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Control of Life-threatening Vesical Hemorrhage by Unilateral Hypogastric Artery Muscle Embolization
\/ o\. l l2, Ju\y
THE JOURNAL OI UROLOG'\:
Copyright© 1974 by The Williams & Wilkins Co.
Printed in U.S.A.
CONTROL OF LIFE-THREATENING VESICAL HEMORRHAGE BY UNILATERAL HYPOGASTRIC ARTERY MUSCLE EMBOLIZATION TAGE HALD
AND
THORKILD MYGIND
From the Departments of Urology Hand Radiology, University of Copenhagen, Gentofte Hospital, Hellerup, Denmark
Bladder hemorrhage secondary to radiation cystitis is a serious threat to patients. A number of methods have been proposed to control such situations, including cauterization, topical silver nitrate or formalin, an operation such as hypogastric artery ligation or diversion procedures ( alone or with cystectomy) and various pharmacological agents with the aim of influencing the coagulation mechanism, for example phytomenadione and epsilon aminocaproic acid. 1 Results are often unsatisfactory except for the most drastic measures. Intravesical pressure treatment is often useful but may prove inefficient. 2 There is a definite need for safe non-invasive methods. We herein report on the method of hypogastric artery muscle embolization, which to our knowledge has not been tested previously. METHOD
With the patient in the supine position on an x-ray table a No. 6 Judkins' catheter for left coronary artery catheterization is introduced into a femoral artery (fig. 1). The catheter is advanced into the aorta, turned tip down by engaging one of the renal arteries, pulled down to override the aortic bifurcation and placed in the anterior trunk of the opposite hypogastric artery. Repeated injections of 76 per cent urografin-meglumine are made while monitoring the procedure on a television image intensifier. An incision is made over 1 vastus lateralis muscle and approximately 5 cc of muscle tissue is excised. The wound is closed and the muscle is chopped in tiny (1 to 5 mm. 3) particles with a pair of fine scissors and a knife. The tissue is then suspended in a mixture of urografin and physiological saline, and aspirated into a syringe. During continuous x-ray monitoring the suspension is injected fraction by fraction through the intra-arterial catheter until the major branches and distal end of the trunk of the hypogastric artery are filled with muscle tissue and stagnating contrast medium. Thrombosis occurs almost immediately and propagates upstream to the origin of the hypogastric artery. A subsequent arteriogram confirms the occlusion of the vessel. We have tested the method as a unilateral procedure only. Accepted for publication January 11, 1974. 1 Holstein, P., Jacobsen, K., Pedersen, J. F. and Sorensen, J. S.: Intravesical hydrostatic pressure treatment: new method for control of bleeding from the bladder mucosa. J. Urol., 109: 234, 1973. 2 Firlit, C. F.: Intractable hemorrhagic cystitis secondary to extensive carcinomatosis: management with formalin solution. J. Urol., llO: 57, 1973. 60
CASE REPORT
A 79-year-old man, well preserved mentally, was
hospitalized on November 13, 1972 with severe hematuria. In 1971 a diagnosis of grade 3 bladder carcinoma, stage T 1 N x M 0 , had been made and treatment with a 6 mev. linear accelerator had been given to a total tumor dose of 6,000R. The disappearance of the tumor had been verified by cystoscopy. A year later a small recurrence was electrocoagulated. The tumor was confined to the right lateral wall. Admission cystoscopy revealed profusely bleeding bladder mucosa but with changes more pronounced on the right side. Biopsy showed no recurrence of tumor. Electrocoagulation was done several times during the following weeks and treatment with epsilon aminocaproic acid was instituted (fig. 2). The patient was in and out of the hospital, still bleeding periodically, until February 7, 1973 when 140 to 160 mm. Hg intravesical pressure treatment was given for 6 hours. The bleeding stopped immediately but septicemia developed and treatment with ampicillin and sulfamethoxazole with trimethoprim was instituted. The patient was discharged from the hospital with clear urine. On April 24 bleeding recurred and increased despite epsilon aminocaproic acid. The patient was rehospitalized on May 29 with a hemoglobin of 5.3 gm. per 100 ml. and was in a distressed condition. Blood transfusions were given to correct the anemia. On June 5 arteriography was performed