Angiography and endovascular embolization play an important role in controlling acute arterial upper gastrointestinal hemorrhage, particularly when endoscopic intervention fails to do so. In our case, the patient presented with recurrent life-threatening bleed in spite of multiple prior endoscopic interventions and gastroduodenal artery embolization. Our teaching points focus on the role of angiography in acute upper gastrointestinal bleed and when to conduct empiric embolization, while reviewing the supraduodenal artery as an atypical but important potential culprit for refractory upper gastrointestinal bleed

Gabriel, Gaby

Han, Qiong

Krohmer, Steven

Qian, Chenghao

Raissi, Driss

English

University of Kentucky

University of KentuckyUKnowledgeRadiology Faculty Publications Radiology9-2017Gastrointestinal Bleeding from SupraduodenalArtery with Aberrant OriginQiong HanUniversity of Kentucky, qiong.han@uky.eduChenghao QianUniversity of Kentucky, che.qian@uky.eduGaby GabrielUniversity of Kentucky, gaby.gabriel@uky.eduSteven KrohmerUniversity of Kentucky, steven.krohmer@uky.eduDriss RaissiUniversity of Kentucky, driss.raissi@uky.eduRight click to open a feedback form in a new tab to let us know how this document benefits you.Follow this and additional works at: https://uknowledge.uky.edu/radiology_facpubPart of the Gastroenterology Commons, and the Radiology CommonsThis Article is brought to you for free and open access by the Radiology at UKnowledge. It has been accepted for inclusion in Radiology FacultyPublications by an authorized administrator of UKnowledge. For more information, please contact UKnowledge@lsv.uky.edu.Repository CitationHan, Qiong; Qian, Chenghao; Gabriel, Gaby; Krohmer, Steven; and Raissi, Driss, "Gastrointestinal Bleeding from SupraduodenalArtery with Aberrant Origin" (2017). Radiology Faculty Publications. 17.https://uknowledge.uky.edu/radiology_facpub/17Gastrointestinal Bleeding from Supraduodenal Artery with Aberrant OriginNotes/Citation InformationPublished in Radiology Case Reports, v. 12, issue 3, p. 526-528.© 2017 the Authors. Published by Elsevier Inc. under copyright license from the University of Washington.This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).Digital Object Identifier (DOI)https://doi.org/10.1016/j.radcr.2017.04.005This article is available at UKnowledge: https://uknowledge.uky.edu/radiology_facpub/17Case ReportGastrointestinal bleeding from supraduodenal artery withaberrant originQiong Han MD, PhDa,*, Chenghao Qian BSb, Gaby Gabriel MDa, Steven Krohmer MDa,Driss Raissi MDaa Department of Radiology, University of Kentucky, HX 315, 800 Rose Street, Lexington, KY 40506, USAb College of Medicine, University of Kentucky, Lexington, KY 40506, USAa r t i c l e i n f oArticle history:Received 3 March 2017Accepted 18 April 2017Available online 30 May 2017Keywords:Interventional radiologyAngiographyEndovascular embolizationUGIBa b s t r a c tAngiography and endovascular embolization play an important role in controlling acutearterial upper gastrointestinal hemorrhage, particularly when endoscopic interventionfails to do so. In our case, the patient presented with recurrent life-threatening bleed inspite of multiple prior endoscopic interventions and gastroduodenal artery embolization.Our teaching points focus on the role of angiography in acute upper gastrointestinal bleedand when to conduct empiric embolization, while reviewing the supraduodenal artery asan atypical but important potential culprit for refractory upper gastrointestinal bleed.© 2017 the Authors. Published by Elsevier Inc. under copyright license from the Universityof Washington. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).IntroductionThe utilization of angiography has decreased in the setting ofacute arterial upper gastrointestinal bleed (UGIB) due to theincreased use of computed tomography angiography. How-ever, angiography and transarterial embolization remain animportant tool in controlling acute arterial UGIB, especiallywhen endoscopic intervention fails to do so [1].Case reportWe report the case of an 86-year-old male, who presentedwith recurrent UGIB, including melena and bright red bloodper rectum, status post recent endoscopic proximal duodenalulcer clipping and subsequent angiography with gastroduo-denal artery (GDA) embolization.Initial digital subtraction angiography of the celiac trunkdid not reveal any active extravasation (Fig. 1).Next, digital subtraction angiography of the superiormesenteric artery was performed, without revealing anybleeding supplied by the inferior pancreaticoduodenal arteryor the gastroduodenal arcade (Fig. 2).The celiac trunk was then revisited, given that the terri-tory’s proximity to the site of the UGIB identified by theendoscopic duodenal clips. The adjacent supraduodenal ar-tery (SDA) was identified as the potential culprit for the bleed(Fig. 3). SDA usually supplies the proximal duodenum, and inour case, it wraps around the duodenal clips. This SDA alsoshowed an aberrant origin, arising from the right gastricCompeting Interests: The authors have declared that no competing interests exist.