The Department of Surgery, McGill University, Montréal, Que.
Can J Surg. 2012 Dec;55(6):382-8. doi: 10.1503/cjs.005611.
Ongoing gastrointestinal bleeding (GIB) following endoscopic therapy and deciding between mesenteric angiography and surgery often challenge surgeons. We sought to identify predictors of positive angiographic study (active contrast medium extravasation) and characterize outcomes of embolization for acute GIB.
We retrospectively analyzed angiographies for GIB at 2 teaching hospitals from January 2005 to December 2008. The χ2, Wilcoxon rank sum and t tests determined significance. A Cox proportional hazards model was used for multivariate analyses.
Eighteen of 83 (22%) patients had active extravasation on initial angiography and 25 (30%) were embolized. Patients with active extravasation had more packed red blood cell (PRBC; 5.3 v. 2.8 units, p < 0.001) and fresh frozen plasma (4.8 v. 1.7 units, p = 0.005) transfusions 24 hours preangiography and were more likely to be hemodynamically unstable at the time of the procedure (67% v. 28%, p = 0.001) than patients without active extravasation. Each unit of PRBC transfused increased the risk of a positive study by 30% (hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.2-1.6 per unit). Embolization did not decrease recurrent bleeding (53% v. 52%) or length of stay in hospital (28.1 v. 27.5 d, p = 0.95), but was associated with a trend toward fewer emergency surgical interventions (13% v. 26%, p = 0.31) and greater 30-day mortality (33% v. 7%, p = 0.006) than nonembolization. Blind embolization was performed in 10 of 83 (12%) patients and was found to be an independent predictor of death in patients without active extravasation (HR 9.2, 95% CI 1.5-55.9).
The number of PRBC units transfused correlates with greater likelihood of a positive study. There was a significant increase in mortality in patients who underwent angioembolization. Large prospective studies are needed to further characterize the indications for angiography and blind embolization.
内镜治疗后持续胃肠道出血（GIB）和在肠系膜血管造影术与手术之间做出选择常常使外科医生面临挑战。我们旨在确定阳性血管造影研究（活性对比剂外渗）的预测因素，并描述急性 GIB 栓塞治疗的结果。
我们回顾性分析了 2005 年 1 月至 2008 年 12 月在 2 所教学医院进行的 GIB 血管造影检查。χ2、Wilcoxon 秩和检验和 t 检验确定了显著性。采用 Cox 比例风险模型进行多变量分析。
18 例（22%）患者的初始血管造影检查有活性外渗，25 例（30%）患者接受了栓塞治疗。有活性外渗的患者在血管造影检查前 24 小时接受的红细胞（PRBC）（5.3 v. 2.8 单位，p < 0.001）和新鲜冷冻血浆（4.8 v. 1.7 单位，p = 0.005）输注量更多，并且在手术时更可能出现血流动力学不稳定（67% v. 28%，p = 0.001）比没有活性外渗的患者。每单位 PRBC 的输注增加了 30%的阳性研究风险（危险比[HR] 1.3，95%置信区间[CI] 1.2-1.6/单位）。栓塞治疗并未降低复发性出血（53% v. 52%）或住院时间（28.1 v. 27.5 d，p = 0.95），但与较少的紧急手术干预（13% v. 26%，p = 0.31）和 30 天死亡率较高（33% v. 7%，p = 0.006）相关，而非栓塞治疗。在 83 例患者中（12%）进行了 10 例盲目栓塞治疗，并且发现对于没有活性外渗的患者，盲目栓塞治疗是死亡的独立预测因素（HR 9.2，95%CI 1.5-55.9）。
PRBC 单位输注量与阳性研究的可能性更大相关。接受血管造影栓塞治疗的患者死亡率显著增加。需要进行大型前瞻性研究以进一步确定血管造影和盲目栓塞治疗的适应证。
