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Indications / Contraindications
Indications
- Upper GI hemorrhage (esophagus to ligament of Treitz) refractory to endoscopic therapy or pharmacologic management
- Hemodynamically unstable: Proceed directly to IR — skip or expedite endoscopy
- GI bleed where endoscopy failed to identify or control source
- Dieulafoy lesion, peptic ulcer disease (gastric/duodenal), gastritis, Mallory-Weiss tear, anastomotic bleeding, post-polypectomy
- Varices: Embolization limited role — TIPS preferred for esophagogastric varices
- Clinical threshold: Active blush on CTA; positive angiography; hemodynamic instability even without positive CTA
Contraindications
- Absolute: None in life-threatening hemorrhage
- Relative: Severe contrast allergy (premedicate or use CO2); Renal insufficiency (minimize contrast, consider CO2); Uncorrectable coagulopathy (correct while proceeding — do not delay)
- Note: Coagulopathy is never a reason to withhold emergent embolization. Correct and proceed simultaneously.
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Pre-Procedure Checklist
Stabilize patient first. Two large-bore IVs, type & cross, blood products ready. Do NOT delay for coagulopathy correction in life-threatening hemorrhage — proceed while correcting simultaneously.
CTA angiography (if hemodynamically stable): CT identifies bleeding site and guides selective catheterization. Sensitivity for active bleed ≥0.5 mL/min. Use as procedural roadmap.
Endoscopy coordination. Upper endoscopy should be first line if patient can tolerate. IR indicated when: endoscopy failed × 2, patient too unstable, or bleed not amenable to endoscopic therapy.
Labs: CBC, PT/PTT/INR, BMP, type & cross. Transfusion threshold >5 units pRBC in 24h = high-risk for requiring IR intervention.
Consent: Bowel ischemia (most feared), post-embolization syndrome, rebleeding (~20–30%), contrast nephropathy, access site complications.
Vasopressors/resuscitation: Continue active resuscitation through the procedure. Anesthesia or nursing support for hemodynamically unstable patients.
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Relevant Anatomy
Vascular Supply — Upper GI
- Esophagus (lower 1/3): Left gastric artery (celiac) + inferior phrenic arteries
- Stomach: Celiac trunk → left gastric (lesser curvature), right gastric (lesser curvature, from GDA), left gastroepiploic (greater curvature, from splenic), right gastroepiploic (greater curvature, from GDA), short gastric arteries (from splenic). Rich DUAL supply → lower ischemia risk.
- Duodenum: GDA → superior pancreaticoduodenal → anterior + posterior branches. GDA arises from common hepatic artery. Inferior pancreaticoduodenal (SMA) meets superior → dual supply = abundant collateral
Key Anatomic Points
- Celiac trunk: T12 level, anterior aorta. Trifurcation: left gastric, splenic, common hepatic → proper hepatic → GDA at junction with right/proper hepatic
- GDA / duodenum dual supply: Celiac (superior pancreaticoduodenal) AND SMA (inferior pancreaticoduodenal) → sandwich technique required to prevent back-filling
- Left gastric artery: #1 vessel for upper GI bleeding — supplies lesser curvature and cardiac stomach
- Stomach has richest dual blood supply in GI tract — gastric ischemia risk <1% with embolization
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Technique
Default RadCall approach · share your own below
Supplies
Micropuncture kit
5 Fr sheath
Flush catheter (pigtail)
Selective catheter (Cobra / SH / Mikaelsson)
Microcatheter 2.7 Fr
0.014–0.018" microwire
Microcoils (0.018" pushable)
Gelfoam pledgets
Contrast + heparinized saline flush
3-way stopcocks
Steps
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Arterial access
Standard common femoral artery (CFA) access. Place 5 Fr sheath. Heparin bolus 3,000–5,000 units IV after access.
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Aortogram (optional)
If CTA not done or source unclear, flush aortogram at T8–T12 level to survey mesenteric vessels and identify celiac and SMA origins.
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Celiac angiogram
Advance catheter to celiac trunk (T12, anterior aorta). AP + lateral arteriogram. Look for: extravasation (blush/contrast pooling), pseudoaneurysm, hypervascular lesion.
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Selective catheterization
Based on CTA or angiography findings, advance to supplying vessel: left gastric for gastric/esophageal bleeding; common hepatic → GDA for duodenal bleeding; splenic for fundal/short gastric bleeding.
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Superselective microcatheter
ALWAYS superselect with microcatheter to the vessel directly supplying the bleed. Get as close to the bleeding point as possible. Superselection minimizes ischemia risk.
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Embolization
First-line: microcoils. Place distal coils first, then proximal. GDA (duodenal) bleeding: sandwich technique — coil BELOW the bleeding point (via inferior pancreaticoduodenal from SMA) AND ABOVE (from celiac/GDA approach) to prevent collateral back-filling. Gelfoam for diffuse gastritis. Avoid PVA particles in GI tract (higher ischemia risk).
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Post-embolization arteriogram
Confirm cessation of extravasation. No residual blush. Document stasis. Confirm no non-target embolization.
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SMA arteriogram
Consider after celiac embolization to assess inferior pancreaticoduodenal supply (especially for duodenal bleeding). May need to embolize from below if dual supply is present and back-filling is a concern.
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Troubleshooting
Problem
Active bleed not seen on angiography (30–50% of cases)
Likely cause: Intermittent bleeding; bleed below angiographic detection threshold.
