J Radiol Sci 2016; 41: 101-108

Clinical Outcome of Lower Gastrointestinal Bleeding Treated

by Transcatheter Arterial Embolization
Chien-Chuan Huang Hua-Ming Cheng R eng -Hong Wu Yu-Ting Kuo

Department of Medical Imaging, Chi-Mei Medical Center, Tainan, Taiwan

ABSTRACT
The purpose of this study is to evaluate the efficacy, safety and clinical outcome of lower gastrointestinal bleeding
treated by transcatheter arterial embolization.
We retrospectively reviewed the patients who underwent transcatheter arterial embolization for lower gastroin-
testinal bleeding in our hospital from January 2006 to November 2016. We reviewed the characteristics of patients,
bleeding location, etiology, details of embolization and clinical outcomes on medical records.
Totally, we enrolled 29 patients in this study. These patents had more medical comorbidities and were not suitable
for invasive surgical intervention, so they received transcatheter arterial embolization to treat lower gastrointestinal
bleeding.
There were six patients with early recurrent bleeding and two patient with bowel ischemia after embolization.
Two patients with local recurrent bleeding underwent secondary embolization for recurrent bleeding and the bleeding
was stopped successfully. The total clinical success rate was 86.2%.
Transcatheter arterial embolization was effective and safe to treat lower gastrointestinal bleeding for non-surgical
candidate. Embolization should be performed as distally as possible, but superselective embolization of vasa recta
still carried risk of post-embolization bowel ischemia. Intensive observation after embolization was necessary to
detect post-embolization bowel ischemia and recurrent bleeding.

Keywords: transcatheter arterial embolization, lower gastrointestinal bleeding, n-butylcyanoacrylate, microcoil.

Introduction to stop the bleeding [6, 7]. However, recurrence bleeding

Lower gastrointestinal bleeding (LGIB) is referred
to gastrointestinal bleeding point distal to the ligament of
Treitz, and with annual incidence rate up to about 20.5 /
100,000 patients [1]. Treatment options in the past included
conservative treatment, endoscopy, surgery and intra-
arterial vasopressin infusion [2, 3].
As development of endovascular device, selective
embolization of bleeding artery became technically feasible.
In previous studies, some patients with lower gastrointes-
tinal bleeding poorly controlled by conservative treatment
or colonoscopy received transcatheter arterial embolization
(TAE) for hemostasis [4, 5]. Embolic agent was injected
or deployed selectively at bleeding site with microcatheter
and some severe complications after transcatheter arterial
embolization were also reported, such as bowel infarction.
[8, 9].
The purpose of this study is to evaluate the efficacy,
safety, and clinical outcome of transcatheter arterial emboli-
zation for lower gastrointestinal bleeding in our institution.
Materials and Methods
This retrospective study was approved by institu-
tional review board in our hospital. We retrospectively
reviewed the patients who underwent TAE for LGIB in
our institution from January 2006 to November 2016. The

Correspondence Author to: Reng-Hong Wu

Department of Medical Imaging, Chi-Mei Medical Center, Tainan, Taiwan
No. 901, Zhong-Hua Road, Yong-Kang, Tainan 710, Taiwan

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 Lower GI bleeding treated by TAE

diagnosis of lower gastrointestinal bleeding was based on
clinical symptom, endoscopic study, or computed tomog-
raphy-angiography. The inclusion criteria was positive
angiographic findings with embolization being performed
at corresponding location. We defined the positive angio-
graphic findings as following: (i) extravasation of contrast
medium during angiography or (ii) vascular anomaly such
as angiodysplasia or aneurysm formation. The exclusion
criteria included (i) LGIB which is related to underlying
tumor bleeding. (ii) TAE with only absorbable gelatin
sponge because of temporary embolization effect.
Patient Characteristics
There were 35 patients underwent TAE for LGIB
in this period. Two patients were excluded because of
tumor-related bleeding (jejunum follicular lymphoma conf
irmed by pathologic results). Four patients were excluded
because the embolization was performed with absorbable
gelatin sponge only. Finally, 29 patients were enrolled in
the analysis.
The characteristics of patients were listed in table
(Table 1). The age of patients ranged from 34 to 93, with
a mean age at 68.7. Among our patients, more than half of
our patients suffered from respiratory failure (55.2%, n=16);
up to one-third of the patients had underlying malignancy
(41.3%, n=12), history of recent gastrointestinal surgery
(41.3%, n=12), coagulopathy (37.9%, n=11) and previous
coronary artery disease or cerebral vascular accidence
(34.5%, n=10). Most of these patents were not suitable for
invasive surgical intervention, so they received TAE to treat
LGIB.
The distributions of bleeding locations and etiologies
were listed in table (Table 2). The most common bleeding
site was jejunum (34.5%, n=10). Ulcer bleeding and
marginal ulcer bleeding accounted for 31% and 24.1% of
bleeding etiology respectively. Five patients (17.2%) had no
specific etiology of lower gastrointestinal bleeding.
Embolization Technique
All TAE procedures were performed by our inter-
ventional radiologist under local anesthesia with femoral
artery approach. Digital subtraction angiographies (DSA)

