Percutaneous endovascular embolization of a gastrointestinal bleeding

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Gastrointestinal bleeding (GIB) is defined as the hemorrhage originating from one or more vessels of the digestive tract.
Clinical status can be extremely variable: some patients are completely asymptomatic (occult bleeding), some others show rapid onset of an hemorrhagic shock.
According to the site of bleeding, GIB are classified in UPPER (UGIB; oral cavity, esophagus, stomach, duodenum) and LOWER (LGIB; small bowel, colon, rectum and anus).

Multiple possibile causes of GI have been describe:

Idiopathic
Neoplastic
Traumatic
Angiodysplasia
Inflammatory
Other

When a GIB is suspected patient management usually changes according to the supposed origin of the bleeding:

UGIB are directly managed with endoscopy that carries out both the diagnostic and therapeutic function. If endoscopy fails to control bleeding, endovascular management is a valid option. CT scan evaluation should be performed before endovascular approach in order to identify the site of bleeding and obtain a vascular map.

LGIB usually cannot be managed with endoscopy due to a lack of intestinal toilet. If the patient is clinically stable, CT scan first and endovascular management later are performed.

PROCEDURAL STEPS AND TECHNIQUE
Vascular access is performed after local anesthesia usually at the common femoral or radial artery site. Vessel puncture can be achieved at free-hand or under ultrasound/fluoroscopic guidance. Once the needle is in the vascular lumen a guidewire is passed through the needle and an arterial vascular sheath is finally placed in the artery. On the basis of the CT examination a diagnostic catheter is placed at the origin of the main vessel (celiac trunk, superior and inferior mesenteric arteries) that is suspected of bleeding. Diagnostic angiography is performed and bleeding site is usually identified. A microcatheter is afterwards moved as near as possible to the site of bleeding and embolization is performed after the embolic agent (Coils, Glue, PVA, Gelfoam, Stent, ecc…) is chosen.

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