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Control of massively bleeding arterioportal fistula using a balloon catheter
Control of Massively Bleeding Arterioportal Fistula Using a Balloon Catheter Robert A. Kane, MD, Boston, Massachusetts Philip Costello, MB, FRCP(C), Boston, Massachusetts Cornelius E. Sedgwick, MD, Boston, Massachusetts
Angiographic localization of focal bleeding sites [l-3] is a well established and clinically valuable procedure. Hemorrhage can often be controlled by selective arterial infusion of vasoconstricting agents [4,5] or selective arterial embolization [6,7], thereby averting operation. Polyethylene occlusion balloon catheters are now available commercially and are being used successfully for massive gastrointestinal hemorrhage not readily controllable by more conventional methods of hemostasis.
gastroduodenal artery and inflated, successfully controlling the bleeding. The catheter was left in place for 12 days with only minimal recurrent bleeding, never more than 1 or 2 units a day. The baloon became deflated several times and was reinflated. Because the bleeding never stopped completely, a third operation was performed to complete the pancreatectomy. Unfortunately, generalized venous
Case Report
Interventional angiography has become an increasingly widespread and clinically effective tool in controlling life-threatening gastrointestinal bleeding. Initially, selective arterial infusion of various vasoconstricting agents was attempted, and vasopressin was particularly effective in controlling hemorrhagic gastritis and diverticular bleeding [4,5]. Bleeding from lower esophageal varices may also frequently be controlled by vasopressin. As experience increased, the rate of failure of vasoconstrictor therapy in certain pathologic conditions was quite high, most notably in’bleeding peptic ulcers. Selective arterial embolization techniques were developed [6,7] in which autologous clot, absorbable gelatin (Gelfoam@) and other materials were used with considerable success in controlling hemorrhage secondary to peptic ulcer. More permanent vascular occlusion may be obtained by selective injection of tissue adhesives, such as cyanoacrylate [S], or by mechanical occluding devices [9]. Balloon catheters were developed initially by Fogarty et al [IO] for use in extracting arterial emboli and thrombi and are used successfully to control massive pelvic hemorrhage secondary to severe pelvic trauma [I 1,I 21. Temporary vascular occlusion in dogs has been reported by Dotter et al [la], using a flowdirected, coaxial Silastic@ catheter. Double-lumen balloon catheters designed for percutaneous insertion by a modified Seldinger technique were designed by
A 48 year old man was admitted to the New England Deaconess Hospital for definitive surgical treatment of a biopsy-proved carcinoma of the ampulla of Vater. Laparotomy at another institution for a presumed calculus of the common bile duct revealed the tumor, and cholecystojejunostomy was performed. At reoperation, pancreatoduodenectomy (Whipple procedure) was performed. On the 3rd day after operation, a pancreaticocutaneous fistula developed and the patient was treated conservatively with drainage and replacement of fluid. On the 13th day after operation, he had a fever of 102°F and copious bleeding through the abdominal wound. On reexploration that night no specific bleeding was found, but the entire operative site showed evidence of necrosis and autodigestion. Eight days later, the patient became hypotensive and vomited large amounts of bright red blood that was believed to arise from the proximal jejunal loop at endoscopy. After further gastrointestinal bleeding and massive bleeding through the sump tubes, arteriography demonstrated a large pseudoaneurysm of the gastroduodenal artery with fistulization into the portal vein (Figure 1) and intermittent gross extravasation into the jejunum (Figure 2). A balloon catheter was positioned in the stump of the From the Departments of Radiology and Surgery, New England Deaconess Hospital, and the Department of Surgery, Lahey Clinic Foundation, Boston, Massachusetts. Reprint requests should be addressed to Cornelius E. Sedgwick, MD, Lahey Clinic Foundation, 605 Commonwealth Avenue, Boston, Massachusetts 02215.