via the left femoral artery with the aim of occluding the right hypogastric artery with an autologous blood clot. After 10 cc clotted blood was injected into the artery occlusion was noted (fig. 3, A). There were no adverse reactions and the vesical hemorrhage stopped immediately. However, within a few days bleeding recurred worse than ever. After observing a temporary effect of the clotting and realizing that the situation was desperate, we planned a definite occlusion of the right hypogastric artery. Until that time a total of 30 units of blood had been given. On June 13 a new arteriogram confirmed the complete lysis of the artificial thrombus (fig. 3, B). Hypogastric artery muscle embolization was performed as described previously and complete occlusion was demonstrated (fig. 4). Bleeding diminished daily and stopped completely in less than a week. No transfusions were required. There was no temperature reaction but a transient tenderness and induration appeared in the right gluteal region and on the back of the right thigh, probably caused by local
CONTROL OF VESICAL HEMORRHAGE
ischemia. However, the patient's general condition has been good. Bladder function was initially characterized by urgency and frequency but this completely disappeared 3 weeks later. The patient was seen 4 months after the muscle embolization (fig. 2). Moderate hematuria was noted during the last few weeks but a normal hemoglobin was maintained. Cystoscopy at this time showed a grade 3 recurrence on the right lateral bladder wall and the tumor was electrocoagulated. DISCUSSION
Embolization of the arteries with muscle tissue has been used by neurosurgeons in the treatment of intracranial arteriovenous fistulas. 3 · 4 Control of gastrointestinal bleeding has been obtained by the intra-arterial infusion of pituitrin '· 6 and soft blood clots. 7 To our knowledge muscle embolization has never been used for control of massive bleeding either in urology or in general surgery. The pathology of irradiation cystitis is the formation of thin-walled vessels in a chronically inflamed hypovascularized bladder. Hypogastric artery muscle embolization is not a causal treat' Brooks, C. M.: Cited by Noland, L. and Taylor, A. S.: Pulsating exophthalmos, the result of injury. Trans. South. Surg. Ass., 43: 171, 1931. 4 Hamby, W. B. and Gardner, W. J.: Treatment of pulsating exophthalmos: with report of two cases. Arch. Surg., 27: 676, 19:33. 5 Baum, S. and :'>iusbaum, M.: The control of gastrointestinal hemorrhage by selective mesenteric arterial infusion of vasopressin. Radiology, 98: 497, 1971. 6 Murray-Lyon, I. M., Pugh, R. N. H., Nunnerley, H. B., Laws, J. W., Dawson, ,J. L. and Williams, R.: Treatment of bleeding oesophageal varices by infusion of vasopressin into the superior mesenteric artery. Gut, 14: 59, 1973. 'Rosch, J., Dotter, C. T. and Brown, M. J.: Selective arterial embolization. A new method for control of acute gastrointestinal bleeding. Radiology, !02: 303, 1972.
ment but it attacks the problem in a radical way. It is superior to vessel ligation by its production of a thrombosis that extends further into the arterial system since collaterals will inevitably arise at a high branching level following ligation. Patients who have chronic occlusion of both hypogastric arteries usually have normal bladder function. This indicates that a bilateral hypogastric artery occlusion by muscle embolization will not, at least when performed in 2 separate stages at some interval allowing collaterals to develop, jeopardize the trophic state of the bladder. The method seems to have worked in our case, although we the procedure on 1 side only. We chose the side that was the source of the most severe hemorrhage,
FIG. 1. Judkins' arterial catheter for left coronary artery catheterization. Loop at end of catheter is 6 cm. long.
d' 79 years S.CCJ. 1972
Hematuria
1973
~~~~~~TE SLIGHT
.I
13
Hemoglobin g/100 ml
\ l
10
•
Transfusron
!l
pressure
embo!i2ation
treatment
procedures
½ = electrocoagu!ation
FIG. 2. Patient data illustrate course of bladder hemorrhage
13,51
62
HALD AND MYGIND
FIG. 3. A, arteriogram following occlusion of right hypogastric artery with blood clot. B, arteriogram 1 week after occlusion of right hypogastric artery. Selective injection into hypogastric artery via Judkins' catheter. Complete lysis of thrombus except for small remnant in main trunk. Numerous arterial branches supply right bladder wall.
