Original Article

Treatment of acute lower gastrointestinal hemorrhage

by superselective transcatheter embolization
Rahul Sheth, Vimal Someshwar, Gireesh Warawdekar
Lilavati Hospital, Sir H N Hospital and Wockhardt Hospital, Mumbai

Aim: To evaluate the technical feasibility, success of

hemostasis, and complications of transcatheter em
bolization in the treatment of acute lower gastrointestinal
(GI) bleeding. Methods: Retrospective review of 63
patients with acute lower GI bleed who had under
gone transcatheter selective embolization of mesen
teric arteries over a two-year period. Embolization
was carried out only if the arteria recta leading to the
bleed could be successfully catheterized (n=52). The
lesions treated were located in the jejunum (n=13),
ileum and ileo-cecal region (n=9), appendicular re
gion (n=2) and colon (n=28). Embolization was per
formed with only polyvinyl alcohol particles (PVA)
(250-500 microns) in 23 patients, only microcoils in
16 patients, and both PVA particles and microcoils
in 13 patients. Twenty-eight patients were evaluated
for objective evidence of ischemia by colonoscopy
(n=21) and/or histologic evidence in the surgical speci
men (n=7); 23 patients were followed up clinically.
Results: Immediate hemostasis was achieved in 61
of 63 patients; of the remaining 2 patients, one un
derwent surgery whereas the other died during the
procedure. Recurrent bleeding occurred in 9 patients
6 were managed surgically, and 3 medically. Endo
scopic evaluation showed mucosal ischemia in 7
patients but they remained asymptomatic on follow
up. Embolization was the sole modality of treatment
in 41 patients (78.9%). Conclusion: Transcatheter
superselective embolization is an effective and safe
modality of treatment for acute lower GI bleeding.
[ Indian J Gastroenterol 2006;25:290-294]

reatment options for acute lower GI hemorrhage

include conservative medical management,
endoscopic coagulation, transcatheter embolization and
surgery. Although most bleeding episodes resolve
spontaneously with conservative management, 10%
15% of patients require some form of intervention. 1
Endoscopy is often the method of choice for
investigation and treatment of lower GI bleeding;
however, massive bleeding may preclude precise
localization of the site of hemorrhage. Surgery is
associated with significant morbidity and mortality. 2
The two transarterial treatment options available
are pharmacologic control using vasopressin infu
Copyright 2006 by Indian Society of Gastroenterology

sion and transcatheter embolization. Vasopressin in

fusion, though associated with high initial control
rate, is associated with high re-bleeding rate (20%
50%) on stopping the infusion and a high rate of
cardiovascular complications.3,4 Superselective cath
eterization and transcatheter vasopressin infusion avoids
the systemic complications of vasopressin and limits
the area of intestinal ischemia.
Although percutaneous embolization has been
widely used for treatment of upper GI hemorrhage, 5,6
there have been few studies to determine its efficacy
for lower GI bleeding. The main concern has been
a poor collateral supply in the lower GI tract. We
report a retrospective review of our experience with
embolization in patients with lower GI bleed.
Methods
We reviewed the case records of 63 patients (age
range 32-81 years [mean 56]) who had undergone
an attempt at angiographic embolization for acute
lower GI hemorrhage between February 2002 and
March 2004. The indications for angiography were
life-threatening hemorrhage, with negative colonoscopy
and upper GI endoscopy. Embolization was done in
only those cases (n=52 [83%]; 28 men) in whom
bleeding site could be demonstrated at angiography
and the bleeding vessels selectively catheterized. After
embolization, the patients were monitored for symp
toms, signs or laboratory evidence of intestinal is
chemia and for recurrent intestinal hemorrhage.
The patients were followed up for 3-18 months
(mean 10). In addition, 28 of 52 patients also under
went investigations to look for ischemia (colonoscopy
17, histological evaluation of tissue 7, or both 4).
Colonoscopy was done 7-180 days after the embo
lization procedure to look for infarcts, submucosal
hemorrhage, ulceration (in the early phase) and stric
tures (in the late phase). Seven patients underwent
surgery for persistent (n=1) or recurrent (n=6) bleeding
0-9 days after embolization.

Embolization technique
All patients underwent a diagnostic digital subtrac
tion angiography (DSA) and conventional (non-sub
tracted) angiography; the latter was done when the