254
bleeding was encountered, covery room.
and the patient died in the re-
Comments
The American Journal of Surgery
Bleeding Arterioportal
NS)rdenstrom [ 131 and Wholey et al [ 15,161. Wholey et al [I:i,lh’] described the clinical use of such a catheter in temporary control of gastrointestinal bleeding from esophageal varices (inflated in the splenic artery to reduce splanchnic blood volume) as well as in bleeding from the spleen, kidney and intracranial aneurysms. They also reported its use
Figure 1.Subtraction view from selective celiac arteriogarising from the raphy shows a large pseudoaneurysm gastroduodenaf artery and shunting into the portal vein (arrows).
Figure 2. Massive extravasation of contrast material into the jejunum. The balloon catheter has been inflated in the stump of the gastroduodenaf artery (arrow).
Volume
139.
February
1980
Fistula
in gastrointestinal hemorrhage after a Whipple procedure for periampullary carcinoma but gave no details. A recent report by Anderson et al [17] described the use of intravascular steel coils to occlude experiment,ally induced arteriovenous fistulas in dogs, with success in 12 of’ 13 animals. However, the fistulas were all approximately 3 cm in length. Arteriography in this instance demonstrated a large pseudoaneurysm of the gastroduodenal artery that had eroded into the portal vein, creating a major arterioportal fistula. Contrast material extravasated intermittently into the loop ot’jejunum that had been anastomosed to the gallbladder. Because of the arterioportal fistula, any type of’ embolization was contraindicated. In addition, only about a 1 cm length of normal gastroduodenal artery was proximal to the pseudoaneurysm, and this might have caused considerable difficulties if a transcatheter steel coil had been used to occlude the fistula. The gastroduodenal artery was therefore occluded with a balloon catheter to reduce the arterial head of pressure into the pseudoaneurysm and thereby diminish or stop the bleeding. We did not expect the pseudoaneursym to thrombose because the relatively high flow in the portal vein would have prevented it. A no. 7 French double-lumen polyethylene occlusion balloon catheter (Meditech Division, Cooper Scientific Corp., Watertown, Massachusetts) that has
Figure 3. fnjection through the balloon catheter again fills the pseudoaneurysm, but no extravasafion is seen, and the amount of portal venous shunting is decreased (arrows).
255
Kane et al
moderately good torque control and can be preshaned in hot water was used. The balloon should not be immersed in hot water, which may potentially weaken the adhesive bond between balloon and catheter. The balloon is inflated with contrast material under fluoroscopic observation with a maximal volume of 0.7 cc giving a maximal diameter of 11.5 mm. Contrast material is then injected distal to the balloon through the central lumen to assess for proper positioning and completeness of the occlusion. In our case the gastroduodenal artery was selected easily with the balloon catheter. After the balloon was inflated, subsequent injection filled the pseudoaneurysm and, as expected, also filled the portal vein (Figure 3). However, the flow was now quite stagnantin the pseudoaneurysm, and the amount of shunting into the portal system was significantly less. More importantly, bleeding was controlled, although never completely eradicated. Minimal hemorrhage with loss of 1 to 2 units of blood a day persisted and ultimately led to the final operation. Nevertheless, the balloon catheter was effective in controlling this potentially exsanguinating hemorrhage. Although the balloon periodically required reinflation, it was used effectively for 12 days, considerably longer than has been reported previously. For this reason balloon catheters should be included in the angiographer’s armamentarium in dealing with gastrointestinal hemorrhage. Summary
The commercial availability of double-lumen balloon catheters has added a new tool for the angiographer in controlling gastrointestinal bleeding. Our report describes a situation in which the unique properties of this catheter were quite effective in controlling life-threatening hemorrhage.
256
References
1. Baum S, Nusbaum M, Clearfield HR, Kuroda K, Tumen HJ. 2. 3.
4.
5.
6.
7.
8.
9.
10.
11
12.
13.
14. 15.
16. 17.
