Embolization of Bleeding Duodenal Ulcer Using Amplatzer Vascular Plug II and Hydrogel Coils: Case Report Vascular and Endovascular Surgery 45(3) 307-310 ª The Author(s) 2011 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1538574411399158 http://ves.sagepub.com Ahmed K. Abdel-Aal, MD, MSc1, Sherif Osman, MD, MSc1, Maysoon F. Hamed, MD, MSc2, Souheil Saddekni, MD, FSIR, FAHA1, and Wael E. A. Saad, MD, FSIR3 Abstract Purpose: To present a case of upper gastrointestinal bleeding (UGIB) that was treated with percutaneous endovascular embolization using Amplatzer vascular plug and hydrogel coils after failed endoscopic treatment. Case Report: A 78-year-old male was referred for endovascular treatment of massive recurrent UGIB from a duodenal ulcer. Attempts at endoscopic treatment were unsuccessful. Based on our knowledge of the site of the bleeder in the duodenum from prior endoscopy, we decided to empirically embolize the gastroduodenal artery (GDA) and the right gastroepiploic artery using a combination of coils (Azur peripheral hydrocoil; Terumo Medical Corporation, Somerset, New Jersey) and Amplatzer vascular plug II (AVP II; AGA Medical, Plymouth, Minnesota). Conclusion: We present this case of UGIB where effective, rapid, precise, and controlled embolization of the GDA was achieved using AVP II device in combination with coils. To our knowledge, the use of AVP II in embolization of GDA for treatment of emergent UGIB has not been described in the literature. Keywords upper gastrointestinal bleeding, duodenal ulcer, Amplatzer Vascular Plug II, gastroduodenal artery, hydrogel coils Introduction Upper gastrointestinal bleeding (UGIB) is defined as gastrointestinal bleeding originating proximal to the ligament of Treitz. The most common cause of acute nonvariceal UGIB is peptic ulcer disease. Effective treatment requires resuscitation followed by endoscopic examination and treatment. Of the small group of patients who fail endoscopic therapy, some are treated surgically. Increasingly, the majority of patients who fail endoscopic treatment are referred for transcatheter embolization which has been shown to be effective in controlling hemorrhage and decreasing mortality due to gastric or duodenal ulcers. The Amplatzer vascular plug II (AVP-II) is a recently developed embolization device. To our knowledge, its use in embolization of gastroduodenal artery (GDA) for treatment of emergent UGIB has not been described in the literature. We present this case of UGIB where effective, rapid, precise, and controlled embolization of the GDA was achieved using a combination of coils and AVP II device. Case Report A 78-year-old male with duodenal ulcer presented to us with recurrent massive UGIB causing hemodynamic instability and necessitating volume replacement with 5 units of packed red blood cell (RBC) transfusion. The patient had a history of acute coronary syndrome, hypertension, and chronic kidney disease. The patient had a similar episode of UGIB a week earlier which was treated endoscopically using epinephrine injections, metal clips, and heater probe applied to the bleeding area which was located at the superior genu of the duodenum. After resuscitation, repeat esophagogastroduodenoscopy (EGD) was performed which identified the ulcer location at the anterior portion of the superior duodenal genu and confirmed the presence of a pulsating, intermittently bleeding vessel at the superior margin of the ulcer that failed to compress with heater probe. Attempts at metal clip placement were unsuccessful due to firm consistency of the ulcer edge. 1 Division of Vascular and Interventional Radiology, Department of Radiology, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA 2 Brookdale University Hospital and Medical Center, Brooklyn, New York, USA 3 University of Virginia Health System, Charlottesville, Virginia, USA Corresponding Author: Ahmed K. Abdel Aal, Division of Vascular and Interventional Radiology, Department of Radiology, University of Alabama at Birmingham (UAB), 619 19th Street South, Birmingham, AL 35249, USA Email: akamel@uabmc.edu Downloaded from ves.sagepub.com at OhioLink on March 13, 2015 308 Vascular and Endovascular Surgery 45(3) Figure 2. Coils placed in the right gastroepiploic artery distal to the metal clips (presumed site of bleeding duodenal ulcer) to avoid back bleeding. Figure 1. A 78-year-old male with massive recurrent upper gastrointestinal bleeding. Celiac arteriogram shows no evidence of active contrast extravasation or any signs of active bleeding. Metallic clips from prior endoscopic intervention are seen along the course of the right gastroepiploic artery (arrows). Other metallic clips are from prior cholecystectomy. Due to failure of endoscopic treatment twice, the patient was referred for endovascular treatment of his UGIB. Access was obtained through the right femoral artery and aortic angiogram using 4-French omniflush catheter (Angiodynamics, Queensbury, New York) was performed showing no arterial anatomical variants. Selective angiography of the celiac trunk was then performed using a 5F RC2 catheter (Cook, Bloomington, Indiana), showing no evidence of active