FIG. 4. Result of muscle embolization of right hypogastric artery. Note stagnation of contrast medium in occluded anterior trunk.
which incidentally corresponded to the previously tumor-bearing side. If efficient, hypogastric artery muscle embolization has obvious advantages over drastic surgical procedures, especially in the elderly person. It was remarkable how well our patient tolerated the procedure. There is a definite risk of spilling emboli into the leg's arterial system with this procedure but this can be counteracted by careful x-ray monitoring and slow injection. Once the emboli have reached
their destiny the risk of a dislocation is minimal since thrombosis occurs rapidly on muscle tissue with its high content of thromboplastin. The particles are embedded in a solid mass. The effect of hypogastric embolization was demonstrated twice in our case but lysis of an autologous thrombus was obviously too effective and prevented a lasting effect. Cessation of bleeding occurred more rapidly when the blood clot was used than when muscle particles were used. Therefore, one can assume that the more smooth and viscous clot occluded the bladder arterial branches immediately at a more distal level. Although it cannot be proved, it is reasonable to believe that the unilateral hypogastric artery muscle embolization accounted for the cessation of bleeding in our patient. The previous 7 months, except for 2 months following intravesical pressure treatment, were dominated by severe vesical bleeding requiring a total of 30 units of blood. We did not consider another pressure treatment justified because of a septic reaction and the limited effect in this case. SUMMARY
A case of severe vesical hemorrhage secondary to radiation for bladder carcinoma in a 79-year-old man is reported. After 7 months of almost continuous bleeding requiring a total of 30 units of blood, hemorrhage stopped following embolization of 1 hypogastric artery with muscle tissue particles via percutaneous arterial catheter. No permanent adverse effects were noted.
CONTROL OF VESICAL HEMORRHAGE ADDENDUM
The patient was rehospitalized in December 1973 with severe vesical hemorrhage. An arteriogram confirmed the occlusion of the right hypogastric artery but some collaterals had developed from the left hypogastric artery system and the right
63
external pudenda! artery. A hypogastric artery occlusion with muscle tissue was performed on th·e left side and the right external pudenda! artery war; ligated. Hemorrhage continued and on 11, 1974 urinary diversion a ureteroileocutaneostomy was performed.
THE JOURNAL OI UROLOG'\:
Copyright© 1974 by The Williams & Wilkins Co.
Printed in U.S.A.
CONTROL OF LIFE-THREATENING VESICAL HEMORRHAGE BY UNILATERAL HYPOGASTRIC ARTERY MUSCLE EMBOLIZATION TAGE HALD
AND
THORKILD MYGIND
From the Departments of Urology Hand Radiology, University of Copenhagen, Gentofte Hospital, Hellerup, Denmark
Bladder hemorrhage secondary to radiation cystitis is a serious threat to patients. A number of methods have been proposed to control such situations, including cauterization, topical silver nitrate or formalin, an operation such as hypogastric artery ligation or diversion procedures ( alone or with cystectomy) and various pharmacological agents with the aim of influencing the coagulation mechanism, for example phytomenadione and epsilon aminocaproic acid. 1 Results are often unsatisfactory except for the most drastic measures. Intravesical pressure treatment is often useful but may prove inefficient. 2 There is a definite need for safe non-invasive methods. We herein report on the method of hypogastric artery muscle embolization, which to our knowledge has not been tested previously. METHOD
With the patient in the supine position on an x-ray table a No. 6 Judkins' catheter for left coronary artery catheterization is introduced into a femoral artery (fig. 1). The catheter is advanced into the aorta, turned tip down by engaging one of the renal arteries, pulled down to override the aortic bifurcation and placed in the anterior trunk of the opposite hypogastric artery. Repeated injections of 76 per cent urografin-meglumine are made while monitoring the procedure on a television image intensifier. An incision is made over 1 vastus lateralis muscle and approximately 5 cc of muscle tissue is excised. The wound is closed and the muscle is chopped in tiny (1 to 5 mm. 3) particles with a pair of fine scissors and a knife. The tissue is then suspended in a mixture of urografin and physiological saline, and aspirated into a syringe. During continuous x-ray monitoring the suspension is injected fraction by fraction through the intra-arterial catheter until the major branches and distal end of the trunk of the hypogastric artery are filled with muscle tissue and stagnating contrast medium. Thrombosis occurs almost immediately and propagates upstream to the origin of the hypogastric artery. A subsequent arteriogram confirms the occlusion of the vessel. We have tested the method as a unilateral procedure only. Accepted for publication January 11, 1974. 1 Holstein, P., Jacobsen, K., Pedersen, J. F. and Sorensen, J. S.: Intravesical hydrostatic pressure treatment: new method for control of bleeding from the bladder mucosa. J. Urol., 109: 234, 1973. 2 Firlit, C. F.: Intractable hemorrhagic cystitis secondary to extensive carcinomatosis: management with formalin solution. J. Urol., llO: 57, 1973. 60