Angiography in the diagnosis of gastrointestinal bleeding. Arch Intern Med 1967;119:16. Reuter SR. Bookstein JJ. Angiographic localization of gastrointestinal bleeding. Gastroenterology 1968;54:876. Nusbaum M, Baum S. Radiographic demonstration of unknown sites of gastrointestinal bleeding. Surg Forum 1963; 14: 374. Baum S, Nusbaum M. The control of gastrointestinal hemorrhage by selective mesenteric arterial infusion of vasopressin. Radiology 1971;98:497. Athanansoulis CA, Brown 8. Shapiro JH. Angiography in the diagnosis and management of bleeding stress ulcers and gastritis. Am J Surg 1973;125:468. Bookstein JJ, Chlosta EM, Foley D, Walter JF. Transcatheter hemostasis of gastrointestinal bleeding using modified autogenous clot. Radiology 1974;113:277. Reuter SR, Shuang VP, Bree RL. Selective arterial embolization for control of massive uooer aastrointestinal bleedina. Am J Roentgen01 1975;125:‘1’19. ” Dotter CT, Goldman ML, Rosch J. Instant selective arterial occlusion with isobutyl P-cyanoacrylate. Radiology 1975; 114:227. Wallace S, Gianturco C, Anderson JH, Goldstein HM, Davis LJ, Bree RL. Therapeutic vascular occlusion utilizing steel coil technique: clinical applications. Am J Roentgen01 1976; 127:381. Fogarty TJ, Cranley JJ, Krause RJ, Strasser ES, Hafner CD. A method for extraction of arterial emboli and thrombi. Surg Gynecol Obstet 1963;116:241. Ring EJ, Athanasoulis C, Waltman AC, Margolies MN, Baum S. Arteriographic mangement of hemorrhage following pelvic fracture. Radiology 1973; 109:65. Paster SB, Van Houten FX, Adams DF. Percutaneous balloon catheterization; a technique for the control of arterial hemorrhage caused by pelvic trauma. JAMA 1974;230:573. Dotter CT, Rosch J, Lakin PC, Lakin RC, Pegg JE. Injectable flow-guided coaxial catheters for selective angiography and controlled vascular occlusion. Radiology 1972; 104:42 1. Nordenstrom B. Balloon catheters for percutaneous insertion into the vascular system. Acta Radio1 1962;57:411. Wholey MH, Stockdale R, Hung TK. A percutaneous balloon catheter for the immediate control of hemorrhage. Radiology 1970:95:65. Whole; MH. The technology of balloon catheters in interventional angiography. Radiology 1977; 125:67 1. Anderson JH, Wallace S, Gianturco C. Transcatheter intravascular coil occlusion of experimental arteriovenous fistulas. Am J Roentgen01 1977;129:795.
The American Journal of Surgery
Angiographic localization of focal bleeding sites [l-3] is a well established and clinically valuable procedure. Hemorrhage can often be controlled by selective arterial infusion of vasoconstricting agents [4,5] or selective arterial embolization [6,7], thereby averting operation. Polyethylene occlusion balloon catheters are now available commercially and are being used successfully for massive gastrointestinal hemorrhage not readily controllable by more conventional methods of hemostasis.
gastroduodenal artery and inflated, successfully controlling the bleeding. The catheter was left in place for 12 days with only minimal recurrent bleeding, never more than 1 or 2 units a day. The baloon became deflated several times and was reinflated. Because the bleeding never stopped completely, a third operation was performed to complete the pancreatectomy. Unfortunately, generalized venous
Case Report
Interventional angiography has become an increasingly widespread and clinically effective tool in controlling life-threatening gastrointestinal bleeding. Initially, selective arterial infusion of various vasoconstricting agents was attempted, and vasopressin was particularly effective in controlling hemorrhagic gastritis and diverticular bleeding [4,5]. Bleeding from lower esophageal varices may also frequently be controlled by vasopressin. As experience increased, the rate of failure of vasoconstrictor therapy in certain pathologic conditions was quite high, most notably in’bleeding peptic ulcers. Selective arterial embolization techniques were developed [6,7] in which autologous clot, absorbable gelatin (Gelfoam@) and other materials were used with considerable success in controlling hemorrhage secondary to peptic ulcer. More permanent vascular occlusion may be obtained by selective injection of tissue adhesives, such as cyanoacrylate [S], or by mechanical occluding devices [9]. Balloon catheters were developed initially by Fogarty et al [IO] for use in extracting arterial emboli and thrombi and are used successfully to control massive pelvic hemorrhage secondary to severe pelvic trauma [I 1,I 21. Temporary vascular occlusion in dogs has been reported by Dotter et al [la], using a flowdirected, coaxial Silastic@ catheter. Double-lumen balloon catheters designed for percutaneous insertion by a modified Seldinger technique were designed by
