easily navigates through tortuous arterial
anatomy with the distal glide portion, while also providing
enough support for sheath placement in the GDA over the proximal stiff portion.
Another disadvantage is the inability to embolize small distal bleeders since the small size AVP II (3 mm) cannot be delivered through the regular 4- to 5-French catheters and requires at
least a 4 French sheath for delivery. Furthermore, the stiff
delivery cable makes it impossible to negotiate these devices
to a distal location. These were the reasons behind using coils
to embolize the right gastroepiploic artery in our case.
Conclusion
The AVP II is a new embolic device that offers effective, rapid,
precise, and controlled embolization of the GDA in the treatment of emergent UGIB. The need to use only 1 device to
achieve complete satisfactory occlusion of the GDA appears
to potentially reduce the procedure time, radiation exposure,
and cost of the procedure compared to coils, although dedicated
studies on larger patient population are required to document
these results.
Development of smaller devices that can be delivered
through 4- or 5-French catheters and a more flexible delivery
cable are necessary for this device to be used for embolization
in more distal vasculature beyond the GDA.
Declaration of Conflicting Interests
The author(s) declared a potential conflict of interest as follows:
Ahmed K. Abdel-Aal and Souheil Saddekni: Consultant, AGA
medical.
Funding
The author(s) received no financial support for the research and/or
authorship of this article.
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