Transcatheter arterial embolization for gastrointestinal bleeding related to pancreatic adenocarcinoma: clinical efficacy and predictors of clinical outcome

ACR Appropriateness Criteria® Nonvariceal Upper Gastrointestinal Bleeding: 2024 Update

This document summarizes the relevant literature for the selection of the initial imaging in five clinical scenarios in patients with suspected or known nonvariceal upper gastrointestinal bleeding (UGIB). These clinical scenarios include suspected nonvariceal UGIB without endoscopy performed; endoscopically confirmed nonvariceal UGIB with clear source but treatment not possible or continued bleeding after endoscopic treatment; endoscopically confirmed nonvariceal UGIB without a confirmed source; suspected nonvariceal UGIB with negative endoscopy; and postsurgical or post-traumatic nonvariceal UGIB when endoscopy is contraindicated. The appropriateness of imaging modalities as they apply to each clinical scenario is rated as usually appropriate, may be appropriate, and usually not appropriate to assist the selection of the most appropriate imaging modality in the corresponding clinical scenarios of nonvariceal UGIB. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Usefulness of palliative radiotherapy in reducing the frequency of red blood cell transfusion in patients with malignant tumor bleeding

Objective

We aimed to evaluate the usefulness of palliative radiotherapy in reducing the frequency of red blood cell (RBC) transfusions in patients with malignant tumor bleeding as a quantitative value to evaluate the hemostatic effect.

Materials and Methods

In this study, we conducted a retrospective review of patients visiting our department between June 2013 and April 2021. All patients underwent RBC transfusions for 30 days before the initiation of radiotherapy. We determined the overall survival (OS) time and RBC transfusion-free (RBCTF) time using statistical tests.

Results

In total, 21 patients were enrolled in our study, including 13 women and 8 men; the median patient age was 63 years (range: 32-82 years). After radiotherapy, 19 of the 21 patients had a decreased frequency of requirement for RBC transfusion compared to that before radiotherapy. Fourteen patients had achieved an RBCTF state 1 month after radiotherapy. The estimated 1-year OS and RBCTF rates were 36.3% (95% confidence interval [CI]: 14.2%) and 66.7% (95% CI: 42.5%-42.5%), respectively.

Conclusion

The present study revealed a reduction in RBC transfusion after palliative radiotherapy in patients with malignant tumor bleeding. We believe that reducing the frequency of blood transfusions in patients with terminal conditions would have significant clinical benefits.

Transcatheter arterial embolization for cancer-related non-variceal upper gastrointestinal bleeding: A multicenter retrospective study of 107 patients

PURPOSE

The purpose of this study was to retrospectively evaluate the outcome of transcatheter arterial embolization (TAE) in the treatment of cancer-related non-variceal upper gastrointestinal bleeding (UGIB).

MATERIALS AND METHODS

One-hundred and seven patients who underwent TAE for the treatment of cancer-related non-variceal UGIB at five institutions between June 2016 and May 2019 were retrospectively included. There were 78 men and 29 women, with a mean age of 60.6 ± 13.2 (SD) (age range: 31-87 years). Clinical success was defined as no rebleeding within 30 days after TAE. Rebleeding was defined as non-variceal UGIB resulting in a decrease in hemoglobin > 2 g/dL within 24 h. The Kaplan-Meier method was used to estimate actuarial probabilities of rebleeding and survival within 30 days after TAE. Univariable and multivariable analyses were performed to identify variables associated with clinical success and 30-day mortality.

RESULTS

Technical success was achieved in 106 out of 107 patients (99.1%). Positive angiographic findings (contrast extravasation and pseudoaneurysm) were observed in 30/107 patients (28.0%). Empiric embolization was performed in 77/107 patients (72.0%). Clinical success was achieved in 60/107 patients (56.1%). The 3-day, 7-day, and 30-day actuarial probabilities of rebleeding were 21.5%, 31.0%, and 44.6%, respectively. No variables were identified as predictors of clinical success. Nineteen patients (19/107; 17.8%) died within 30 days after TAE; of them, 14 (14/107; 13.1%) died due to bleeding-related causes. The 3-day, 7-day, and 30-day actuarial probabilities of survival were 91.6%, 88.8%, and 77.4%, respectively. A baseline hemoglobin level of ≤ 60 g/L (Odds ratio [OR]: 3.376; 95% confidence interval [CI]: 1.223-9.318; P = 0.019) and clinical failure (OR: 6.149; 95% CI: 2.113-17.893; P = 0.001) were identified as predictors of 30-day mortality. Major complications (gastrointestinal perforation) occurred in one patient (1/107; 0.9%). Minor complications (abdominal pain, fever, and vomiting) occurred in 19 patients (19/107; 17.8%).

CONCLUSION

TAE is a safe treatment option for patients with cancer-related non-variceal UGIB, and seems to be effective in more than half of these patients.

