Interact CardioVasc Thorac Surg 2007;6:558-560. doi:10.1510/icvts.2006.150102
© 2007 European Association of Cardio-Thoracic Surgery
Brief communication - Cardiac general |
Selective embolotherapy as a treatment option for lower gastrointestinal haemorrhage following open-heart surgery
Vasilis Kosmoliaptsisa,
Vikas Singhala,
Anil Vohrahb and
Wade Dimitria,*
a Department of Cardiothoracic Surgery, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, CV2 2DX, UK
b Department of Radiology, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
Received 7 December 2006;
received in revised form 17 February 2007;
accepted 20 February 2007
*Corresponding author. Tel.: +44 24 76965678; fax: +44 24 76965657.
E-mail address: wade.dimitri{at}uhcw.nhs.uk (W. Dimitri).
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Abstract
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Lower gastrointestinal haemorrhage following cardiac surgery is a rare but potentially life threatening complication. Conservative or endoscopic management often fails to detect and control the bleeding, with surgery, often in the form of a major colonic resection, being the last resort. Surgical intervention, however, is associated with high morbidity and mortality. Our case describes the successful management of small bowel haemorrhage, following coronary artery bypass surgery, with angiographic embolotherapy of a branch of the ileocolic artery. We suggest that selective arterial embolisation is a safe and effective therapeutic option available to hospitals undertaking cardiothoracic surgery and should always be considered in the above context.
Key Words: Gastrointestinal haemorrhage; Selective embolotherapy; Coronary artery bypass grafting
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1. Introduction
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Gastrointestinal (GI) haemorrhage following heart operations is a rare but potential life threatening complication. The incidence of upper GI haemorrhage varies from 0.38% to 0.9% in different series [1–3], while D'Ancona et al. [4] describe only one case of lower GI bleeding in a cohort of 11,058 patients after cardiac surgery. The mortality, however, in this subgroup of patients is very high. The therapeutic options include medical management, endoscopic coagulation, transcatheter embolotherapy and surgery. Endoscopy commonly fails as a result of massive bleeding that limits precise localisation of the site of haemorrhage. Although surgery is still considered the mainstay of treatment it is associated with significant morbidity and mortality [5, 6]. Selective coil embolisation, on the other hand, may represent a safe and effective treatment for lower GI haemorrhage following heart operations.
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2. Case presentation
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A 57-year-old male patient was referred to our department for emergency coronary artery bypass grafting. His past medical history included a myocardial infarction 12 years previously, type I diabetes mellitus complicated by peripheral neuropathy and retinopathy, hypertension and asthma. His immediate postoperative course was complicated, requiring prolonged ventilation, inotropic support and haemofiltration for acute renal failure. Whilst haemofiltration was discontinued after a week, he underwent a tracheostomy to facilitate respiratory weaning. However, on the 27th postoperative day, he developed profound rectal bleeding. An urgent OGD did not identify the bleeding source and a flexible sigmoidoscopy, possible up to 40 cm, revealed fresh blood but an otherwise normal intestinal mucosa. A short course of supportive management had to be discontinued as the transfusion requirements increased to seven units and the patient became haemodynamically unstable. After consultation with the general surgical team and the interventional radiologists it was decided to proceed with mesenteric angiography. This was performed through the right femoral artery and revealed contrast extravasation into an ileal loop, supplied by a branch of the ileocolic artery (Fig. 1). Selective catheterisation was achieved with the use of a 5F selective catheter and a Terumo wire. Three coils (3x3 mm) were then positioned at the nearest level of the arcade of vasa recta. Subsequent angiography confirmed coil position and cessation of bleeding (Fig. 2). The patient made a complete recovery, without clinical evidence of intestinal ischaemia and was discharged a week later for rehabilitation. He remained well at three months follow-up; an out-patient colonoscopy was normal.
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3. Discussion
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Gastrointestinal haemorrhage following cardiac surgery is rare, with an incidence that ranges between 0.38% to 0.9% in different series [1–3]. In most cases the source is in the upper GI tract and is due to stress ulceration [1]. Lower GI bleeding arises distal to the ligament of Treitz and involves the small bowel and the colon. Reports in the literature are rare and indeed D'Ancona described only one case of lower GI bleeding in a cohort of 11,058 patients. Therapeutic management can be very difficult, with an estimated mortality as high as 53% [2, 3, 7]. Options include medical management, endoscopic coagulation, transcatheter embolotherapy and surgery. Although the latter is still considered the mainstay of treatment, it is associated with significant morbidity and mortality [5, 6].
Our case describes a patient who suffered life-threatening, lower GI bleeding following coronary artery bypass grafting. Medical management was unsuccessful and it was clear that a decision to proceed with surgery, most probably in the form of a hemicolectomy or sub-total colectomy, would have carried a major risk. Furthermore, it would have failed to control the bleeding as the source was in the small bowel. Transcatheter mesenteric embolisation led to immediate clinical improvement with subsequent discharge one week later.
Arterial embolotherapy is a relatively safe and effective procedure for the treatment of these patients. The choice of occlusive agent used is dependent upon the transcatheter embolisation site and the comfort of the operator. Although polyvinyl alcohol particles have been used successfully [6], some authors do not support their use as a first-line agent; small polyvinyl alcohol particles (<100 µm) may reach the intramural circulation and thus occlude the submucosal plexus beyond the level of collateralisation [8] leading to bowel ischaemia. Gelfoam has the disadvantage of being a temporary occlusive agent. Coils, in contrast to other agents, can be directly visualised under fluoroscopy allowing for more precise placement. The use of microcoils and coaxial microcatheters (superselective embolisation) has the advantage of theoretical preservation of blood flow adjacent to the haemorrhagic site, thus minimizing ischemia to the bowel mucosa [9].
This is particularly important distal to the ligament of Treitz because of decreased collateral blood supply to the colon and to a lesser extent the small bowel, when compared with the stomach and the duodenum.
Bandi et al.[6] reviewed the literature from the past two decades to determine the incidence of postembolisation infarction. Studies in the 1980s showed a 10–20% incidence of postembolisation infarction, whereas later studies in the 1990s demonstrated no or few such cases. This has been attributed to the development of finer coaxial systems and microcoils and is in agreement with other authors [9]. Some patients develop mild mucosal ischaemia, which in most cases is asymptomatic [6, 8, 9]. Complete clinical success, defined as cessation of bleeding following embolotherapy, is reported to be between 65 and 86% [6, 9]. In patients with active bleeding (0.5–1.0 ml/min), mesenteric angiography can localise the site of small bowel bleeding in 50–72% of patients, but the diagnostic yield drops if active bleeding has slowed or stopped [10]. The chance of localising the source of bleeding is higher in cases associated with haemodynamic instability that require more than five units of blood [11]. Even when haemostasis is not achieved, identification of the bleeding site is paramount if subsequent operative treatment is contemplated. Surgery has a definite role for patients with persistent or recurrent bleeding. For the latter cases, however, embolotherapy could serve to stabilise the patient for later more elective surgery, if necessary.
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4. Conclusion
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The incidence of lower GI bleeding following open-heart surgery is low, but is associated with high mortality. Our case suggests that selective embolotherapy represents a safe and effective therapeutic option that should be considered in the above context.
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References
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Abstract
1. Introduction
