Correspondence Acta Radiologica 2014, Vol. 55(3) 325–326 ! The Foundation Acta Radiologica 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0284185113511081 acr.sagepub.com
Transcatheter arterial embolization for gastroduodenal ulcer bleeding: the use of cyanoacrylate glue has gained acceptance We read with great interest the article by Mine et al. (1) recently published in Acta Radiologica and reporting outcomes of transcatheter arterial embolization (TAE) using N-butyl cyanoacrylate (NBCA) in patients with acute arterial bleeding from gastroduodenal ulcers. We have several comments. First of all, we would like to congratulate the authors for their study, which represents one of the most important series to date reporting results on TAE with NBCA glue as an embolic agent in such a setting. TAE has gained widespread acceptance for first-line treatment of acute upper gastrointestinal (GI) bleeding resistant to endoscopic therapy over the last decade (1–3). Coils have emerged as the currently preferred embolic agent for upper GI bleedings. However, higher rates of recurrent bleeding have been reported with coil embolization, especially in patients with coagulopathy (2). Indeed, we previously reported our experience with TAE used to treat refractory massive bleeding from gastroduodenal ulcers (2). Using coils alone to occlude the feeding artery and the presence of a coagulation disorder significantly predicted early rebleeding. Furthermore, no cases of rebleeding occurred in the 10 patients in whom NBCA was used alone for selective embolization of the bleeding vessel, and no cases of bowel ischemia occurred. High clinical success rate with the use of glue is confirmed in the present study, as recently reported in other studies (4,5), suggesting that this embolic agent has gained acceptance. So we absolutely agree with Mine et al. (1) about efficacy and safety of glue embolization in gastroduodenal ulcer bleeding. In our institution, selective TAE using NBCA glue as the only embolic agent has became the salvage treatment of choice of upper GI bleeding from gastroduodenal ulcers. We find the use of NBCA glue particularly interesting in hemodynamically unstable patients or in cases of underlying coagulopathy, because it provides faster and better hemostasis than other embolic agents, as described by the authors (1). However, we want to
stress the fact that the use of NBCA requires training and considerable experience, given the risk of bowel infarction and glue reflux into other vessels. Reflux of NBCA may also result in its polymerization to the catheter tip. This bit of NBCA may then be stripped from the catheter during catheter retraction, resulting in non-target embolization. Prompt microcatheter removal after injection can significantly reduce this risk (2), but can be problematic because it gives up superselective vessel access before confirmation of adequate cessation of hemorrhage. A last drawback is the potential risk of bowel stenosis in the long term as suggested by Lang et al. (6) who reported a 25% duodenal stenosis rate in a study of 28 patients followed up for at least 5 years after TAE for bleeding duodenal ulcers. In the present study (1), follow-up endoscopic evaluations were performed only within 30 days of follow-up, after a mean delay of less than 10 days. Otherwise, evidence of arterial embolization-induced bowel stricture cannot be really appreciated on the long-term. In conclusion, our experience and recent literature suggest that TAE using cyanoacrylate glue in welltrained hands could be more effective in controlling bleeding from the upper GI tract than other embolic agents if used with great caution, and does not cause more ischemic complications. NBCA may be specifically useful in the setting of hemodynamic instability, coagulopathy, extreme vessel tortuosity, and narrowed vessels that are not amenable to distal embolization by microcoils. However, NBCA glue should not be used by interventional radiologists without a large experience with its use in other territories.
References 1. Mine T, Murata S, Nakazawa K, et al. Glue embolization for gastroduodenal ulcer bleeding: contribution to hemodynamics and healing process. Acta Radiol 2013;54:934–938. 2. Loffroy R, Guiu B, D’Athis P, et al. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol 2009;7:515–523.
326 3. Loffroy R, Lin M, Thompson C, et al. A comparison of the results of arterial embolization for bleeding and nonbleeding gastroduodenal ulcers. Acta Radiol 2011;52:1076–1082. 4. Yata S, Ihaya T, Kaminou T, et al. Transcatheter arterial embolization of acute arterial bleeding in the upper and lower gastrointestinal tract with N-butyl-2-cyanoacrylate. J Vasc Interv Radiol 2013;24:422–431. 5. Huang CC, Lee CW, Hsiao JK, et al. N-butyl cyanoacrylate embolization as the primary treatment of acute hemodynamically unstable lower gastrointestinal hemorrhage. J Vasc Interv Radiol 2011;22:1594–1599.
Acta Radiologica 55(3) 6. Lang EK. Transcatheter embolization in management of hemorrhage from duodenal ulcer: long-term results and complications. Radiology 1992;182:703–707.
