The following is a high-level clinical reference. Full step-by-step angiographic technique, catheter and embolic agent selection, troubleshooting, and post-procedure management are available in RadCall Pro.
Upper GI Bleed Embolization
Indications
Upper GI hemorrhage (esophagus to ligament of Treitz) refractory to endoscopic therapy or pharmacologic management. Upper endoscopy should be first line — IR indicated when: endoscopy failed × 2, patient too unstable for endoscopy, or bleed not amenable to endoscopic control. Active blush on CTA, positive angiography, or hemodynamic instability even without positive CTA are all triggers for IR intervention.
Coagulopathy is never a reason to withhold emergent embolization. Correct coagulopathy while proceeding simultaneously — never delay for lab correction in a hemorrhaging patient.
Vascular Anatomy
Left gastric artery is the #1 vessel for upper GI bleeding — supplies the lesser curvature and cardiac stomach. The stomach has the richest dual blood supply in the GI tract: celiac (left gastric, right gastric, left gastroepiploic, short gastric) and GDA branches (right gastric, right gastroepiploic). Gastric ischemia risk with embolization is <1%.
Duodenum: GDA → superior pancreaticoduodenal (SPDA) meets inferior pancreaticoduodenal from SMA → abundant dual supply. The GDA "sandwich technique" (coils proximal AND distal to bleeding point) is required to prevent back-filling from SMA via IPDA.
Technique Highlights
- Celiac arteriogram in AP and oblique views maps left gastric, GDA, and collateral supply
- Left gastric embolization: Empiric embolization is acceptable even without active extravasation if clinical suspicion is high — rich dual supply means low ischemia risk
- GDA sandwich technique: Place coils distal to bleeding point first, then proximal — prevents retrograde filling from SPDA/IPDA via SMA. Both proximal and distal occlusion are required for durable hemostasis
Lower GI Bleed Embolization
Indications and Patient Selection
Lower GI hemorrhage (distal to ligament of Treitz) refractory to endoscopic management or in hemodynamically unstable patients. Most common causes: diverticulosis (#1, ~30%), angiodysplasia, ischemic colitis, hemorrhoids, post-polypectomy, IBD, tumor. Oakland Score ≥15: high risk — CTA + IR consultation; consider tagged RBC scan if CTA negative.
Critical difference from upper GI: Lower GI has LESS collateral supply than upper GI — ischemia risk is significantly HIGHER. Superselective catheterization to vasa recta level is mandatory. Do NOT empirically embolize in lower GI without angiographic visualization of bleeding — the ischemia risk is unacceptable without a confirmed target.
Colonic Ischemia Risk by Location
| Location | Arterial Supply | Ischemia Risk | Strategy |
|---|---|---|---|
| Cecum / Ascending | Ileocolic, R colic | Low | More proximal embolization acceptable |
| Transverse colon | Middle colic | Moderate | Superselective preferred |
| Splenic flexure | Middle colic ↔ L colic | HIGH — watershed | Vasa recta only — no exceptions |
| Descending / Sigmoid | L colic, sigmoid branches | Moderate–high | Superselective mandatory |
| Rectosigmoid | Sigmoid, sup. rectal | HIGH — watershed | Superselective; consider rectal vasculature |
| Rectum | Sup. rectal + middle/inf. rectal | Low | Dual supply (IMA + internal iliac) protective |
Technique: Superselective Vasa Recta Embolization
Advance the microcatheter as far distally as possible — ideally to the vasa recta directly adjacent to the bleeding point. Use CTA as roadmap for navigation. Confirm active extravasation before embolizing — unlike upper GI, empiric embolization is not acceptable in the lower GI tract.
Embolic agents: Microcoils (pushable) are the first choice for superselective vasa recta embolization. Gelfoam is acceptable if the microcatheter cannot reach the vasa recta level. AVOID particles in the colon — unacceptable ischemia risk.
GDA Blowout / Post-Surgical Arterial Hemorrhage
Recognition — The Sentinel Bleed
Post-pancreaticoduodenectomy (Whipple) hemorrhage occurs in 3–8% of cases but carries 10–40% mortality. Activated pancreatic enzymes erode the GDA stump suture line → pseudoaneurysm → blowout. Any unexplained bleed 7–21 days post-Whipple — drain output, hematemesis, falling Hgb — is a GDA stump problem until proven otherwise. Act immediately at the sentinel bleed; do not wait for massive hemorrhage.
Anatomy After Whipple
After pancreaticoduodenectomy, the GDA is ligated at its origin from the common hepatic artery (CHA). Hepatic blood flow continues via CHA → proper hepatic artery. The covered stent principle: place a stent in CHA spanning the GDA stump origin, maintaining hepatic perfusion while excluding the bleeding stump.
Treatment Decision
| Approach | Indication | Limitation |
|---|---|---|
| Covered stent (preferred) | Good vessel caliber, non-tortuous anatomy, non-infected field; maintains hepatic artery flow | Size stent 1–2 mm larger than vessel diameter (6–8 mm); requires adequate landing zones in CHA |
| Coil embolization | When covered stent not feasible (tortuous anatomy, stent sizing issues) | Risk of hepatic ischemia if CHA/proper hepatic supply compromised |
Technique
CFA access (5F); selective celiac arteriogram with 5F C2 catheter — identify pseudoaneurysm at GDA stump on AP and oblique views. Selective CHA angiogram; confirm GDA stump location relative to hepatic bifurcation. Exchange for Rosen wire (atraumatic); advance 6F Ansel sheath. Deploy covered stent spanning the GDA stump origin in the CHA/proper hepatic artery. Completion angiogram: confirm hepatic artery flow preserved, GDA stump excluded, no residual pseudoaneurysm filling. If residual sac fills: additional coil packing via microcatheter.
General Pre-Procedure Checklist (All GI Bleeds)
- Stabilize first: Two large-bore IVs; type and cross; blood products ready. Transfusion threshold: Hgb >7 g/dL (or >8 in CAD). Do not delay IR for lab corrections in life-threatening hemorrhage.
- CTA angiography (if stable): identifies bleeding site and guides selective catheterization; use as procedural roadmap
- Labs: CBC, PT/PTT/INR, BMP, type and cross
- Surgical consultation on standby — if endovascular fails, the patient needs emergent OR; maintain surgical involvement
- Post-procedure: ICU monitoring; serial abdominal exams q6h; colonoscopy at 24h (lower GI) or repeat EGD (upper GI)
References
- Bandi R, Shetty PC, Sharma RP, et al. Superselective arterial embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol. 2001;12(12):1399–1405.
- Strate LL, Naumann CR. The role of colonoscopy and radiological procedures in the management of acute lower intestinal bleeding. Clin Gastroenterol Hepatol. 2010;8(4):333–343.
- Aina R, Oliva VL, Therasse E, et al. Arterial embolotherapy for upper gastrointestinal hemorrhage: outcome assessment. J Vasc Interv Radiol. 2001;12(2):195–200.
- Wente MN, Veit JA, Bassi C, et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery definition. Surgery. 2007;142(1):20–25.