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• W2137348525 abstract "Sir — We read with great interest the article written by Anil et al. 1 Anil G. Tan A.G.S. Cheong H.W. et al. Emergency gastroduodenal artery embolization by sandwich technique for angiographically obvious and oblivious, endotherapy failed bleeding duodenal ulcers. Clin Radiol. 2012; 67: 468-475 Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar reporting the outcomes of emergency gastroduodenal artery embolization by sandwich technique for angiographically obvious and oblivious, endotherapy-failed bleeding duodenal ulcers. First of all, we would like to congratulate the authors for their results. However, we have several comments and questions. Transcatheter embolization is now accepted as the salvage treatment of choice for acute haemorrhage from gastroduodenal ulcers despite endoscopic treatment. Many published studies confirm the high technical and clinical success rates of this approach, ranging from 69–100% and from 63–97%, respectively, in all case series including more than 20 patients over the last decade. 2 Defreyne L. Vanlangenhove P. De Vos M. et al. Embolization as a first approach with endoscopically unmanageable acute nonvariceal gastrointestinal hemorrhage. Radiology. 2001; 218: 739-748 Crossref PubMed Scopus (160) Google Scholar , 3 Loffroy R. Guiu B. D'Athis P. et al. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol. 2009; 7: 515-523 Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar First, we are surprised that in this study only three (20%) of the 15 patients had signs of active bleeding at angiography (i.e., extravasation of contrast medium): do the authors have any specific explanation? Indeed, in our experience, the extravasation rate is much higher (over 60%), as usually reported in the literature. 3 Loffroy R. Guiu B. D'Athis P. et al. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol. 2009; 7: 515-523 Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar One factor may contribute to explain these findings here: intra-arterial anticoagulants, vasodilators, or fibrinolytic agents may be used during the procedure to provoke contrast medium extravasation. It seems that pharmacoarteriography was not performed by the authors. Second, a major limitation of this study is the small number of patients, which led to a high risk of type II error. In particular, no meaningful conclusion can be drawn regarding the sandwich technique for coil and gelfoam occlusion of the gastroduodenal artery (GDA) used by the authors. However, the primary clinical success rate (86.6%) reported by Anil et al. seems to be very high compared with that of other published series. 3 Loffroy R. Guiu B. D'Athis P. et al. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol. 2009; 7: 515-523 Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar , 4 Padia S.A. Geisinger M.A. Newman J.S. et al. Effectiveness of coil embolization in angiographically detectable versus non-detectable sources of upper gastrointestinal hemorrhage. J Vasc Interv Radiol. 2009; 20: 461-466 Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar The comparatively better results in the present study may be attributed to two factors. First, the sandwich technique was used in all patients. Second, the mean time from bleeding onset to the embolization procedure, which was very short in this study, might have influenced the clinical success rate. Indeed, we recently reported our results obtained during nearly 10 years of experience with arterial embolization used to treat refractory massive bleeding from duodenal ulcers. 3 Loffroy R. Guiu B. D'Athis P. et al. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol. 2009; 7: 515-523 Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar The study comprised 60 patients; the largest case series in the literature. Using coils alone to occlude the feeding artery significantly predicted early re-bleeding by univariate (p = 0.003) and multivariate (p = 0.022) analysis. We, therefore, advocate the use of gelatin particles between the proximal and distal coils in the trunk of the GDA, when the sandwich coiling technique is used in this territory, as recommended by the authors. In addition, we found that early re-bleeding was associated with a longer time from shock onset to angiography (p = 0.0005). Consequently, every effort should be made to perform embolization early after bleeding onset, as was done here. On the other hand, we agree with the authors regarding the efficacy of empiric embolization of the GDA. We also showed that embolization can be performed successfully even when angiography fails to visualize extravasation of contrast medium. In our series, active bleeding was present in 38 (63.3%) of the 60 patients and did not predict the outcome of embolotherapy. 3 Loffroy R. Guiu B. D'Athis P. et al. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol. 2009; 7: 515-523 Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar Several previous studies found that empiric embolization based on endoscopic findings, in the absence of contrast extravasation, was helpful in achieving bleeding control, with no difference according to whether angiography identified the bleeding site. 4 Padia S.A. Geisinger M.A. Newman J.S. et al. Effectiveness of coil embolization in angiographically detectable versus non-detectable sources of upper gastrointestinal hemorrhage. J Vasc Interv Radiol. 2009; 20: 461-466 Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar , 5 Loffroy R. Lin M. Thompson C. et al. A comparison of the results of arterial embolization for bleeding and non-bleeding gastroduodenal ulcers. Acta Radiol. 2011; 52: 1076-1082 Crossref PubMed Scopus (18) Google Scholar Emergency gastroduodenal artery embolization by sandwich technique for angiographically obvious and oblivious, endotherapy failed bleeding duodenal ulcersClinical RadiologyVol. 67Issue 5PreviewTo determine the feasibility, safety, and efficacy of adopting a standardized protocol for emergency transarterial embolization (TAE) of the gastroduodenal artery (GDA) with a uniform sandwich technique in endotherapy-failed bleeding duodenal ulcers (DU). Full-Text PDF Re: Emergency gastroduodenal artery embolization by sandwich technique for angiographically obvious and oblivious, endotherapy failed bleeding duodenal ulcers. A replyClinical RadiologyVol. 68Issue 1PreviewSir — We appreciate the opportunity to respond to the comments on our article.1 This correspondence attempts to address the queries that have been raised. Full-Text PDF" @default.
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• W2137348525 title "Re: Emergency gastroduodenal artery embolization by sandwich technique for angiographically obvious and oblivious, endotherapy failed bleeding duodenal ulcers" @default.
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