Sheth, Someshwar, Warawdekar

Vascular embolization for lower GI hemorrhage

patient could not hold breath adequately, or it was

thought that bowel movements would interfere with
interpretation of DSA findings. Celiac, superior and
inferior mesenteric arteries were selectively cath
eterized, using either a 5 Fr Renal or Simmons 1
diagnostic catheter (Cordis, Johnson and Johnson,
USA). Embolization was performed only if the bleeding
site could be identified (Figs. 1 and 2). Superselective
catheterization of the vessel feeding the bleed site
was done using a coaxial 0.018/0.21 microcatheter
(Microferrete, Cook, USA; Progreat, Terumo, Ja
pan) and a 0.014/0.021 microwire system (Transend,
Boston Scientific; Terumo, Japan). Although in most
cases the target vessels were vasa recta supplying
the bleeding site, in a few cases (n=3) embolization

was done within the marginal artery of Drummond

or in the distal intestinal arcades/distal colonic branches.
The embolization agents used were polyvinyl alcohol
(PVA) particles (250-500 m in size; Contour, Tar
get Therapeutics, Boston Scientific) (n=23), or 0.018
Microcoils (Cook, USA) (n=16), or both (n=13).
After embolization, a check angiogram was per
formed. For PVA particles, occlusion of the feeding
vessel with stasis of the contrast material in it, and
reflux of contrast material into adjacent normal ves
sels were considered as success. For coils (with or
without PVA), total occlusion of the feeding vessel
without extravasation of the contrast material be
yond the coil was considered as success.

Fig 1: A: Superior mesenteric angiogram shows frank contrast extravasation of contrast material from branch of second
jejunal artery. B: Superselective catheterisation of feeder branch done using microcatheter/microwire system; contrast
extravasation seen. C: Angiogram post particulate and coil embolization shows cessation of contrast extravasation from
bleeding jejunal artery

Fig. 2: A: Inferior mesenteric angiogram shows frank contrast extravasation from left branch of superior rectal artery.
B: Superselective embolization done with PVA particles through microcatheter. Post embolization angiogram shows
cessation of contrast extravasation from bleeding vessel

Indian Journal of Gastroenterology 2006 Vol 25 November - December 291

Sheth, Someshwar, Warawdekar

Results
The causes and sites of bleeding are listed in the
Table. Embolization could not be done in 11 of 63
patients because of failure to localize the bleeding
site (n=7), severe vasospasm of the blood vessels
not relieved by vasodilators (n=3), or severe angu
lation of the feeder vessel precluding superselective
catherization (n=1). Among the 52 patients who
underwent embolization, 37 had catheterization of
the superior mesenteric artery and 15 had that of
the inferior mesenteric artery. Superselective cath
eterization of the superior mesenteric artery involved
the distal jejunal artery (n=13), ileal and ileo-colic
arteries (9), appendicular artery (2), a branch of the
middle colic artery (4), or a branch of the right
colic artery (9). Catheterization in the inferior me
senteric artery territory involved a branch of the left
colic artery (n=8), a branch of the sigmoid artery
(6) or a branch of the superior rectal artery (1). In
41 (79%) patients, embolization was the sole treat
ment modality.
Immediate hemostasis was achieved in 50 (96%)
of the 52 cases. In one patient with failed treatment,
the bleeding site was localized to the ileo-cecal junc
tion. In this patient, embolization with PVA particles
led to a sluggish blood flow in the feeder arteries
but the bleeding persisted; at surgery, multiple ul
cers involving the ileo-cecal junction and the cecum
were seen, and a resection-anastomosis was done.
Histological examination revealed the disease to be
tubercular in nature. The other patient with failed
treatment had been referred to us with massive bleed
ing, poor vital signs and a platelet count of 70,000/
mL. Angiography revealed bleeding from the sig
moid branch of the inferior mesenteric artery, pos
sibly due to diverticular disease. Embolization was
performed with microcoils; however the patient had
a massive cardio-respiratory arrest during the pro
cedure, and died despite resuscitative measures.
Table: Causes of lower gastrointestinal hemorrhage

Site of bleeding
Jejunum

Ileum and ileocolic

Appendix and colon

Number
13

9
30

Etiology
Number
Ulcerative
2
Angiodysplasia
3
Anastomotic
3
Unknown
5
Ulcerative
2
Unknown
7
Diverticulum
13
Angiodysplasia
4
Ulcerative colitis
1
Anastomotic
3
Unknown
9