Figure 1

1a 1b 1c

Figure 1. A 69 year-old male had massive bloody stool, and colonoscopy

suggested bleeding from upstream small bowel. a. CT-angiography revealed
active bleeding in terminal ileum. b. Superior mesenteric arteriography showed
active bleeding from branches of ileal artery. c. Selective embolization at vasa
recta with NBCA using microcatheter (black arrow). d. Arteriography after
embolization showed no residual bleeding (white arrow).

1d

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 Lower GI bleeding treated by TAE

of superior mesentery artery, inferior mesentery artery and
internal iliac artery (according to the bleeding location)
were obtained for initial evaluation. If there was positive
findings of active bleeding, we advanced the microcatheters
(Progreat; Terumo, Tokyo, Japan and Excelsior SL-10;
Boston Scientific, Natick, Massachusetts and Cantata; Cook,
Bloomington, Indiana, U.S.A.) using coaxial method to
select the vessel as distally as possible. Then we selectively
injected or deployed the embolic agents via microcatheter.
We always performed post-embolization angiography to
determine the immediate effect of embolization.
We reviewed the medical records of each patient after
TAE in 30-day following interval. According to the quality
improvement guidelines for percutaneous transcatheter
embolization from Society of Interventional Radiology,
technical success was defined as immediate embolization

Table 1. Patient characteristics and comorbidities. Table 2. Bleeding locations and etiologies.
Patient characteristics Total (N = 29) Bleeding location Total (N = 29)
Mean age (year) 68.7 Jejunum 10 (34.5)
Gander Ileum 8 (27.6)

Male 22 (75.9) Colon 6 (20.7)

Female 7 (24.1) Rectum 5 (17.2)
Comorbidities Bleeding etiology Total (N = 29)
Respiratory failure 16 (55.2) Ulcer bleeding 9 (31)

End stage renal disease 9 (31) Marginal ulcer 7 (24.1)

Underlying malignancy 12 (41.3) Post-surgery bleeding 3 (10.3)

Recent gastrointestinal tract surgery 12 (41.3) Angiodysplasia 2 (6.9)
Previous coronary artery disease or Diverticulitis 2 (6.9)
10 (34.5)
cerebral vascular accidence
Fungal infection 1 (3.4)
Coagulopathy 11 (37.9)
Values in parentheses are percentages. Unspecific 5 (17.2)
Coagulopathy: platelet fewer than 80000/mL or INR greater than Values in parentheses are percentages.
1.5.

Figure 2

2a 2b 2c
Figure 2. A 65 year-old male came to our emergent department because of tarry stool passage. a. CT-angiography showed
suspicious jejunal angiodysplasia. b. Focal ectatic arterial segment of jejunal artery on superior mesenteric arteriography
(white arrow) with early drainage vein suggested angiodysplasia. c. Four microcoils (2mm and 3mm in diameter) were
deployed in the feeding arteries respectively (black arrow), and with complete disappearance of bleeding after emboliza-
tion (white arrows). The patient recovered well after embolization and discharged from hospital six days later under stable
condition.

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 Lower GI bleeding treated by TAE

results in completion angiography and clinical success was

Table 3. Embolization procedure.
defined as embolization results within 30 days assessed
by clinical or image follow-up [10]. Major complication Embolic materials Total (N = 29)
after embolization reflected unplanned increase in the N-butylcyanoacrylate 20 (69)
level of care, prolonged hospitalization, permanent adverse
Microcoils 7 (24.1)
sequelae, or death.
Microcoils + N-butylcyanoacrylate 2 (6.9)
Embolization locations
Results Vasa recta or terminal branches of rectal artery 14 (48.3)
Marginal artery 15 (51.7)
Selective embolization of vasa recta was achieved in
48.3% of patients (n = 14), and others at marginal artery Number of embolized vasa recta
because of tortuous or small feeding arteries. The most Three of fewer 23 (79.3)
used embolic agent was n-butylcyanoacrylate (NBCA;
Four or more 6 (20.7)
Histoacyrl; Braun, Carretera de Terrassa, Rub, Spain)
Values in parentheses are percentages.

