Mesenteric Angiography and Embolization for GI Bleeding in IR

Mesenteric Angiography and Embolization for GI Bleeding in IR Barbara Wilkey, MD Bob Ryu, MD

Purpose: The purposes of this document are 1) To provide education pertaining to the process of Messenteric Angiography and emoboilization for GI bleeding in IR and this population’s common peri- procedure management concerns. 2) To provide peri-procedure management suggestions.

Content: This content is a combination of published literature and peer recommendation (Interventional Radiology and Anesthesiology).

The procedure

Most common indications: arteriography diagnosis and embolization for cessation of acute upper or lower gastrointestinal hemorrhage

Length of procedure: 1-2 hours of IR MD time

Antibiotic prophylaxis: not routinely, although at the operator’s discretion

Imaging: ultrasound, fluoroscopy

Contrast agents: intravenous iodinated contrast, CO2

Ancillary procedures: none routinely, although central venous access is requested occasionally.

Preprocedural testing: CTA, nuclear medicine tagged RBC scan, routine laboratory tests including comprehensive blood chemistries (Cr, etc), hematology (plt >50K), coagulation parameters (INR<2), type and screen/crossmatch (for actively bleeding patients)

Patient positioning: supine, mostly performed from right femoral artery; left femoral or transradial approaches are also occasionally used.

Procedural details: Ultrasound guided femoral artery access, selective catheterization/arteriography of celiac artery, superior mesenteric artery, inferior mesenteric artery, left gastric artery, gastroduodenal artery, embolization of targeted bleeding branch, completion arteriography of potential collateral pathways after embolization, removal or arterial access sheath and deployment of hemostasis device. The patient severity of bleeding will vary significantly from case to case. Specific management should be tailored to the needs of the individual patient and their comorbidites. All patients with active upper GI bleeds should have general anesthesia with a cuffed endotracheal tube or cuffed trach tube unless there is a strongly compelling reason to do otherwise. Maintenance of paralysis is helpful if the patient is under general anesthesia as respiratory movement degrades mesenteric angiography images. MAC may be appropriate for patients with sub- acute lower GI bleeds who are hemodynamically stable and cooperative.

The pre-anesthesia assessment starts with a standard evaluation, with careful attention to the following:

1) Hemodynamic stability. 2) Transfusion requirements. Massive Transfusion Protocol is initiated if the patient likely will require 10U PRBCs in 12 hours, greater than 4u PRBCs in 4 hours, has active bleeding or hemodynamic instability (Blood Bank 8-4444). Use emergency release (uncrossmatched Type O) PRBCs if crossmatched PRBCs are not ready then switch to crossmatched PRBCs when available (as guided by UCH Blood Bank policy). Please also see CVC document entitled regarding how to get blood products in the CVC. 3) Amount of blood product available for the patient. 4) TRALI, TACO or other complication of transfusion. 5) Coagulopathy (Consider baseline TEG). 6) Presence or absence of acidosis from hypoperfusion. 7) IV access, both actual and potential.

Room Setup standard set up plus an additional large bore peripheral IV, pumps for any necessary infusions, and a Level One if there is active bleeding. Invasive arterial blood pressure monitoring is appropriate if there is active bleeding or transfusion. Central venous access may be necessary if not already present and/or the patient does not have adequate peripheral access.

Anesthesia induction:

- Patients who require intubation should have a rapid sequence induction. - Consider avoiding propofol in patients who have evidence of volume depletion pre-operatively. - Consider placement of a pre-induction arterial line for patients who have evidence of intravascular depletion.

Maintenance Agent of choice with consideration of hemodynamic stability.

Emergence/extubation/disposition is at the discretion of the anesthesia team. Patients received from the ICU generally go back to the ICU.

Procedural Risks -Access site hematoma (<2%) - Continued GI hemorrhage - Contrast induced nephropathy (especially for elderly, diabetes, or chronic renal insufficiency). -Intestinal ischemia is rarely reported after embolization and usually manifests 2-12 hours after the procedure).