Prophylactic transcatheter arterial embolization for high-risk ulcers following endoscopic hemostasis: a meta-analysis

Recent progress in polysaccharide microsphere-based hemostatic material for intravascular and extravascular hemostasis: A review

Hemorrhage, a common consequence of diseases, surgical procedures, and traffic accidents, poses a significant threat to public health. Effective hemostasis is crucial for patient survival and prognosis, particular in case of internal bleeding. While polysaccharide microsphere-based hemostatic materials have gained clinical acceptance due to their effectiveness, good biocompatibility, and versatility in both intravascular and extravascular hemostasis, they are limited by their single function and insufficient hemostatic properties. Recently, booming developments have been witnessed in microsphere-based biomaterials to achieve a combination therapy for hemostasis. This review first examines the fundamentals of coagulation process, hemostatic mechanisms, and microsphere fabrication techniques. We then discuss the latest investigations in functionalized microsphere-based hemostatic materials for controlling intravascular and extravascular hemorrhage, focusing on design strategies, hemostatic properties, and clinical implementation. Finally, we also propose some limitations and challenges of these hemostatic materials, aiming to provide valuable insights for future research in novel polysaccharide microsphere-based biomaterial.

Prophylactic transarterial embolization in patients with bleeding peptic ulcers following endoscopic control of bleeding

BACKGROUND

Bleeding peptic ulcer is a serious condition that often requires immediate endoscopic or surgical intervention to stop the bleeding (haemostasis). Following haemostasis, patients are at risk of rebleeding, leading to reintervention and risk of morbidity or mortality. In order to prevent rebleeding and associated complications, prophylactic measures have been developed and investigated. Prophylactic transarterial embolization (TAE), where the blood vessel leading to the site of the bleeding ulcer is closed via embolization (e.g. using coils to stop blood flow), has emerged as a potential therapeutic approach to address this challenge. However, a comprehensive evaluation of its efficacy and impact on patient outcomes is essential.

OBJECTIVES

To assess the effects of prophylactic transarterial embolization after successful endoscopic treatment compared with endoscopic haemostasis only on the risk of rebleeding after bleeding peptic ulcer, in patients where endoscopic haemostasis has been successful.

SEARCH METHODS

In August 2023 we searched CENTRAL, MEDLINE, Embase, PubMed Central, Clinicaltrials.gov and the International Clinical Trials Registry Platform (ICTRP). There were no language or publication status constraints.

SELECTION CRITERIA

This review included prospective randomized controlled trials that evaluated prophylactic TAE in patients with bleeding peptic ulcers. The selection process involved meticulous screening, full-text reviews, and considerations of study design, intervention, and patient populations.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and conducted risk of bias assessments. The outcomes of interest were rebleeding within 30 days, need for reintervention within 30 days, 30-day mortality, complications within 30 days, duration of hospitalization and success rate of the embolization. We contacted authors of included studies for missing and more detailed data, allowing us to carry out sensitivity analyses. We used GRADE to assess the certainty of evidence.

MAIN RESULTS

The review includes two studies involving 346 participants. Prophylactic TAE may not reduce the odds of rebleeding within 30 days (odds ratio (OR) 0.58, 95% confidence interval (CI) 0.18 to 1.83; 2 studies, 346 participants; low-certainty evidence). There may be little or no effect on reintervention rates per event (OR 0.68, 95% CI 0.35 to 1.35; 2 studies, 346 participants; low-certainty evidence) or per participant (OR 0.65, 95% CI 0.25 to1.69; 2 studies, 346 participants; low-certainty evidence), and there may be no reduction in 30-day mortality (OR 0.41, 95% CI 0.14 to 1.21; 2 studies, 346 participants; low-certainty evidence). Unfortunately, we were unable to analyze complications other than rebleeding, reintervention and mortality, as data for these outcomes were not available in the included studies. The duration of hospitalization may be shorter for participants undergoing prophylactic TAE (mean difference (days) -2.41, 95% CI -4.06 to -0.76; 2 studies, 346 participants; low-certainty evidence). Overall, the risk of bias in the included studies was low, but there was a high risk of performance bias and detection bias as none of the included studies were blinded. Further, one study had a high risk of selection bias as the randomization lists were created by the primary investigator.

AUTHORS' CONCLUSIONS

In conclusion, there is low-certainty evidence that prophylactic TAE may not reduce the odds of rebleeding, reintervention or mortality for participants following peptic ulcer bleeding. It may, however, reduce the duration of hospitalization. Ultimately, due to the limited number of studies and participants, further research with larger populations is warranted to validate these findings and explore additional outcomes, including adverse events other than rebleeding, reintervention and mortality.

Preliminary report on embolization with quick-soluble gelatin sponge particles for angiographically negative acute gastrointestinal bleeding

Prophylactic embolization is usually performed using gelatin sponge particles, which are absorbed within several weeks, for managing angiographically negative gastrointestinal bleeding. This study aimed to evaluate the safety and effectiveness of transcatheter arterial embolization (TAE) with quick-soluble gelatin sponge particles (QS-GSP) that dissolve in less than 4 h for treating angiographically negative gastrointestinal bleeding. We included ten patients (M:F = 7:3; mean age, 64.3 years) who underwent prophylactic TAE with QS-GSP for angiographically negative acute gastrointestinal bleeding between 2021 and 2023. The technical success rate of TAE, clinical outcomes focusing on rebleeding, and procedure-related complications were evaluated. The embolized arteries were the gastroduodenal (n = 3), jejunal (n = 4), and ileal (n = 3) arteries. QS-GSP (150-350 µm or 350-560 µm) were used alone (n = 8) or in combination with a coil (n = 1). A 100% technical success rate was accomplished. In 1 patient (10%), rebleeding occurred 2 days after prophylactic TAE of the gastroduodenal artery, and this was managed by repeat TAE. There were no procedure-related complications. The use of QS-GSP for prophylactic TAE appears to be safe and effective for controlling bleeding among patients with angiographically negative gastrointestinal bleeding. There were no cases of related ischemic complications of the embolized bowels likely attributable to recanalization of the affected arteries following biodegradation of QS-GSP.

Pulsation of visible vessel or adherent clot in duodenal ulcer may indicate pseudoaneurysm: Case series

RATIONALE

Owing to the anatomical characteristics of the duodenum, gastroduodenal artery (GDA) pseudoaneurysms can be caused by duodenal ulcers, which may rupture and lead to massive or repeated bleeding. Pseudoaneurysms are usually diagnosed using enhanced computerized tomography or angiography, whereas endoscopic signs have rarely been reported.

PATIENT CONCERNS

Three patients aged 18 to 83 years with bleeding duodenal ulcers and GDA pseudoaneurysms were treated.

DIAGNOSIS

All patients had symptoms of gastrointestinal bleeding, and endoscopy revealed duodenal ulcers with visible vessels or adherent clot pulsations. Angiography confirmed the presence of a GDA pseudoaneurysm, which had an adjacent relationship with the duodenum.

INTERVENTIONS

The GDA pseudoaneurysm was embolized in each patient.

OUTCOMES

Through transcatheter arterial embolization, endoscopic treatment, and traditional treatment, hematemesis or melena was gradually stopped and all patients were discharged.

LESSONS

The pulsation of visible vessels or adherent clots observed during endoscopy in patients with duodenal ulcer may indicate the formation of a gastroduodenal artery pseudoaneurysm. Therefore, we suggest that such patients receive enhanced computerized tomography or angiography to assess whether they need timely endovascular intervention treatment to avoid bleeding caused by a pseudoaneurysm.