Romaric Loffroy University of Dijon School of Medicine, Bocage Teaching Hospital 14 Rue Gaffarel BP 77908 Dijon, 21079 France Email: [email protected]
Copyright of Acta Radiologica is the property of Sage Publications, Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Transcatheter arterial embolization for gastroduodenal ulcer bleeding: the use of cyanoacrylate glue has gained acceptance We read with great interest the article by Mine et al. (1) recently published in Acta Radiologica and reporting outcomes of transcatheter arterial embolization (TAE) using N-butyl cyanoacrylate (NBCA) in patients with acute arterial bleeding from gastroduodenal ulcers. We have several comments. First of all, we would like to congratulate the authors for their study, which represents one of the most important series to date reporting results on TAE with NBCA glue as an embolic agent in such a setting. TAE has gained widespread acceptance for first-line treatment of acute upper gastrointestinal (GI) bleeding resistant to endoscopic therapy over the last decade (1–3). Coils have emerged as the currently preferred embolic agent for upper GI bleedings. However, higher rates of recurrent bleeding have been reported with coil embolization, especially in patients with coagulopathy (2). Indeed, we previously reported our experience with TAE used to treat refractory massive bleeding from gastroduodenal ulcers (2). Using coils alone to occlude the feeding artery and the presence of a coagulation disorder significantly predicted early rebleeding. Furthermore, no cases of rebleeding occurred in the 10 patients in whom NBCA was used alone for selective embolization of the bleeding vessel, and no cases of bowel ischemia occurred. High clinical success rate with the use of glue is confirmed in the present study, as recently reported in other studies (4,5), suggesting that this embolic agent has gained acceptance. So we absolutely agree with Mine et al. (1) about efficacy and safety of glue embolization in gastroduodenal ulcer bleeding. In our institution, selective TAE using NBCA glue as the only embolic agent has became the salvage treatment of choice of upper GI bleeding from gastroduodenal ulcers. We find the use of NBCA glue particularly interesting in hemodynamically unstable patients or in cases of underlying coagulopathy, because it provides faster and better hemostasis than other embolic agents, as described by the authors (1). However, we want to
stress the fact that the use of NBCA requires training and considerable experience, given the risk of bowel infarction and glue reflux into other vessels. Reflux of NBCA may also result in its polymerization to the catheter tip. This bit of NBCA may then be stripped from the catheter during catheter retraction, resulting in non-target embolization. Prompt microcatheter removal after injection can significantly reduce this risk (2), but can be problematic because it gives up superselective vessel access before confirmation of adequate cessation of hemorrhage. A last drawback is the potential risk of bowel stenosis in the long term as suggested by Lang et al. (6) who reported a 25% duodenal stenosis rate in a study of 28 patients followed up for at least 5 years after TAE for bleeding duodenal ulcers. In the present study (1), follow-up endoscopic evaluations were performed only within 30 days of follow-up, after a mean delay of less than 10 days. Otherwise, evidence of arterial embolization-induced bowel stricture cannot be really appreciated on the long-term. In conclusion, our experience and recent literature suggest that TAE using cyanoacrylate glue in welltrained hands could be more effective in controlling bleeding from the upper GI tract than other embolic agents if used with great caution, and does not cause more ischemic complications. NBCA may be specifically useful in the setting of hemodynamic instability, coagulopathy, extreme vessel tortuosity, and narrowed vessels that are not amenable to distal embolization by microcoils. However, NBCA glue should not be used by interventional radiologists without a large experience with its use in other territories.
References 1. Mine T, Murata S, Nakazawa K, et al. Glue embolization for gastroduodenal ulcer bleeding: contribution to hemodynamics and healing process. Acta Radiol 2013;54:934–938. 2. Loffroy R, Guiu B, D’Athis P, et al. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol 2009;7:515–523.
326 3. Loffroy R, Lin M, Thompson C, et al. A comparison of the results of arterial embolization for bleeding and nonbleeding gastroduodenal ulcers. Acta Radiol 2011;52:1076–1082. 4. Yata S, Ihaya T, Kaminou T, et al. Transcatheter arterial embolization of acute arterial bleeding in the upper and lower gastrointestinal tract with N-butyl-2-cyanoacrylate. J Vasc Interv Radiol 2013;24:422–431. 5. Huang CC, Lee CW, Hsiao JK, et al. N-butyl cyanoacrylate embolization as the primary treatment of acute hemodynamically unstable lower gastrointestinal hemorrhage. J Vasc Interv Radiol 2011;22:1594–1599.
Acta Radiologica 55(3) 6. Lang EK. Transcatheter embolization in management of hemorrhage from duodenal ulcer: long-term results and complications. Radiology 1992;182:703–707.
Romaric Loffroy University of Dijon School of Medicine, Bocage Teaching Hospital 14 Rue Gaffarel BP 77908 Dijon, 21079 France Email: [email protected]
Copyright of Acta Radiologica is the property of Sage Publications, Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