Figure 3

3a 3b 3c

3d 3e
Figure 3. A 41 year-old male with underlying cirrhosis received surgical ligation of rectal ulcer. Five days after the opera-
tion, the patient presented with massive rectal bleeding with hypovolemic shock. a. CT-angiography showed hematoma with
active bleeding at rectum. b. Angiography at inferior mesentery artery (not shown) and left internal iliac artery revealed
active bleeding from middle rectal artery of left internal iliac artery. c. NBCA was injected directly into the bleeding site
by using microcatheter (black arrow). d. Recurrent bleeding from superior rectal artery of inferior mesenteric artery after
6 days. e. We performed further selective embolization of superior rectal artery (black arrow) and there was still retained
NBCA from first embolization (white arrow). The bleeding was stopped successfully after second embolization.

104 J Radiol Sci December 2016 Vol.41 No.4

 Lower GI bleeding treated by TAE

(69%, n=10; Table 3). We mixed NBCA with iodized oil
(Lipiodol Ultrafluide; Guerbet, Aulnay-sous-Bois, France)
at ratio from 1:1 to 1:4 to control the solidification time and
the concentration of NBCA was dependent on the distance
between microcatheter and the bleeding point. After infu-
sion with 5% dextrose solution, the mixture was injected
superselectively into target vessel using microcatheter
under real-time fluoroscopy (Fig. 1). In some situation when
there was high risk of NBCA reflux or there were multiple
feeding arteries, we deployed microcoils or combined
usage of NBCA with microcoils (Nester; MReye; Cook,
Bloomington, Indiana, U.S.A.) to embolize bleeding vessels
(Fig. 2). The smallest helical coil available in our institu-
tion was 2mm in diameter, and microcoils with diameter of
2mm and 3mm were used in this study.
Post-Embolization Outcome
After TAE, no residual bleeding on post-embolization
angiography was identified in all patients. In the 30-day
following interval, there were six patients with local recur-
rent bleeding (Table 4). Two of these patients underwent
secondary TAE and the bleeding was stopped successfully
(Fig. 3). Two patients received further surgery and bowel
ischemic change at corresponding location of TAE was
mentioned in operation findings (Figs. 4, 5). The other
two patients with recurrent bleeding received conservative
treatment because of clinical deterioration in condition, and
expired few days later.

Figure 4

4b 4a 4c

4d 4e
Figure 4. A 28 year-old male received Hartmanns operation with end-T-colostomy for colonic ulcer perforation. Ten days
after the surgery, there was massive bleeding from the colostomy. a.Angiography revealed active bleeding from ileal artery.
b. Selective embolization was performed using NBCA injection (white arrow), the black arrow indicated the location of
microcatheter in marginal artery. c. Recurrent bleeding two days later, and following angiography showed residual bleeding
from ileal artery. d. Secondary embolization with NBCA was performed, but the microcatheter can still only be advanced
into distal segment of marginal artery (black arrow). There was a segment of bowel with poor mucosal enhancement after
NBCA injection (white arrows). e. The patient received surgical treatment for persistent bleeding, and extensive bowel
necrosis was mentioned in the operation findings.

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 Lower GI bleeding treated by TAE

In summary, the total early recurrent bleeding rate was
20.7% (n=6) and major complication rate was 6.9% (n=2).
The 30-day procedure-related in-hospital mortality rate is
6.9% (n = 2). The clinical success rate of TAE for LGIB was
86.2 % (n=25; Table 4).
Discussion
The most common cause of lower gastrointestinal
bleeding was diverticular bleeding followed by colorectal
polyps, angiodysplasia and inflammatory bowel disease
[11]. In our experience, most of lower gastrointestinal
bleeding had single feeding artery to the bleeding point,
so we preferred NBCA as primary embolic agent. Liquid
embolic agents such as NBCA can be delivered into the
bleeding point as distally as possible. In addition, the embo-
lization effect of NBCA was not compromised by coagu-
lopathy theoretically because NBCA achieved hemostasis
by polymerization after contact with ions in blood [12].
Therefore, NBCA was also suitable for the patients with
coagulopathy. In our patients, there were 37.9% (n=11) of
patients with coagulopathy, and nine of them underwent
TAE using NBCA. However, NBCA injection required
experience to prevent regurgitation, catheter adhesion, non-
target embolization or premature solidification.
Lower gastrointestinal bleeding from angiodysplasia
was reported to have possibility of multiple feeding arteries
[13]. In the situations that there were multiple feeding
vessels to the bleeding points, we can deployed microcoils
in each feeding artery respectively without withdrawing
the microcatheter (We needed to pull out the microcatheter
after NBCA injection to prevent adhesion). Embolization
with microcoils or with combination of microcoils and
NBCA was more convenient for multiple bleeding arteries.
In contrast to NBCA, embolization with microcoils resulted
in more proximal embolization, so we should inspect
post-embolization angiography very carefully to ensure
no residual bleeding from collateral arteries. In addition,
the diameter of vasa recta was sometimes smaller than the
smallest helical coil and mismatch of helical coil diameter
and target vessel diameter would result in elongation of

