Safety & Efficacy of TAE for LGIB
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1 Safety & Efficacy of TAE for LGIB Jin Wook Chung, MD Seoul Nat l Univ Hosp
2 Jin Wook Chung, M.D. No relevant financial relationship reported
3 Editorials or Commentaries Risk of Bowel Ischemia Glue embolization
4
5
6 Risk of bowel ischemia Literature review Experimental study
7 Recent Literature Review After 2000 Year Country Journal N Emb. materials T. S. e_r.r Bowel Ischemia Op. or M C.S. h_m 2000 USA J Vasc Interv Radiol 17? USA Dis Colon Rectum 17? (5.9%) 1 (5.9%) USA J Vasc Interv Radiol 39 PVA 28; microcoil 4; mixed 4; GSP (15.4%) Belgium Radiology 11 PVA 9; PVA/coil 1; glue (9.1%) 1 (9.1%) USA Dis Colon Rectum 27 coils, PVA (7.4%) 1 (3.7%) USA J Vasc Interv Radiol 14( 12): Coil (main) with/without GSP Japan Acta Radiol 44(3): Coil 6; GSP 4; combi (7.0%) USA Curr Surg 10? (10.0%) 1 (10.0%) 2004 Australia Australas Radiol 27 Coil/PVA 20; GSP (14.8%) 3 (11.1%) 2004 Australia ANZ J Surg 15 PVA 9; GSP 2; coil 2; combi (20.0%) 2 (13.3%) Korea Korean J Gastroenterol 19 Coil 5; gelfoam 3; combination NA 2005 USA Am Surg 23? (13.0%) 3 (13.0%) 2005 USA Am J Surg ? (63.6%) 6 (54.5%) India Indian J Gastroenterol 52 PVA 23; coil 16; both (13.5%) USA Cardiovasc Intervent Rad iol 19 Coil (+PVA 2, +GSP 1) (10.5%) 2 (10.5%) Singapore World J Surg 32 Coil 23; others(pva, GSP) (3.1%) 1 (3.1%) Switzerland J Vasc Interv Radiol 20 Coil 16; PVA2; both (5.0%) 1 (5.0%) USA Dis Colon Rectum 71? (7.0%) 4 (5.6%) 2009 Belgium Am J Gastroenterol 39 Coil 17; PVA 10; both 10; GSP 1;glue (10.3%) 4 (10.3%)
8 Recent Literature Review After 2000 Year Country Journal N Emb. materials T. S. e_r.r Bowel Ischemia Op. or M C.S. h_m 2009 Singapore Colorectal Dis 68 Coil 20; PVA 15; both (3 op) USA J Vasc Interv Radiol 14 Glue Korea Korean J Radiol 17 Coil Australia Dis Colon Rectum 38? (5.3%) 2 (5.3%) Taiwan J Vasc Interv Radiol 27 Glue 26; coil Germany Eur J Gastroenterol Hepatol 6 Coil?? 5 (83.3%) 5 (83.3%) 2013 Japan J Vasc Interv Radiol 23 Glue USA J Trauma Acute Care Surg 22 Coil/PVA14;GSP 5; both (13.6%) 1 (4.5%) Taiwan Korean J Radiol 26 Coil ( 9.1%) 2( 9.1%) USA Dig Dis Sci 19 Coil, PVA, GSP Switzerland Int J Colorectal Dis 24 GSP 8; coil 7; PVA 5; silk thread (20.8%) 5 (20.8%) Spain J Vas cinterv Radiol 31 Onyx Singapore ANZ J Surg 26 GSP 10 coil 4; both Korea J Vasc Interv Radiol 112 Glue 84; GSP 20; coils 2; PVA+GSP 1; blood clot (4.5%) 2 (1.8%) Japan Minim Invasive Ther Allied Technol 5 Coil Korea AJR Am J Roentgenol 30 Glue 100.0? ?? 2016 Japan J Vasc Interv Radiol 16 Glue (12.5%) 2 (12.5%) 87.5 Total (7.9%) 52 (5.3%)