A 48 year old man was admitted to the New England Deaconess Hospital for definitive surgical treatment of a biopsy-proved carcinoma of the ampulla of Vater. Laparotomy at another institution for a presumed calculus of the common bile duct revealed the tumor, and cholecystojejunostomy was performed. At reoperation, pancreatoduodenectomy (Whipple procedure) was performed. On the 3rd day after operation, a pancreaticocutaneous fistula developed and the patient was treated conservatively with drainage and replacement of fluid. On the 13th day after operation, he had a fever of 102°F and copious bleeding through the abdominal wound. On reexploration that night no specific bleeding was found, but the entire operative site showed evidence of necrosis and autodigestion. Eight days later, the patient became hypotensive and vomited large amounts of bright red blood that was believed to arise from the proximal jejunal loop at endoscopy. After further gastrointestinal bleeding and massive bleeding through the sump tubes, arteriography demonstrated a large pseudoaneurysm of the gastroduodenal artery with fistulization into the portal vein (Figure 1) and intermittent gross extravasation into the jejunum (Figure 2). A balloon catheter was positioned in the stump of the From the Departments of Radiology and Surgery, New England Deaconess Hospital, and the Department of Surgery, Lahey Clinic Foundation, Boston, Massachusetts. Reprint requests should be addressed to Cornelius E. Sedgwick, MD, Lahey Clinic Foundation, 605 Commonwealth Avenue, Boston, Massachusetts 02215.
254
bleeding was encountered, covery room.
and the patient died in the re-
Comments
The American Journal of Surgery
Bleeding Arterioportal
NS)rdenstrom [ 131 and Wholey et al [ 15,161. Wholey et al [I:i,lh’] described the clinical use of such a catheter in temporary control of gastrointestinal bleeding from esophageal varices (inflated in the splenic artery to reduce splanchnic blood volume) as well as in bleeding from the spleen, kidney and intracranial aneurysms. They also reported its use
Figure 1.Subtraction view from selective celiac arteriogarising from the raphy shows a large pseudoaneurysm gastroduodenaf artery and shunting into the portal vein (arrows).
Figure 2. Massive extravasation of contrast material into the jejunum. The balloon catheter has been inflated in the stump of the gastroduodenaf artery (arrow).
Volume
139.
February
1980
Fistula
in gastrointestinal hemorrhage after a Whipple procedure for periampullary carcinoma but gave no details. A recent report by Anderson et al [17] described the use of intravascular steel coils to occlude experiment,ally induced arteriovenous fistulas in dogs, with success in 12 of’ 13 animals. However, the fistulas were all approximately 3 cm in length. Arteriography in this instance demonstrated a large pseudoaneurysm of the gastroduodenal artery that had eroded into the portal vein, creating a major arterioportal fistula. Contrast material extravasated intermittently into the loop ot’jejunum that had been anastomosed to the gallbladder. Because of the arterioportal fistula, any type of’ embolization was contraindicated. In addition, only about a 1 cm length of normal gastroduodenal artery was proximal to the pseudoaneurysm, and this might have caused considerable difficulties if a transcatheter steel coil had been used to occlude the fistula. The gastroduodenal artery was therefore occluded with a balloon catheter to reduce the arterial head of pressure into the pseudoaneurysm and thereby diminish or stop the bleeding. We did not expect the pseudoaneursym to thrombose because the relatively high flow in the portal vein would have prevented it. A no. 7 French double-lumen polyethylene occlusion balloon catheter (Meditech Division, Cooper Scientific Corp., Watertown, Massachusetts) that has
Figure 3. fnjection through the balloon catheter again fills the pseudoaneurysm, but no extravasafion is seen, and the amount of portal venous shunting is decreased (arrows).
