Department of Vascular and Interventional Radiology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium.
Eur Radiol. 2021 Apr;31(4):2161-2172. doi: 10.1007/s00330-020-07232-7. Epub 2020 Sep 22.
To evaluate the clinical effect and safety of cone-beam CT (CBCT)-guided empirical embolization for acute lower gastrointestinal bleeding (LGIB) in patients with a positive CT angiography (CTA) but subsequent negative digital subtraction angiography (DSA).
A retrospective study of consecutive LGIB patients with a positive CTA who received a DSA within 24 h from January 2008 to July 2019. Patients with a positive DSA were treated with targeted embolization (TE group). Patients with a negative DSA underwent an empiric CBCT-guided embolization of the assumed ruptured vas rectum (EE group) or no embolization (NE group). Recurrent bleeding, major ischemic complications, and in-hospital mortality were compared by means of Fisher's exact test. Further subgroup analysis was performed on hemodynamic instability.
Eighty-five patients (67.6 years ± 15.7, 52 men) were included (TE group, n = 47; EE group, n = 19; NE group, n = 19). If DSA was positive, technical success of targeted embolization was 100% (47/47). If DSA was negative and the intention to treat by empiric CBCT-guided embolization, technical success was 100% (19/19). Recurrent bleeding rates in the TE group, EE group, and NE group were 17.0% (8/47), 21.1% (4/19), and 52.6% (10/19) respectively. Empiric CBCT-guided embolization reduced rebleeding significantly in patients with a negative DSA and hemodynamic instability (EE group, 3/10 vs NE group, 10/12, p = .027). Major ischemic complications occurred in one patient (TE group). Overall, the in-hospital mortality rate was 7.1% (6/85).
Empiric cone-beam CT-guided embolization proved to be a feasible, effective, and safe treatment strategy to reduce rebleeding and improve clinical success in hemodynamically unstable patients with acute LGIB, positive CTA but negative DSA.
• A novel transarterial embolization technique guided by cone-beam CT could be developed extending the "empiric" embolization strategy to lower gastrointestinal bleeding. • By implementing the empiric treatment strategy, nearly all patients with an active lower gastrointestinal bleeding on CTA will be eligible for a superselective empiric embolization, even if subsequent catheter angiography is negative. • In patients with a negative catheter angiography, empiric embolization reduces the rebleeding rate and, particularly in hemodynamically unstable patients, improves clinical success compared with a conservative "wait-and-see" management.
评估锥形束 CT（CBCT）引导的经验性栓塞治疗 CT 血管造影（CTA）阳性但随后数字减影血管造影（DSA）阴性的急性下消化道出血（LGIB）患者的临床效果和安全性。
回顾性分析 2008 年 1 月至 2019 年 7 月连续收治的 CTA 阳性且在 24 小时内接受 DSA 的 LGIB 患者。DSA 阳性患者采用靶向栓塞（TE 组）治疗。DSA 阴性患者行假设破裂直肠血管的经验性 CBCT 引导栓塞（EE 组）或不行栓塞（NE 组）。采用 Fisher 确切概率法比较复发性出血、主要缺血性并发症和住院死亡率。对血流动力学不稳定的患者进行进一步的亚组分析。
共纳入 85 例患者（67.6 岁±15.7 岁，52 例男性）（TE 组 47 例，EE 组 19 例，NE 组 19 例）。如果 DSA 阳性，靶向栓塞的技术成功率为 100%（47/47）。如果 DSA 阴性且意向行经验性 CBCT 引导栓塞治疗，技术成功率为 100%（19/19）。TE 组、EE 组和 NE 组的复发出血率分别为 17.0%（8/47）、21.1%（4/19）和 52.6%（10/19）。在 DSA 阴性且血流动力学不稳定的患者中，经验性 CBCT 引导栓塞可显著降低复发出血率（EE 组 3/10 与 NE 组 10/12，p=0.027）。1 例患者发生严重缺血性并发症（TE 组）。总体而言，住院死亡率为 7.1%（6/85）。
经验性锥形束 CT 引导栓塞可降低血流动力学不稳定的急性 LGIB、CTA 阳性但 DSA 阴性患者的再出血率并提高临床成功率，是一种可行、有效且安全的治疗策略。
一种新的经动脉栓塞技术可通过锥形束 CT 引导，将“经验性”栓塞策略扩展到下消化道出血。
通过实施经验性治疗策略，几乎所有 CTA 上有活动性下消化道出血的患者都有资格接受超选择性经验性栓塞，即使随后的导管血管造影为阴性。
在导管血管造影阴性的患者中，与保守的“观察等待”管理相比，经验性栓塞可降低再出血率，特别是在血流动力学不稳定的患者中，可提高临床成功率。