9 Technical Success After 2000 Year Country Journal N Emb. materials T. S. e_r.r Bowel Ischemia Op. or M C.S. h_m 2000 USA J Vasc Interv Radiol 17? USA Dis Colon Rectum 17? (5.9%) 1 (5.9%) ~100% 2001 USA J Vasc Interv Radiol 39 PVA 28; microcoil 4; mixed 4; GSP (15.4%) Belgium Radiology 11 PVA 9; PVA/coil 1; glue (9.1%) 1 (9.1%) USA Dis Colon Rectum 27 coils, PVA (7.4%) 1 (3.7%) 0.0 J Vasc Interv Radiol 14( 2003 USA 22 Coil (main) with/without GSP ): Mean: 97% 2003 Japan Acta Radiol 44(3): Coil 6; GSP 4; combi (7.0%) USA Curr Surg 10? (10.0%) 1 (10.0%) 2004 Australia Australas Radiol 27 Coil/PVA 20; GSP (14.8%) 3 (11.1%) 2004 Australia ANZ J Surg 15 PVA 9; GSP 2; coil 2; combi (20.0%) 2 (13.3%) Korea Korean J Gastroenterol 19 Coil 5; gelfoam 3; combination NA 2005 USA Am Surg 23? (13.0%) 3 (13.0%) 2005 USA Am J Surg ? (63.6%) 6 (54.5%) India Indian J Gastroenterol 52 PVA 23; coil 16; both (13.5%) USA Cardiovasc Intervent Rad iol 19 Coil (+PVA 2, +GSP 1) (10.5%) 2 (10.5%) Singapore World J Surg 32 Coil 23; others(pva, GSP) (3.1%) 1 (3.1%) Switzerland J Vasc Interv Radiol 20 Coil 16; PVA2; both (5.0%) 1 (5.0%) USA Dis Colon Rectum 71? (7.0%) 4 (5.6%) 2009 Belgium Am J Gastroenterol 39 Coil 17; PVA 10; both 10; GSP 1;glue (10.3%) 4 (10.3%)
10 Early Rebleeding / Clinical Success After 2000 Year Country Journal N Emb. materials T. S. e_r.r Bowel Ischemia Op. or M C.S. h_m 2000 USA J Vasc Interv Radiol 17? USA Dis Colon Rectum 17? (5.9%) 1 (5.9%) ~50% / 63~100% 2001 USA J Vasc Interv Radiol 39 PVA 28; microcoil 4; mixed 4; GSP (15.4%) Belgium Radiology 11 PVA 9; PVA/coil 1; glue (9.1%) 1 (9.1%) USA Dis Colon Rectum 27 coils, PVA (7.4%) 1 (3.7%) 0.0 J Vasc Interv Radiol 14( 2003 USA 22 Coil (main) with/without GSP ): ~30% / 65~90% 2003 Japan Acta Radiol 44(3): Coil 6; GSP 4; combi (7.0%) USA Curr Surg? (10.0%) 1 (10.0%) 2004 Australia Australas Radiol 27 Coil/PVA 20; GSP (14.8%) 3 (11.1%) 2004 Australia ANZ J Surg 15 PVA 9; GSP 2; coil 2; combi (20.0%) 2 (13.3%) Korea Korean J Gastroenterol 19 Coil 5; gelfoam 3; combination NA 2005 USA Am Surg 23? (13.0%) 3 (13.0%) 2005 USA Am J Surg ? (63.6%) 6 (54.5%) India Indian J Gastroenterol 52 PVA 23; coil 16; both (13.5%) USA Cardiovasc Intervent Rad iol 19 Coil (+PVA 2, +GSP 1) (10.5%) 2 (10.5%) Singapore World J Surg 32 Coil 23; others(pva, GSP) (3.1%) 1 (3.1%) Switzerland J Vasc Interv Radiol 20 Coil 16; PVA2; both (5.0%) 1 (5.0%) USA Dis Colon Rectum 71? (7.0%) 4 (5.6%) 2009 Belgium Am J Gastroenterol 39 Coil 17; PVA 10; both 10; GSP 1;glue (10.3%) 4 (10.3%)