Next step: Provocative angiography — heparin + thrombolytics (tPA 4 mg intra-arterial) can unmask intermittent bleeding. Or vasodilators (nitroglycerin 100 mcg IA). If negative × 2 — empiric embolization of most likely vessel based on endoscopy report. Left gastric most commonly.
Problem
Cannot advance microcatheter to bleeding vessel
Likely cause: Vessel tortuosity, spasm, or sheath instability.
Next step: Hydrophilic microwire (Fathom, Synchro). Coaxial technique. Larger guiding catheter for support. Consider radial arterial access for different approach curve to celiac axis.
Problem
Post-embolization rebleeding
Likely cause: Common (20–30%). Collateral back-filling (especially GDA), incomplete embolization, or new bleeding source.
Next step: Re-embolize if technically feasible (sandwich technique if not already done). Escalate to surgery if repeated failure. Vasopressin infusion as bridge only — 50% rebleed rate long-term.
Problem
Variceal bleeding mistaken for arterial
Likely cause: Esophagogastric varices present with hematemesis similar to arterial UGIB.
Next step: TIPS is definitive for esophagogastric varices — embolization is not. Embolization can temporarily tamponade gastric varices (BRTO for gastric varices is definitive alternative). Coordinate with hepatology/endoscopy early.
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Complications
Primary Risks
- Bowel ischemia — most feared; gastric ischemia <1% due to rich dual supply; duodenal ischemia with GDA occlusion rare but possible
- Rebleeding — 20–30% within 30 days; repeat embolization or surgery
- Non-target embolization — inadvertent hepatic or splenic artery occlusion
Secondary Risks
- Post-embolization syndrome — fever, leukocytosis, pain; usually mild and self-limited; supportive care
- Access site hematoma — standard CFA access complication; manual compression or closure device
- Contrast nephropathy — minimize contrast; consider CO2 angiography in renal insufficiency
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Post-Procedure Care
Monitoring
- ICU admission post-procedure — mandatory
- Serial abdominal exams for ischemia: severe pain + peritoneal signs = emergency surgical consult
- NPO initially; advance diet per clinical trajectory
- Serial CBC q6–8h for first 24h; falling Hgb = urgent repeat CTA/angiography
- Hematemesis, melena return, or hemodynamic deterioration → urgent repeat CTA/angiography
Medical Management
- Repeat upper endoscopy at 24h to confirm hemostasis and plan definitive therapy
- IV proton pump inhibitor → transition to oral
- Treat underlying cause: H. pylori eradication, anticoagulation reassessment
- Rebleeding assessment: Return of hematemesis, melena, or falling Hgb → urgent workup
- Surgical consultation on standby for failed embolization
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Critical Pearls
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GDA sandwich technique is mandatory: For duodenal ulcer bleeding, coil DISTAL to the bleed (from below, via inferior pancreaticoduodenal from SMA) AND PROXIMAL to the bleed (from above, celiac/GDA approach). Coiling one side only = collateral back-filling = rebleed.
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Superselective = gold standard: The smaller the embolization zone, the lower the ischemia risk. Always use a microcatheter. Get as close to the bleed as possible.
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Negative angiogram with active clinical bleeding: Proceed with empiric embolization based on endoscopy localization. Left gastric artery most commonly. Technical success is achievable even without blush visualization.
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Gastric embolization is relatively safe: Rich dual supply (left/right gastric, gastroepiploics, short gastric arteries) — gastric ischemia rate <1% with superselective technique.
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Left gastric artery is #1: Supplies lesser curvature and cardiac stomach — the most common source vessel for upper GI arterial bleeding. Know it cold.
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Vasopressin infusion is largely historical: 50% rebleed rate. Coil embolization is superior for upper GI bleeding. Vasopressin may serve only as a bridge in exceptional circumstances.
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CTA sensitivity: ≥0.5 mL/min for active bleed detection. Negative CTA does not exclude intermittent bleeding — use provocative angiography if clinical suspicion remains high.
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Vascular Anatomy Quick Reference
| Bleeding Site | Primary Vessel | Secondary / Collateral | Embolization Target |
|---|---|---|---|
| Gastric body/antrum | Left gastric + right gastric | Gastroepiploics | Left gastric — superselective |
| Gastric fundus | Short gastric arteries (from splenic) | Left gastroepiploic | Short gastric / splenic branches |
| Gastric cardia/esophagus | Left gastric artery | Inferior phrenic | Left gastric |
| Duodenal bulb (post-bulbar) | GDA → superior pancreaticoduodenal | Inferior pancreaticoduodenal (SMA) | GDA sandwich technique |
| Duodenum 2nd–3rd | Post. superior pancreaticoduodenal | Post. inferior pancreaticoduodenal | Bilateral coil embolization |
| Anastomotic (post-gastrectomy) | GDA remnant or left gastric | Variable — review operative report | Superselective to bleeding vessel |
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References & Resources
Primary sources · Key data · Related procedures
Key Guidelines
- CIRSE Standards of Practice for GI Bleed Embolization
- ACR Appropriateness Criteria for GI Bleed
- SIR Standards of Practice
Primary References
- Yap FY et al. Embolotherapy for arterial hemorrhage: experience and role in the management of upper and lower gastrointestinal hemorrhage. J Vasc Interv Radiol. 2013;24(10):1439-1447.
- Loffroy R et al. Transcatheter arterial embolization for acute nonvariceal upper gastrointestinal hemorrhage: indications, techniques and outcomes. Diagn Interv Imaging. 2015;96(7-8):731-744.
- Mirsadraee S et al. Management of upper gastrointestinal hemorrhage: current state of play. Expert Rev Gastroenterol Hepatol. 2016;10(5):617-625.