The non-traumatic bleeding patient - acute vascular interventions Nils-Einar Kløw

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1 The non-traumatic bleeding patient - acute vascular interventions Nils-Einar Kløw

2 Acute bleeding General approach Upper gastrointestinal Kidneys Acute gynecology Abdominal varices

3 Before you decide to stop the bleeding What is your algoritm for the treatment What have been tried so far When to stop the bleeding Can patient be safely transferred to the angio suite Is hemodynamic stabilization necessary Should hematologic correction be done Blood products needed Anestesia and sedation

4 Check points Indication Labs Review all available imaging Patient information Plan with the radiographer the actual examination and possible treatment Make plan for the position on the table Review possible catheters and wires needed and have them ready for the procedure Decide whether power injector should be used

5 The femoral access

6 Hemostasis Occlusion device most often used (AngioSeal) When to leave the introducer in place? Manual compression for some?

7 Angiographic findings in the bleeding patients Extravasation of contrast > ongoing bleeding Occluded arterial branches Spasm Dissection Surgically occluded Externally compressed Irregular contours Spasm Externally compressed Normal findings still to be embolized?

8 Choose the right embolization material Principles Should the occlusion be permanent or temporary? How close should the occlusion be to the bleeding site? the size and type of occlusion material What is the risk of necrosis of normal tissue? What is the risk og distant embolization?

9 Embolization material Particles Coils

10 Other occlusion material Stentgraft balloon- or self ekspanding Onyx Viatorr stent graft Histoacryl

11 Anatomy and embolization The arterial supply and collaterals varies much Embolising end arteries may result in necrosis Renal arteries are end arteries Arteries to the gall bladder and bile ducts are end arteries Operated patients may have limited collaterals Embolising areas with good collaterals have low risk of necrosis, but may continue bleeding The spleen Pelvis Uterus The liver has double blood supply from arteries and the portal veins. The veins may drain directly to the sentral veins

12 Gastroduodenal bleeding A C

13 How to stop the bleeding 1. Endoscopy 2. Embolization 3. Surgery

14 Indication for embolization at Ullevål Acute bleeding when endoscopy failed Rebleeding after 2nd endoscopy High risk of rebleeding

15 Forrest classification Forrest Classification Rebleeding Incidence Surgical Requirement Incidence of Death Type I: Active Bleed Ia: Spurting Bleed Ib: Oozing Bleed Type II: Recent Bleed Ila: Non-Bleeding Visible Vessel (NBVV) Ilb: Adherent Clot % 35% 11% 40-50% 34% 11% 20-30% 10% 7% Type III: Lesion without Bleeding Flat Spot Clean Base 10% 6% 3% 5% 0.5% 2% Refr 2005, Cleveland

16 Angiographic findings: -Extravasation -Narroved arteries -Erosion -Normal findings

17

18 Coils the endoscopy view Mostly coils, but gelfoam and particles may be used From dr Hofstad, UUS

19 Results after embolization (n=35) No. Inclusion Direct 11 Rebleeding after endoscopy 15 Failed endoscopy 9 Success Technical (acute) 33 (94%) Clinical (30 days) 25 (71%) L Larssen et al. Scand J Gastroenterol. 2008;43(2):

20 Duodenalbleeding at US Number Age Mortality (30 days) All (29-98) 10% Endoscopy (49-94) 12% Embolization (56-92) 20% Surgery (56-86) 20% Embolization 2013/ (47-93) 7% L Larssen et al. Scand J Gastroenterol. 2008;43(2):

21 Other locations Stomach often the left gastric artery Good collaterals May be difficult to reach the lesion Addition of particles may help Lower GI bleeding When endoscopy does not find the bleeding spot do CT abdomen Most of these should be operated Embolization may stop the bleeding with coils Patient should be observed afterwards for necrosis Bleeding from stomach, esophagus and rectum may be cancer and varices

22 Kidneys - when to embolize Most kidney bleeding stops spontaneously End arteries results in necrosis Indications Aneurisms Tumors After biopsy After nephrostomy tube

23 Male, 57 yrs old DM 2, uric acid, recent viral infection, Hb drop, pain left flank FINDINGS: Large renal hematoma, multiple aneurisms, kidney stone occluding the ureter

24 Angiography: Multiple aneurisms, one with extravasation Embolization: Microcatheter and detachable coils JJ-stent

25 Acute gynecology

26 Embolization of post partum bleeding at Ullevål

27 Post partum blødning Main etiology for mortality of the mother May bleed several days after delivery, def.: <6 weeks Primary = early bleeding def.: >500 ml blood loss within first 24 hrs Secondary = delayed post partum bleeding def.: 24 h 6 weeks, >500 ml blood loss 3 5% insidence (underestimated?)