CASE REPORT
A 79-year-old man, well preserved mentally, was
hospitalized on November 13, 1972 with severe hematuria. In 1971 a diagnosis of grade 3 bladder carcinoma, stage T 1 N x M 0 , had been made and treatment with a 6 mev. linear accelerator had been given to a total tumor dose of 6,000R. The disappearance of the tumor had been verified by cystoscopy. A year later a small recurrence was electrocoagulated. The tumor was confined to the right lateral wall. Admission cystoscopy revealed profusely bleeding bladder mucosa but with changes more pronounced on the right side. Biopsy showed no recurrence of tumor. Electrocoagulation was done several times during the following weeks and treatment with epsilon aminocaproic acid was instituted (fig. 2). The patient was in and out of the hospital, still bleeding periodically, until February 7, 1973 when 140 to 160 mm. Hg intravesical pressure treatment was given for 6 hours. The bleeding stopped immediately but septicemia developed and treatment with ampicillin and sulfamethoxazole with trimethoprim was instituted. The patient was discharged from the hospital with clear urine. On April 24 bleeding recurred and increased despite epsilon aminocaproic acid. The patient was rehospitalized on May 29 with a hemoglobin of 5.3 gm. per 100 ml. and was in a distressed condition. Blood transfusions were given to correct the anemia. On June 5 arteriography was performed via the left femoral artery with the aim of occluding the right hypogastric artery with an autologous blood clot. After 10 cc clotted blood was injected into the artery occlusion was noted (fig. 3, A). There were no adverse reactions and the vesical hemorrhage stopped immediately. However, within a few days bleeding recurred worse than ever. After observing a temporary effect of the clotting and realizing that the situation was desperate, we planned a definite occlusion of the right hypogastric artery. Until that time a total of 30 units of blood had been given. On June 13 a new arteriogram confirmed the complete lysis of the artificial thrombus (fig. 3, B). Hypogastric artery muscle embolization was performed as described previously and complete occlusion was demonstrated (fig. 4). Bleeding diminished daily and stopped completely in less than a week. No transfusions were required. There was no temperature reaction but a transient tenderness and induration appeared in the right gluteal region and on the back of the right thigh, probably caused by local
CONTROL OF VESICAL HEMORRHAGE
ischemia. However, the patient's general condition has been good. Bladder function was initially characterized by urgency and frequency but this completely disappeared 3 weeks later. The patient was seen 4 months after the muscle embolization (fig. 2). Moderate hematuria was noted during the last few weeks but a normal hemoglobin was maintained. Cystoscopy at this time showed a grade 3 recurrence on the right lateral bladder wall and the tumor was electrocoagulated. DISCUSSION
Embolization of the arteries with muscle tissue has been used by neurosurgeons in the treatment of intracranial arteriovenous fistulas. 3 · 4 Control of gastrointestinal bleeding has been obtained by the intra-arterial infusion of pituitrin '· 6 and soft blood clots. 7 To our knowledge muscle embolization has never been used for control of massive bleeding either in urology or in general surgery. The pathology of irradiation cystitis is the formation of thin-walled vessels in a chronically inflamed hypovascularized bladder. Hypogastric artery muscle embolization is not a causal treat' Brooks, C. M.: Cited by Noland, L. and Taylor, A. S.: Pulsating exophthalmos, the result of injury. Trans. South. Surg. Ass., 43: 171, 1931. 4 Hamby, W. B. and Gardner, W. J.: Treatment of pulsating exophthalmos: with report of two cases. Arch. Surg., 27: 676, 19:33. 5 Baum, S. and :'>iusbaum, M.: The control of gastrointestinal hemorrhage by selective mesenteric arterial infusion of vasopressin. Radiology, 98: 497, 1971. 6 Murray-Lyon, I. M., Pugh, R. N. H., Nunnerley, H. B., Laws, J. W., Dawson, ,J. L. and Williams, R.: Treatment of bleeding oesophageal varices by infusion of vasopressin into the superior mesenteric artery. Gut, 14: 59, 1973. 'Rosch, J., Dotter, C. T. and Brown, M. J.: Selective arterial embolization. A new method for control of acute gastrointestinal bleeding. Radiology, !02: 303, 1972.