11 Bowel Ischemia (n: 20) Year Country Journal N Emb. materials T. S. e_r.r Bowel Ischemia Op. or M 2001 USA J Vasc Interv Radiol 39 PVA 28, microcoil 4; mixed 4; GSP (15.4%) USA Dis Colon 0~83.3% Rectum 27 coils, PVA (0~15%) (7.4%) 1 (3.7%) 0.0 coil (main) with/witho 2003 USA J Vasc Interv Radiol % ut GSP or gelfoam 2004 Australia Australas Radiol 27 GSP 7; PVAs & microc oils (14.8%) 3 (11.1%) 2005 USA 9% Am Surg BI 23 / 5%? Op or 3 (13.0%) M3 (13.0%) PVA 23; microcoils 16; 2006 India Indian J Gastroenterol (13.5%) 0.0 both Singapore World J Surg coils 23; others(pva, G 32 SP) (3.1%) 1 (3.1%) Switzerland J Vasc Interv Radiol microcoils 16; PVA2; b 20 oth (5.0%) 1 (5.0%) USA Dis Colon Rectum 71? (7.0%) 4 (5.6%) 2009 Belgium Am J Gastroenterol Singapore Colorectal Dis 68 microcoils 17; PVA 10; both 10; GSP 1; Lipiod ol/enbucrilate 1 microcoils 20; PVA 15; both (10.3%) 4 (10.3%) C.S. h_m (5.9%) 3 (4.4%) 0? Total (8.8%) 20 (4.7%)
12 Risk of bowel ischemia Literature review Experimental study
13 Experimental Study Superselective embolization was performed in 6 dogs at the vasa recta level using NBCA (1:3 ratio, ml) in five isolated branches of the SMA Sacrificed 24hrs after TAE Histologic evaluation J Vasc Interv Radiol 2008; 19: Specimen radiography
14 Experimental Study Group A: Embolization of 3 or fewer vasa recta without antimesenteric border zone involvement Ischemic changes: Mucosa Submucosa Muscle layer 0% 0% 0% Jae HJ, Chung JW, et al. J Vasc Interv Radiol 2008; 19:755-63
15 Experimental Study Group A: Embolization of 3 or fewer vasa recta with antimesenteric border zone involvement Ischemic changes: Mucosa Submucosa Muscle layer 10% 10% 0% Jae HJ, Chung JW, et al. J Vasc Interv Radiol 2008; 19:755-63
16 Experimental Study Group B: Embolization of 4 or more vasa recta without antimesenteric border zone involvement Ischemic changes: Mucosa Submucosa Muscle layer 10% 0% 0% Jae HJ, Chung JW, et al. J Vasc Interv Radiol 2008; 19:755-63
17 Experimental Study Group B: Embolization of 4 or more vasa recta with antimesenteric border zone involvement Ischemic changes: Mucosa Submucosa Muscle layer 100% 50% 10% Jae HJ, Chung JW, et al. J Vasc Interv Radiol 2008; 19:755-63
18 Experimental Study Group A: 3 or fewer vasa recta embolization Group B: 4 or more vasa recta embolization No. Depth Mucosa Sub M Muscle 1 M M M M M M AM AM AM AM AM AM AM AM AM No. Depth Mucosa SubM Muscle 1 M M AM AM AM AM AM AM AM AM AM AM AM AM AM
19 Experimental Study: Conclusion Bowel ischemia (BI) after TAE is related to selectiveness of the procedure & penetration depth of embolic materials. Permenant embol. of 1-2 vasa recta without antimesenteric border involvement do not induce BI. Wide and deep embolization carries high risk of BI.