28 Etiology Uterus atony - ca 70 % Laceration/hematoma in lower genital tract Retained placenta Uterus rupture AV fistula, pseudoaneurysms

29 Treatment Medication Surgery Packing Ligature of both hypogastric arteries Hysterectomy Embolisation Ref.: N Ledee et al. Eur J Obstet Gynecol Reprod Biol 2001 Temporary occlusion of the aorta Ref.: E Søvik et al. Acta Anaestesiol Scand 2010

30 Embolization method Normal angiography: Spongostan in both the uterine arteries Pseudoaneurysm, occluded branch: coils at the pathological side, spongostan at the contralateral side Myoma: To be decided. Possibly particles

31 The aorta balloon Complete package for bedside procedure Effective to stabilise the patient May be the only treatment To be used during transportation to angio suite Heparin IE during balloon inflation Final treatment may be decided for the hemodynamically stabile patient Risk: - Thrombosis - Arterial injury

32 Table 2 Patient characteristics embolization group (n=34) Success (n=28) No success (n=6) Age (years) median 33 (range 24-40) 31 (range 29-42) Primiparous 14 (50% ) 2 (33%) Multiparous 11 (39%) 4 (67%) Unknown parity 3 (11%) 0 (0%) Induced labor 9 (32%) 0 (0%) Unassisted vaginal deliveries Instrumental vaginal deliveries 7 (25%) 0 (0%) 6 (21%) 1 1 (17%) Cesarean section, elective 3 (11%) 3 (50%) 1 Cesarean section, acute 12 (43%) 1 2 (33%) Previous cesarean section 6 (21%) 1,2 4 (67%) 1 One patient with twins 2 One patient had two previous cesarean section

33 Table 3 Cause of major postpartum hemorrhage Embolization only (n=29) Hysterectomy (n=20) 1 p-value Atony 18 (62%) 9 (45%) Uterine rupture 0 (0%) 5 (25%) Placenta accreta 2 4 (14%) 1 (5%) Placenta increta 2 0 (0%) 1 (5%) Inversio uteri 0 (0%) 2 (10%) Genital tract lacerations 2 (7%) 0 (0%) Placenta praevia 2 (7%) 1 (5%) HELLP 1 (3%) 0 (0%) Retained placental tissue/placenta 2 (7%) 1 (5%) Five patients with UAE ended with hysterectomy and are included in the hysterectomy group, third column. 2 Histologically verified after delivery.

34 Abdominal varices Short gastric veins Left gastric veins Posterior gastric veins

35 Etiology of the varices Liver failure with portal hypertension Child-Pugh score A -> C (bilirubin, albumin, INR, ascites og encephalopathy) MELD score (Model for End-Stage Liver Disease, eller MELD) (bilirubin, se-creatinin og INR) Thrombosis of the portal veins Budd-Chiary disease (occluded hepatic veins)

36 Alternative methods Liver cirrhosis: TIPS Budd-Chiari: open the liver veins with PTA or TIPS Portal vein thrombosis: transhepatic PTA + Embolization of the varices with coils Transvenous occlusion of the varices through collaterals to the left kidney vein

37 TIPS Transjugular Intrahepatic Portosystemic Shunt

38

39 Indication for TIPS - varices Ongoing bleeding with no respons from endoscopic treatment Recurrent bleeding >once Not for prevention Alternative surgery Porto-caval shunt Liver Tx Contraindications are less important when ongoing bleeding than TIPS for other reasons.

40 Preoperative examinations US of the right jugular vein for access. CT abdomen Open liver- and portal veins Portal vein anatomy Liver size Liver tumors Degree of ascites Location of the varices Classify the liver failure from labs Ecco of the heart Recommodations Drain the ascites Corrects abnormal labs if possible

41 CT abdomen: -Ascitis -Small liver -Open liver veins -Open portal veins -The R/L portal vein bifucation is extrahepatic

42 CT and varices

43 CT and varices Female 52 yrs Portal vein thrombosis and duodenal varices

44 1: trykkmåling 2: CO2 angiografi 3: punksjon av portvene 4: guide wire ut i miltvene

45 5: PTA 8 mm av kanal 7: trykkmåling 6: Viatorr stent graft

46 Complications Bleeding main problem when bleeding into free abdomen Puncture of the liver capsula pain, bleeding Hematom in the neck Arrythmias Pneumothorax Hemobili Fistula between the liver artery and the portal vein or the biliary tubes Mortality: % Total complication rate: %

47 Acute success is % Prognosis Early rebleeding is high in acute intervensions, nearly 36% within 6 weeks Early rebleeding otherwise ca 10% Longtime cumulative rebleed is 20-30% Mortality closely related to the liver disease (MELD, Child Pugh) Rate of encephalopathy is high when preoprativ encephalopathy The shunt may be occluded afterwards Liver transplantation can be done later on

48 Takk for oppmerksomheten

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