Endovascular therapy
Transcatheter arterial embolization (TAE) was first used in 1972 as an alternative to surgical management of GIB that failed endoscopic therapy.83 Since then, there have been several innovations in the field of endovascular therapy. TAE is generally sought after failure of endoscopic therapy with simultaneous use of intravenous PPI therapy. The classic patient presents with massive GIB with significant hemodynamic compromise, unsuccessful medical management (PPI and resuscitation), and unsuccessful attempts at endoscopic treatment.84 Endovascular therapy for NVUGIB is mostly centered on the celiac and superior mesenteric arteries and their respective branches. The left gastric artery which branches from the celiac artery provides blood to the distal esophagus and the fundus of the stomach. The gastroduodenal artery provides blood to the gastric antrum and proximal duodenum. The superior mesenteric artery provides blood to the rest of the duodenum through pancreaticoduodenal anastomoses. TAE is most commonly performed by interventional radiologists in the United States. The common femoral artery is accessed and subsequently different sized guidewires and microcatheters are introduced until they reach the celiac artery.85 Active GIB is identified by contrast extravasation into the bowel lumen which is positive in up to 61% of ongoing GIB.85–87 If the site of bleeding cannot be recognized, blind embolization can also be performed. Prior studies have shown no difference in outcomes in patients with or without contrast extravasation during embolization.84,88 During an esophagogastroduodenoscopy (EGD), an endo-clip can sometimes be placed close to the arterial bleed which helps to locate the approximate artery for selective embolization. Vasopressin was previously used due to its vasoconstrictive properties, but this therapy fell out of favor since it required 12–48 hours of continuous infusion until the bleeding ceased.85 The advent of embolization greatly expedited the process and has replaced the use of vasopressin over the past two decades. Due to several endovascular therapies arising in the past few decades, selection depends on operator ease, experience, and availability of equipment.