20 As selective as possible Selection of adequate embolic material
21 Clinical Case M/46, rectal bleeding, coagulopathy (+) The microcatheter could not adequately reach the bleeding point, but wedged in the bleeding a. NBCA embolization
22 Clinical Case M/46, rectal bleeding, coagulopathy (+)
23 Recent Literature Review (n: 20) Year Country Journal N Emb. materials T. S USA J Vasc Interv Radiol 39 PVA 28, microcoil 4; mixed 4; GSP 3 e_r.r Bowel Ischemia Op. or M (15.4%) USA Dis Colon Rectum 27 coils, PVA (7.4%) 1 (3.7%) USA J Vasc Interv Radiol Australia Australas Radiol 27 coil (main) with/witho ut GSP or gelfoam GSP 7; PVAs & microc oils 20 C.S % (14.8%) 3 (11.1%) 2005 USA Am Surg 23? (13.0%) 3 (13.0%) 2006 India Indian J Gastroenterol Singapore World J Surg Switzerland J Vasc Interv Radiol 20 PVA 23; microcoils 16; both 13 coils 23; others(pva, G SP) 8 microcoils 16; PVA2; b oth (13.5%) 0.0 h_m (3.1%) 1 (3.1%) (5.0%) 1 (5.0%) USA Dis Colon Rectum 71? (7.0%) 4 (5.6%) 2009 Belgium Am J Gastroenterol Singapore Colorectal Dis 68 microcoils 17; PVA 10; both 10; GSP 1; Lipiod ol/enbucrilate 1 microcoils 20; PVA 15; both (10.3%) 4 (10.3%) (5.9%) 3 (4.4%) 0? Total (8.8%) 20 (4.7%)
24 Recent Literature Review (n: 20) Year Country Journal N Emb. materials T. S. e_r.r Bowel Ischemia Op. or M C.S. h_m 2010 Australia Dis Colon Rectum 38? (5.3%) 2 (5.3%) Taiwan J Vasc Interv Radiol 27 Glue 26; coil Japan J Vasc Interv Radiol 23 Glue USA J Trauma Acute Care Su rg 22 Coil/PVA14;GSP 5; bot h (13.6%) 1 (4.5%) Taiwan Korean J Radiol 26 Coil ( 9.1%) 2( 9.1%) Switzerland Int J Colorectal Dis 24 GSP 8; coil 7; PVA 5; s ilk thread (20.8%) 5 (20.8%) Spain J Vas cinterv Radiol 31 Onyx Singapore ANZ J Surg 26 GSP 10 coil 4; both Korea J Vasc Interv Radiol 112 Glue 84; GSP 20; coils 2; PVA+GSP 1; blood clot (4.5%) 2 (1.8%) Korea AJR Am J Roentgenol 30 Glue NA Total (4.7%) 12(3.3%)
25 Recent Literature Review After 2000 (glue embolization alone) Year Country Journal N Emb. materials T. S. e_r.r Bowel Ischemia Op. or M C.S. h_m 2009 USA J Vasc Interv Radiol. 20: Glue 100.0% 14.2% % 2011 Taiwan J Vasc Interv Radiol. 22: Glue 100.0% 14.8% % 2013 Japan J Vasc Interv Radiol. 24: Glue 100.0% 4,3% Korea J Vasc Interv Radiol. 25: Glue 96.4% 17.4% 4(4.8%) 1(1.2%) 75% 25.0% 2014 Spain J Vas cinterv Radiol. 25: Onyx 93.5% 10.0% % 2015 Korea AJR 204(3): Glue 100.0%? 0 0?? 2016 Japan J Vasc Interv Radiol [Epub ahead of print] 16 Glue 100.0% 6.3% 2(12.5%) 2(12.5%) 88% Total (2.7%) 3 (1.3%) After 2000 (other embolic materials) Year Country Journal N Emb. materials T. S. e_r.r Bowel Ischemia Op. or M C.S. h_m Total (9.5%) 49 (6.5%) 2009~ (8.8%) 22 (7.7%)
26 Conclusion Safety of TAE for LGIB is improving. Superselective embolization of vasa recta is proven to be safe. Familiarity to use liquid embolics may improve outcome of the procedure.
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