Figure 5

5a 5b 5c

Figure 5. A 70 year-old female received operation for sigmoid colon perfora-

tion. Massive fresh blood from the colostomy after 2 weeks of surgery was
noted. a. Angiography of superior mesentery artery showed active bleeding from
ileocolic artery. b. Selective angiography of ileocolic artery showed angiodys-
plasia of cecum with active bleeding. c. Selective embolization was performed
using NBCA injection (white arrow), and the black arrow indicated the location
of microcatheter in vasa recta. d. Following angiography revealed no residual
bleeding, with NBCA retention in vasa recta. The single vasa rectum embolized
in this patient had several branches (white arrow). The patient received further
surgical intervention because of clinical deterioration in condition, and ischemic
change of cecum was mentioned in operation findings.

5d

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 Lower GI bleeding treated by TAE

The clinical successful rate in previous studies ranged

Table 4. Post-embolization results.
from 74% to 91.2% and the recurrent bleeding rate ranged
Early recurrent bleeding Total (N = 29) from 8.8% to 18% [6, 8, 9, 16, 17]. Saebeom et al. reported
Jejunum 1
a higher recurrent bleeding rate at rectum up to 30% and
might contributed by multiple collateral arteries from infe-
Ileum 1 rior mesentery artery and bilateral internal iliac artery [8].
Colon 2 Similar results were observed in our study. Five patients
received TAE for rectal bleeding, and the recurrent bleeding
Rectum 2
rate is 40 %( n= 2) in the 30-day following interval. Close
Total 6 (20.7) monitoring of clinical condition or colonoscopic follow-up
was necessary to detect early recurrent bleeding.
Bowel ischemic change Total (N = 29)
Jejunum 0 Limitations
Ileum 1 Some patients with LGIB were diagnosed with clinical
symptom only, so there were five patients with uncertain
Colon 1 bleeding etiology in our study. In recent years, we requested
Rectum 0 endoscopic study and computed tomography- angiography
for better localization, anatomic information and detection
Total 2 (6.9)
of potential underlying neoplasm before TAE [18]. There
Procedure-related 30-day in-hospital mortality 2 (6.9) might be better correlation between bleeding etiology and
Clinical success 25 (86.2) success rate in the further study.
Values in parentheses are percentages.

Conclusion

microcoils. Elongation of microcoil decreased the embolic
effect of microcoils and the embolic effect of microcoils
might also be compromised by coagulopathy.
Previous animal study presumed that superselective
embolization of three or fewer vasa recta was relatively
tolerable and embolization of four or more vasa recta
increased risk of substantial ischemic bowel damage [14].
Recently Mika et al. reported limited embolization of one
vasa rectum using NBCA was unlikely to result in severe
ischemic complication, but embolization of single vasa
rectum with many branches would induce more ischemia
[15]. In our study, there were six patients with more than
four vasa recta being embolized during the procedure. One
of the patents underwent twice embolization and more
than eight of vasa recta were embolized totally. The patient
suffered from consequent bowel ischemia at corresponding
location of embolization. Another patient with cecum
bleeding received superselective embolization with NBCA
at single vasa rectum but post-embolization bowel ischemia
was confirmed by operation findings. The single vasa rectum
embolized in this patient had more than three branches so
embolization might induce larger area of ischemia. Emboli-
zation of a vasa rectum with many branches was considered
the reason that this patient suffered from colon ischemic
change after embolization. Deployment of single straight
microcoil can be an alternative option to prevent emboliza-
tion of multiple branches. In our opinion, the presence of
bowel ischemia after TAE might depend not only on the
number of embolized vasa recta, but also on the branch
number of embolized vasa recta.
Transcatheter arterial embolization was effective and
safe to treat lower gastrointestinal bleeding for non-surgical
candidate. Embolization should be performed as distally as
possible, but superselective embolization of vasa recta still
carried risk of post-embolization bowel ischemia. Intensive
observation after embolization was necessary to detect
post-embolization bowel ischemia and recurrent bleeding.
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