bleeding (Figure 1). The GDA was then catheterized and angiogram also failed to show any active arterial bleeder. The metal clips that were previously placed by endoscopy were seen superimposed over the course of the right gastroepiploic artery. Based on our knowledge of the site of the bleeder in the duodenum from prior EGD results, and the location of the metal clips seen on angiograms, we decided to empirically embolize the GDA and the right gastroepiploic artery. A 6-French sheath (Destination; Terumo Medical Corporation, Somerset, New Jersey) was then placed in the common hepatic artery over a 0.035 inch Glidewire Advantage (Terumo Medical Corporation, Somerset, New Jersey). A 5French RC2 catheter was then placed through the sheath and used to catheterize the GDA. Subselective catheterization of the right gastroepiploic artery was then performed using a 2.8-French Progreat microcatheter (Terumo Medical Corporation, Somerset, New Jersey) which was advanced beyond the location of the visualized metal clips in order to embolize distal to the suspected bleeding site to avoid ‘‘backbleeding.’’ Embolization was performed using hydrogel coils (Azur peripheral hydrocoil; Terumo Medical Corporation, Somerset, New Jersey; Figure 2). Angiogram was performed after each coil deployment to assess for contrast stasis. Following deployment of several Figure 3. Subselective gastroduodenal arteriogram showing active contrast extravasation between duodenal folds giving ‘‘pseudo-vein sign’’ (arrow). coils, and during postdeployment angiogram, we noticed contrast extravasation from the right gastroepiploic artery at the site of the visualized metal clips denoting active bleeding. The extravasated contrast pooled between the duodenal folds giving the pseudovein sign (Figure 3). We continued coil deployment proximal to the bleeding site using the same coil type till the distal GDA was embolized. Due to its large size measuring about 5.0 mm, we decided to embolize the proximal GDA using AVP II. The RC2 catheter was removed and the Destination sheath was advanced into the patent GDA over the Glidewire Advantage. We then placed an 8-mm AVP II into the GDA. A single nonsubtracted image was obtained immediately after device Downloaded from ves.sagepub.com at OhioLink on March 13, 2015 Abdel-Aal et al 309 Figure 4. A single nonsubtracted image demonstrating satisfactory position of the Amplatzer vascular plug II (AVP-II) in the gastroduodenal artery (GDA) prior to its release (arrows). placement, demonstrating satisfactory position of the device (Figure 4), which was then released from the delivery cable. The sheath was then retracted into the common hepatic artery and another angiogram was performed showing complete occlusion of the GDA (Figure 5). The occlusion time for the AVP II was 1 minute and 35 seconds, which was determined by subtracting the reference time recorded on the single nonsubtracted image obtained after the placement of the device from the reference time recorded on the common hepatic angiogram that showed total occlusion of the GDA. The procedure was then terminated and there were no immediate or late adverse events related to the procedure. The patient was discharged from the hospital 3 days after the procedure. The patient was administered Pantoprazole intravenous infusion at a rate of 10 mg/h until he was discharged, and continued on Omeprazole 20 mg capsules, twice per day after discharge. The patient was placed on oxygen therapy through a nasal cannula at a rate of 2 L/min during the day of the procedure. The patient received 2 units of intravenous packed red blood cells (RBCs) immediately after the procedure. His hematocrit was 21.5% before the procedure and gradually increased to 29.2% when he was discharged. He remained alert and oriented and his blood pressure remained stable until discharged. The patient had no other episodes of UGIB up to 6 months following the procedure. Discussion Acute UGIB is the most common complication of peptic ulcer disease and about 50% of the cases of UGIB are due to gastric or duodenal ulcers. The mortality rate in patients with bleeding peptic ulcers remains as high as 10%.1 Recent development in a variety of endoscopic hemostatic therapies has been considered to be the main reason for a Figure 5. Common hepatic arteriogram showing total occlusion of the gastroduodenal artery (GDA) with no flow distal to the Amplatzer vascular plug II (AVP II) device. substantial decline in urgent surgery as well as decline in mortality. Nevertheless, about 10% of patients with UGIB still require urgent surgery. In another 10%, urgent endoscopy fails or is severely impaired due to excessive bleeding in the gastroduodenal tract that hampers diagnosis. When surgical intervention is warranted, the mortality rate is about 15% to 20% and rises up to 40% in high-risk patients.1-3 Endovascular embolization has been proposed as an alternative to open surgical approach, especially for high-risk patients. The obvious advantage to this approach is avoidance of laparotomy in critically ill patients.3 As the advent of microcatheters technology and associated embolic agents, transcatheter embolization