255
Kane et al
moderately good torque control and can be preshaned in hot water was used. The balloon should not be immersed in hot water, which may potentially weaken the adhesive bond between balloon and catheter. The balloon is inflated with contrast material under fluoroscopic observation with a maximal volume of 0.7 cc giving a maximal diameter of 11.5 mm. Contrast material is then injected distal to the balloon through the central lumen to assess for proper positioning and completeness of the occlusion. In our case the gastroduodenal artery was selected easily with the balloon catheter. After the balloon was inflated, subsequent injection filled the pseudoaneurysm and, as expected, also filled the portal vein (Figure 3). However, the flow was now quite stagnantin the pseudoaneurysm, and the amount of shunting into the portal system was significantly less. More importantly, bleeding was controlled, although never completely eradicated. Minimal hemorrhage with loss of 1 to 2 units of blood a day persisted and ultimately led to the final operation. Nevertheless, the balloon catheter was effective in controlling this potentially exsanguinating hemorrhage. Although the balloon periodically required reinflation, it was used effectively for 12 days, considerably longer than has been reported previously. For this reason balloon catheters should be included in the angiographer’s armamentarium in dealing with gastrointestinal hemorrhage. Summary
The commercial availability of double-lumen balloon catheters has added a new tool for the angiographer in controlling gastrointestinal bleeding. Our report describes a situation in which the unique properties of this catheter were quite effective in controlling life-threatening hemorrhage.
256
References
1. Baum S, Nusbaum M, Clearfield HR, Kuroda K, Tumen HJ. 2. 3.
4.
5.
6.
7.
8.
9.
10.
11
12.
13.
14. 15.
16. 17.
Angiography in the diagnosis of gastrointestinal bleeding. Arch Intern Med 1967;119:16. Reuter SR. Bookstein JJ. Angiographic localization of gastrointestinal bleeding. Gastroenterology 1968;54:876. Nusbaum M, Baum S. Radiographic demonstration of unknown sites of gastrointestinal bleeding. Surg Forum 1963; 14: 374. Baum S, Nusbaum M. The control of gastrointestinal hemorrhage by selective mesenteric arterial infusion of vasopressin. Radiology 1971;98:497. Athanansoulis CA, Brown 8. Shapiro JH. Angiography in the diagnosis and management of bleeding stress ulcers and gastritis. Am J Surg 1973;125:468. Bookstein JJ, Chlosta EM, Foley D, Walter JF. Transcatheter hemostasis of gastrointestinal bleeding using modified autogenous clot. Radiology 1974;113:277. Reuter SR, Shuang VP, Bree RL. Selective arterial embolization for control of massive uooer aastrointestinal bleedina. Am J Roentgen01 1975;125:‘1’19. ” Dotter CT, Goldman ML, Rosch J. Instant selective arterial occlusion with isobutyl P-cyanoacrylate. Radiology 1975; 114:227. Wallace S, Gianturco C, Anderson JH, Goldstein HM, Davis LJ, Bree RL. Therapeutic vascular occlusion utilizing steel coil technique: clinical applications. Am J Roentgen01 1976; 127:381. Fogarty TJ, Cranley JJ, Krause RJ, Strasser ES, Hafner CD. A method for extraction of arterial emboli and thrombi. Surg Gynecol Obstet 1963;116:241. Ring EJ, Athanasoulis C, Waltman AC, Margolies MN, Baum S. Arteriographic mangement of hemorrhage following pelvic fracture. Radiology 1973; 109:65. Paster SB, Van Houten FX, Adams DF. Percutaneous balloon catheterization; a technique for the control of arterial hemorrhage caused by pelvic trauma. JAMA 1974;230:573. Dotter CT, Rosch J, Lakin PC, Lakin RC, Pegg JE. Injectable flow-guided coaxial catheters for selective angiography and controlled vascular occlusion. Radiology 1972; 104:42 1. Nordenstrom B. Balloon catheters for percutaneous insertion into the vascular system. Acta Radio1 1962;57:411. Wholey MH, Stockdale R, Hung TK. A percutaneous balloon catheter for the immediate control of hemorrhage. Radiology 1970:95:65. Whole; MH. The technology of balloon catheters in interventional angiography. Radiology 1977; 125:67 1. Anderson JH, Wallace S, Gianturco C. Transcatheter intravascular coil occlusion of experimental arteriovenous fistulas. Am J Roentgen01 1977;129:795.
The American Journal of Surgery