* Corresponding author.E-mail address: qiong.han@uky.edu (Q. Han).Available online at www.sciencedirect.comScienceDirectjournal homepage: ht tp: / /Elsevier .com/locate/radcrR a d i o l o g y C a s e R e p o r t s 1 2 ( 2 0 1 7 ) 5 2 6e5 2 8http://dx.doi.org/10.1016/j.radcr.2017.04.0051930-0433/© 2017 the Authors. Published by Elsevier Inc. under copyright license from the University of Washington. This is an openaccess article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).artery, which is less than 8% in all cases [2]. The SDA wasselected by a microcatheter (Fig. 3) and empirically embolizedwith EmbozeneMicrospheres (Boston Scientific, Marlborough,MA) (Fig. 4), in spite of the lack of obvious active extravasation.SDA angiography demonstrates hyperemia and delayedvenous clearance suggestive of underlying vascular injury.Patient remained hemodynamically stable and did not requirefurther blood transfusion in the immediate postproceduralperiod.DiscussionIndicationsThe main indications for angiography in the setting of UGIBinclude the followings [3,4], with our patient fitting in thesecond category. Limited endoscopic visibility from vigorous bleeding Bleeding not controlled by endoscopic therapyFig. 1 e Digital subtraction angiography (DSA) of the celiactrunk showed the region of interest involving the proximalduodenum (circle), with endoscopically placed clips in thevicinity and previously coil-embolized GDA. GDA,gastroduodenal artery.Fig. 2 e DSA of the superior mesenteric artery (SMA) withpreviously embolized GDA showed no active bleeding.DSA, digital subtraction angiography; GDA,gastroduodenal artery.Fig. 3 e With the main catheter in the celiac trunk, SDAmicrocatheter superselective angiography demonstratedhyperemia and delayed venous clearance suggestive ofunderlying vascular injury. SDA, supraduodenal artery.Fig. 4 e Postembolization using Embozene Microspheres:DSA of the common hepatic artery showed total stasis ofthe aberrant SDA. DSA, digital subtraction angiography;SDA, supraduodenal artery.R a d i o l o g y C a s e R e p o r t s 1 2 ( 2 0 1 7 ) 5 2 6e5 2 8 527 Medical or anatomic reasons limiting endoscopic route,such as previous gastric bypass surgery Qualified endoscopic operator not availableEmpiric embolizationEmpiric embolization may be pursued if prior endoscopylocalizes the suspected bleeding site, and there is high suspi-cion for continued bleeding from that site. In our case, empiricembolization of the supraduodenal artery, which wrappedaround the preexisting duodenal clips placed during priorendoscopy, was effective to control patient’s UGIB. Empiricembolization has been shown to be effective in controllingUGIB, particularly in refractory cases [3,5]. Having the endo-scopic clips as a target was of paramount importance to guidethe prophylactic therapy in this case. While prophylactic GDAembolization is a common intervention in UGIB withoutangiographic evidence of bleeding, other duodenal branchesmay be the culprits and must be considered if GDA emboli-zation has failed to control the bleeding, especially after rulingout retrograde bleeding via the pancreaticoduodenal arcade,which can be interrogated via SMA angiography.Supraduodenal arteryAs one of the arterial branches supplying the duodenum, thesupraduodenal artery can be a potential culprit for UGIB.However, it has a variety of origins. The possible origins of thesupraduodenal artery and the associated frequencies are lis-ted as follows [2]: GDA, 26%; common or proper hepatic artery,20%; left hepatic artery, 20%; right hepatic artery, 13%; cysticartery, 10%; and right gastric artery, 8%. In this case, thesupraduodenal artery branches off an aberrant right gastricartery, which arises from the right hepatic artery. The anat-omy of this case is reviewed in detail (Fig. 5).The patient remained hemodynamically stable since thelast embolization of the aberrant SDA. Although SDA is anuncommon source for UGIB, knowing this variant is importantclinically, especially in cases of refractory gastrointestinalbleed status post endoscopic intervention and GDAembolization.r e f e r e n c e s[1] Miller M, Smith SP. Angiographic diagnosis and endovascularmanagement of nonvariceal gastrointestinal hemorrhage.Gastroenterol Clin North Am 2005;34(4):735e52.[2] Bianchi HF, Albanese EF. The supraduodenal artery. SurgRadiol Anat 1989;11:37e40. Image courtesy of David, Liu MD.[3] Ramaswamy RS, Choi HW, Mouser HC, Narsinh KH,McCammack KC, Treesit T, et al. Role of interventionalradiology in the management of acute gastrointestinalbleeding. World J Radiol 2014;6(4):82e92.[4] Eriksson L, Ljungdahl M, Sundbom M, Nyman R.Transcatheter arterial embolization versus surgery in thetreatment of upper gastrointestinal bleeding after therapeuticendoscopy failure. J Vasc Interv Radiol 2008;19(10):1413e8.[5] Dixon S, Chan V, Shrivastava V, Anthony S, Uberoi R,Bratby M, et al. Is there a role for empiric gastroduodenalartery embolization in the management of patients withactive upper GI hemorrhage? Cardiovasc Intervent Radiol2013;36:970e7.Fig. 5 e DSA of celiac trunk (C) shows an aberrant origin ofthe right gastric artery (7), arising from the right hepaticartery (6), gives rise to an aberrant supraduodenal artery (8)supplying the proximal duodenum and wrapping aroundthe duodenal clips (D). S, splenic artery; 1, left gastricartery; 2, accessory left hepatic artery arising from (1); 3,common hepatic artery; 4, coil-embolized GDA; 5, lefthepatic artery, small in caliber due to (2); 9, right gastricartery proper; 10, middle hepatic artery; 11, right hepaticartery proper. GDA, gastroduodenal artery.R a d i o l o g y C a s e R e p o r t s 1 2 ( 2 0 1 7 ) 5 2 6e5 2 8528

Gastrointestinal Bleeding from Supraduodenal Artery with Aberrant Origin

https://uknowledge.uky.edu/cgi/viewcontent.cgi?article=1017&amp;context=radiology_facpub

Gastrointestinal Bleeding from Supraduodenal Artery with Aberrant Origin

Abstract

Similar works

Full text

Available Versions

University of Kentucky