of UGIB has been performed expeditiously and safely with outcomes that have been more favorable compared with surgical interventions.3 In several cases, a bleeding artery cannot be identified on angiography and a target vessel is usually empirically embolized based on the prior knowledge of location of the bleeding ulcer from prior imaging or endoscopic studies.4 Currently, microcoils are used by many institutions for endovascular embolization of the GDA in cases of UGIB, as they are easy to use and pose a lesser threat of ischemia than other embolic agents such as polyvinyl alcohol, microspheres, tris-acryl gelatin microspheres or gelfoam pledgets.5 The AVP-II is a recently developed occlusive device. To our knowledge, its use in treatment of UGIB has not been described Downloaded from ves.sagepub.com at OhioLink on March 13, 2015 310 Vascular and Endovascular Surgery 45(3) in literature. It is composed of a self-expanding cylindrical nitinol basket that is compressed inside a delivery catheter and expanded to its intended shape to occlude the target vessel.6,7 The AVP is available in diameters ranging from 3 to 22 mm. It is preloaded and delivered through 4 to 7 French guiding sheaths or 5 to 9 French guiding catheters.8 Amplatzer vascular plug has many advantages in GDA embolization in the emergency UGIB setting. First, it allows rapid precise placement within the artery and the position of the device can be easily verified with a test injection through the guiding catheter prior to its release. If device position is unsatisfactory, it can be repositioned or removed. Second, the risk of migration appears to be lower compared to coils, if an appropriately sized device is used. Third, only single device is used in most cases and the device has an acceptable occlusion time which is advantageous in this emergency setting when rapid occlusion of the target vessel is required. Fourth, less metallic artifacts are encountered compared to coils on CTA studies, which allows this modality to be used for precise assessment of the results of treatment. In a prospective randomized study comparing AVP-II with platinum-fibered microcoils in prophylactic GDA embolization prior to Y90 administration, Pech et al showed efficient embolization induced by AVP II, shorter duration of the procedure, shorter embolization time, and less exposure of the medical personnel to radiation.8 Disadvantages of AVP II include the need to place a 4 to 7 French delivery sheath in the GDA, which is sometimes hard to achieve in tortuous anatomy. In our case, we used the Glidewire advantage which we found useful in this particular situation. This wire combines Glidewire construction on the distal 25 cm, with a PTFE coating on the proximal stiff end. The result is a guidewire that easily navigates through tortuous arterial anatomy with the distal glide portion, while also providing enough support for sheath placement in the GDA over the proximal stiff portion. Another disadvantage is the inability to embolize small distal bleeders since the small size AVP II (3 mm) cannot be delivered through the regular 4- to 5-French catheters and requires at least a 4 French sheath for delivery. Furthermore, the stiff delivery cable makes it impossible to negotiate these devices to a distal location. These were the reasons behind using coils to embolize the right gastroepiploic artery in our case. Conclusion The AVP II is a new embolic device that offers effective, rapid, precise, and controlled embolization of the GDA in the treatment of emergent UGIB. The need to use only 1 device to achieve complete satisfactory occlusion of the GDA appears to potentially reduce the procedure time, radiation exposure, and cost of the procedure compared to coils, although dedicated studies on larger patient population are required to document these results. Development of smaller devices that can be delivered through 4- or 5-French catheters and a more flexible delivery cable are necessary for this device to be used for embolization in more distal vasculature beyond the GDA. Declaration of Conflicting Interests The author(s) declared a potential conflict of interest as follows: Ahmed K. Abdel-Aal and Souheil Saddekni: Consultant, AGA medical. Funding The author(s) received no financial support for the research and/or authorship of this article. References 1. Loffroy R, Guiu B, Cercueil JP, et al. Refractory bleeding from Gastroduodenal ulcers. Arterial embolization in high-operative risk patients. J Clin Gastroenterol. 2008;42(4):361-367. 2. 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Emerg Radiol. 2008;15(3):153-160. 7. Abdel Aal AK, Hamed MF, Biosca RF, Saddekni S, Raghuram K. Occlusion tie for Amplatzer vascular plug in the management of pulmonary arteriovenous malformation. AJR Am J Roentgenol. 2009;192(3):793-799. 8. Pech M, Kraetsch A, Wieners G, et al. Embolization of the gastroduodenal artery before selective internal radiotherapy: a prospective randomized trial comparing platinum-fibered microcoils with amplatzer vascular plug II. Cardiovasc Intervent Radiol. 2009; 32(3):455-461. Downloaded from ves.sagepub.com at OhioLink on March 13, 2015