ment but it attacks the problem in a radical way. It is superior to vessel ligation by its production of a thrombosis that extends further into the arterial system since collaterals will inevitably arise at a high branching level following ligation. Patients who have chronic occlusion of both hypogastric arteries usually have normal bladder function. This indicates that a bilateral hypogastric artery occlusion by muscle embolization will not, at least when performed in 2 separate stages at some interval allowing collaterals to develop, jeopardize the trophic state of the bladder. The method seems to have worked in our case, although we the procedure on 1 side only. We chose the side that was the source of the most severe hemorrhage,
FIG. 1. Judkins' arterial catheter for left coronary artery catheterization. Loop at end of catheter is 6 cm. long.
d' 79 years S.CCJ. 1972
Hematuria
1973
~~~~~~TE SLIGHT
.I
13
Hemoglobin g/100 ml
\ l
10
•
Transfusron
!l
pressure
embo!i2ation
treatment
procedures
½ = electrocoagu!ation
FIG. 2. Patient data illustrate course of bladder hemorrhage
13,51
62
HALD AND MYGIND
FIG. 3. A, arteriogram following occlusion of right hypogastric artery with blood clot. B, arteriogram 1 week after occlusion of right hypogastric artery. Selective injection into hypogastric artery via Judkins' catheter. Complete lysis of thrombus except for small remnant in main trunk. Numerous arterial branches supply right bladder wall.
FIG. 4. Result of muscle embolization of right hypogastric artery. Note stagnation of contrast medium in occluded anterior trunk.
which incidentally corresponded to the previously tumor-bearing side. If efficient, hypogastric artery muscle embolization has obvious advantages over drastic surgical procedures, especially in the elderly person. It was remarkable how well our patient tolerated the procedure. There is a definite risk of spilling emboli into the leg's arterial system with this procedure but this can be counteracted by careful x-ray monitoring and slow injection. Once the emboli have reached
their destiny the risk of a dislocation is minimal since thrombosis occurs rapidly on muscle tissue with its high content of thromboplastin. The particles are embedded in a solid mass. The effect of hypogastric embolization was demonstrated twice in our case but lysis of an autologous thrombus was obviously too effective and prevented a lasting effect. Cessation of bleeding occurred more rapidly when the blood clot was used than when muscle particles were used. Therefore, one can assume that the more smooth and viscous clot occluded the bladder arterial branches immediately at a more distal level. Although it cannot be proved, it is reasonable to believe that the unilateral hypogastric artery muscle embolization accounted for the cessation of bleeding in our patient. The previous 7 months, except for 2 months following intravesical pressure treatment, were dominated by severe vesical bleeding requiring a total of 30 units of blood. We did not consider another pressure treatment justified because of a septic reaction and the limited effect in this case. SUMMARY
A case of severe vesical hemorrhage secondary to radiation for bladder carcinoma in a 79-year-old man is reported. After 7 months of almost continuous bleeding requiring a total of 30 units of blood, hemorrhage stopped following embolization of 1 hypogastric artery with muscle tissue particles via percutaneous arterial catheter. No permanent adverse effects were noted.
CONTROL OF VESICAL HEMORRHAGE ADDENDUM
The patient was rehospitalized in December 1973 with severe vesical hemorrhage. An arteriogram confirmed the occlusion of the right hypogastric artery but some collaterals had developed from the left hypogastric artery system and the right
63
external pudenda! artery. A hypogastric artery occlusion with muscle tissue was performed on th·e left side and the right external pudenda! artery war; ligated. Hemorrhage continued and on 11, 1974 urinary diversion a ureteroileocutaneostomy was performed.