Transcatheter intervention for non-variceal gastrointestinal bleeding: what have we learned in 45 years?

Despite considerable advances in diagnostic testing, medical treatment, surgical and non-surgical interventions, therapy of gastrointestinal (GI) bleeding remains a challenge for physicians. Although GI bleeding ceases spontaneously in roughly 75 % of patients, it still carries a relatively high morbidity and mortality in our aging population [1]. When faced with a bleeding patient, clinicians initially attempt to separate hemorrhage arising in the upper gastrointestinal (UGI) tract from that originating in the lower gastrointestinal (LGI) tract, delineated by the ligament of Treitz, due to the considerable differences in diagnosis, treatment and prognosis associated with each region. Regardless of location, endovascular interventions remain important for the diagnosis and treatment of GI bleeding, likely only increasing in application and efficacy in the coming decades. Before 1968, endovascular physicians had little to offer the acutely bleeding patient. The first major therapeutic intervention for GI bleeding was catheter directed intraarterial vasopressin infusion [2]. A somewhat cumbersome procedure that has largely been abandoned in contemporary practice, vasoconstrictor infusion offered a minimally invasive therapy that could be employed in stable and unstable patients alike, for variceal and non-variceal hemorrhage [3]. In the 1970s, arterial embolization initially appeared promising, although its widespread adoption was thwarted by unacceptably high complication rates, primarily colonic ischemia [4]. When technological advances in imaging, embolic agents, and catheters caught up with physician ingenuity in the late 1990s and early 2000s, a paradigm switch occurred with arterial embolization assuming primacy for catheter-based therapy of UGI and LGI bleeding. In the past several years, numerous studies, predominantly retrospective series, have reported the safety and efficacy of arterial embolization for UGI and LGI bleeding [5–7]. Although published algorithms for the management of GI bleeding exist, the application of mesenteric angiography with transcatheter arterial embolization in the therapy of GI hemorrhage remains controversial. The study by Yap et al. [8] in this issue describes a single-center experience with transcatheter arterial embolization for non-variceal GI bleeding over a period of 8 years. The authors demonstrate a high technical success rate in keeping with other reported series and national guidelines. Of note, the data are reported without strict separation of UGI from LGI bleeding, which dilutes their conclusions. Despite this limitation, the authors provide a detailed look at patients requiring transcatheter arterial embolization, and identify important risk factors for rebleeding, notably underlying peptic ulcer disease and coagulopathy. Their experience highlights an important concept in the endovascular treatment for GI bleeding; embolization in the UGI tract can either be ‘‘targeted’’ at visualized arterial abnormalities, or ‘‘empiric’’, where the suspected culprit arterial branch is occluded despite no demonstrated angiographic abnormality. In the LGI tract, where the collateral arterial supply is tenuous, targeted embolization is recommended such as in the accompanying article, D. S. BouHaidar (&) Department of Internal Medicine, Interventional Endoscopy, Virginia Commonwealth University Health Center, Box 980341, Richmond, VA 23298-0341, USA e-mail: dsbouhaidar@vcu.edu