Vascular embolization for lower GI hemorrhage

In 9 patients, the bleeding recurred 1-103 days
after successful initial embolization. Three of them
were treated conservatively. The other 6 patients
underwent surgical treatment; of these, one under
went attempt at repeat angiographic embolization of
the feeder artery (a branch of the middle colic ar
tery), which failed because of severe vasospasm
unresponsive to intra-arterial nitroglycerine and
nikorandil. In two of the 6 patients who underwent
surgery, recurrent hemorrhage was at the site of
initial embolization, and in 2 patients from a differ
ent site. At surgery, 2 patients underwent resectionanastomosis for ileo-cecal tuberculosis of ulcerative
variety, 2 underwent resection for diverticular dis
ease of the descending colon, 2 underwent total colec
tomy for ulcerative colitis, and 1 patient underwent
resection-anastomosis for a solitary ulcer in the dis
tal jejunum, probably due to long-term anti-inflam
matory drug use. Overall, 7 of the 52 (14%) pa
tients taken up for embolization required surgery for
persistent or recurrent hemorrhage.
Of the 52 patients who underwent emboliza
tion, one died; of the remaining 51, 28 underwent
evaluation for objective signs of ischemia (colonoscopy
17, histology 7, both 4) and 23 were followed up
clinically. Signs of post-embolization intestinal is
chemia were seen in 7 patients (25%), ischemic
infarcts (2), submucosal hemorrhages (4), ulcer
ation (1). These patients remained clinically asymp
tomatic and did not develop any long-term compli
cations. Mucosal ischemia was seen in all 7 pa
tients, with minimal inflammation.
One patient developed subacute intestinal ob
struction after 92 days, in the mid-jejunal region,
diagnosed on small bowel enema; this was managed
conservatively.
Discussion
Angiographic embolization is widely accepted as an
effective and safe treatment for upper GI hemor
rhage. The presence of a widespread collateral net
work in the upper GI tract makes embolization a
relatively safe procedure.
The first attempts at transcatheter embolization
for acute lower GI hemorrhage were reported by
Goldberger and Bookstein. 7 In 1982, Rosenkrantz et
al 8 reported colonic embolization in 23 patients, of
whom three had bowel necrosis. In initial years,
most procedures were done using large catheters.
With refinement of the technique and equipment,
and a better understanding of the vascular anatomy
of the small bowel and the colon, the results of

292 Indian Journal of Gastroenterology 2006 Vol 25 November - December

Sheth, Someshwar, Warawdekar

Vascular embolization for lower GI hemorrhage

transcatheter embolization therapy for acute lower

GI hemorrhage have improved. Thus, in four stud
ies, 9-12 superselective embolization was performed
in 47 patients with acute lower GI hemorrhage (small
bowel 18, colon 29). This was done usually at the
level of the marginal artery, distal intestinal arcade,
or vasa recta. Although a variety of occlusive agents
were used, in 29 patients coils were used alone or in
combination. Immediate hemostasis was achieved in
43 patients (91%) and in no case did infarction occur
as a direct result of the procedure. Two more recent
studies13,14 have reported success rates of 76% and
44%, respectively, for transcatheter embolization in
the treatment of acute lower GI hemorrhage.
The goal of embolization therapy is to decrease
the pulse pressure at the bleeding site to allow for
hemostasis. 7 Although the lower GI tract has a pau
city of large collaterals, it has rich intramural vascu
lar networks, which may protect against ischemia
during distal, selective embolization. 15,16,17 Thus, in
embolization for lower GI bleed, in order to reduce
the area at risk for ischemia, the most distal site
should be chosen.9 The vasa recta or marginal ar
tery seem to be the most plausible sites. This is
supported by recent evidence, including ours, which
report extremely low complication rates.9-12
A wide variety of embolization agents, including
gelfoam, PVA particles, liquid embolization agents
and microcoils, have been used. Gelfoam is no longer
widely used for lower GI hemorrhage since its ef
fect is temporary and it cannot easily be deployed in
a superselective manner. Similarly, liquid embolic agents
such as glue are suboptimal because of difficulty in
assessing adequate dilution and in controlling vascu
lar penetration. 18 Guy9 and Defreyne18 successfully
used PVA particles as the primary embolization agent
in the treatment of lower GI hemorrhage, with no
evidence of bowel infarction. However, there have
been some reports, though inconclusive, that PVA
particles may lead to post-embolization ischemia.19,20,21
The advent of coaxial microcatheters and
torquable microwires has made it possible to reach
the bleeding site in nearly all cases, leading to a
marked rise in the use of microcoils. These are available
in various diameters and lengths. Since the coils are
radio-opaque and their delivery can be reasonably
controlled, they are the agents of first choice in
transcatheter embolization. Funaki et al 22 have shown
that microcoils can achieve immediate hemostasis in
96% and long-term clinical success in 81% of pa
tients with colonic bleeding. Kuo et al 23 found
superselective microcoil embolization to be a safe

and effective technique for acute lower GI hemor

rhage, with immediate hemostasis in all their 22
patients, complete clinical success in 86% of pa
tients, and no major ischemic complications.
Transcatheter therapy cannot be done in the
presence of vasospasm and unfavorable vascular
anatomy. In addition, operator skill and experience
also play a role.
In conclusion, superselective transcatheter em
bolization using PVA particles or microcoils is an
effective and safe modality for the treatment of acute
lower GI hemorrhage. This treatment is not associ
ated with significant clinical ischemia or infarction,
and should be used in patients with failure of con
servative management.
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Correspondence to: Dr Sheth, 10 Krishna Kunj, 29/30 K M
Munshi Marg, Chowpatty, Mumbai 400 007. E-mail:
rahulsheth7@hotmail.com
Received May 24, 2006. Received in final revised form
September 4, 2006. Accepted November 4, 2006

294 Indian Journal of Gastroenterology 2006 Vol 25 November - December