Transarterial Embolization for Active Gastrointestinal Bleeding: Predictors of Early Mortality and Early Rebleeding

Background: The aim of this study was to determine predictive factors of early mortality and early rebleeding (≤30 days) following transarterial embolization (TAE) for treatment of acute gastrointestinal bleeding. Methods: All consecutive patients admitted for acute gastrointestinal bleeding to the interventional radiology department in a tertiary center between January 2012 and January 2022 were included. Exclusion criteria were patients: (1) aged < 18-year-old, (2) referred to the operation room without TAE, (3) treated for hemobilia, (4) with mesenteric hematoma, (5) lost to follow-up within 30 days after the procedure. We evaluated pre and per-procedure clinical data, biological data, outcomes, and complications. Results: Sixty-eight patients were included: 55 (80.9%) experienced upper gastrointestinal bleeding and 13 (19.1%) lower gastrointestinal bleeding. Median age was 69 (61−74) years. There were 49 (72%) males. Median hemoglobin was 7.25 (6.1−8.3) g/dL. There were 30 (50%) ulcers. Coils were used in 46 (67.6%) procedures. Early mortality was 15 (22.1%) and early rebleeding was 17 (25%). In multivariate analysis, hyperlactatemia (≥2 mmol/L) were predictive of early mortality (≤30 days). A high number of red blood cells units was associated with early rebleeding. Conclusion: This study identified some predictive factors of 30-day mortality and early rebleeding following TAE. This will assist in patient selection and may help improve the management of gastrointestinal bleeding.

Safety and efficacy of emergency transarterial embolization for mesenteric bleeding

Background

Patients with spontaneous or traumatic active mesenteric bleeding cannot be treated endoscopically. Transarterial embolization can serve as a potential alternative to emergency surgery. Literature on transarterial embolization for mesenteric bleeding remains very scarce. The objective of this study was to evaluate the safety and efficacy of transarterial embolization for mesenteric bleeding. We reviewed all consecutive patients admitted for mesenteric bleeding to the interventional radiology department, in a tertiary center, between January 2010 and March 2021. Mesenteric bleeding was defined as mesenteric hematoma and contrast extravasation and/or pseudoaneurysm visible on pre-operative CT scan. We evaluated technical success, clinical success, and complications.

Results

Among the 17 patients admitted to the interventional department for mesenteric bleeding, 15 presented with active mesenteric bleeding requiring transarterial embolization with five patients with hemodynamic instability. Mean age was 67 ± 14 years, including 12 (70.6%) males. Technical success was achieved in 14/15 (93.3%) patients. One patient with technical failure was treated by percutaneous embolization with NBCA-Lipiodol mixture. Three patients (20%) had early rebleeding: two were treated by successful repeat embolization and one by surgery. One patient (6.7%) had early death within 30 days and two patients (13.3%) had late death after 30 days. Mean length of hospitalization was 12.8 ± 7 days. There were no transarterial embolization-related ischemic complications.

Conclusion

Transarterial embolization is a safe and effective technique for treating mesenteric bleeding even in patients with hemodynamic instability. Transarterial embolization doesn’t close the door to surgery and could be proposed as first intention in case of mesenteric bleeding.

Management of Pancreatico-duodenal arterio-venous malformation

Purpose

To describe the interventional management and clinical outcome of pancreatico-duodenal arterio-venous malformations (PDAVMs).

Material and Methods

Seven patients presenting a PDAVM (6 women, 1 male; mean age: 61) were retrospectively reviewed. Technical, clinical success and complications of embolization and surgical management of symptomatic PDAVMs were assessed. Technical success was defined as a complete occlusion of the PDAVM and clinical success as no clinical symptom or recurrence during follow-up. Patients with asymptomatic PDAVMs were followed clinically, by Doppler ultrasound and CT-angiography.

Results

Mean follow-up time was 69 months (15-180). Five symptomatic patients presented with upper gastrointestinal bleeding (n=3), ascites (n=1), and abdominal pain (n=1). Two patients were asymptomatic. The PDAVMs were classified as follow: Yakes I (1), IIIa (2), IIIb (3) and IV (1). Five symptomatic patients were treated with 9 embolization sessions with arterial approach (onyx®, glue, coils) in 7 and venous approach in 2 (plugs, coils, covered stents, STS foam and onyx®). Technical success of embolization was 60% (3/5). Devascularization was incomplete for 2 Yakes IIIB patients. Clinical success of embolization was estimated at 80% (4/5) as one patient required additional surgery (Whipple) because of persistent bleeding. One splenic vein thrombosis was treated successfully by mechanical thrombectomy and heparin. No recurrence occurred during follow-up. No progression was documented in asymptomatic patients.

Conclusion

Embolization of symptomatic PDAVMs is effective and surgery should be performed in second intention. Complete devascularization is more difficult to obtain in Yakes III PDAVM.

Pancreaticobiliary Malignancies in the Emergency Room: Management of Acute Complications and Oncological Emergencies

Background

Management of pancreaticobiliary (PB) malignancies remains a clinical challenge. In this review, we focus on the management of oncological emergencies in PB malignancies and the potential complication of associated therapeutic interventions.

Methods

Biobliographic review of current evidence on the management of oncological emergencies, their potential complications, as well as synthesis of recommendations was performed. The pathogenesis, frequency, related symptoms as well as appropriate investigations are presented.

Results

The oncologic emergencies in PB patients were summarised in six categories: (1) hematological (including febrile neutropaenia, thrombocytopenia, coagulopathies), (2) gastrointestinal (gastric outlet and biliary obstruction, gastrointestinal bleeding), (3) thromboembolic events, (4) ascites, (5) metabolic disorders and (6) neurologic complications. The pathogenesis, frequency, related symptoms as well as appropriate investigations are also presented.

Conclusion

Patients with PB malignancies are at increased risk of a wide variation of medical emergencies. Clinical knowledge, early recognition and collaboration with the relevant specialties are critical to manage these complications effectively, tailoring overall management around the actual prognosis and individuals’ expectations.