1. Arterial Embolization for the Management of Gastrointestinal Bleeding from Small Bowel Metastases
Geraldine N. Abbey-Mensah, MD
Weill Cornell Medical College
New York Presbyterian Hospital
Jeremy C. Durack, MD, MS
Memorial Sloan Kettering Cancer Center

2. History
53F with history of metastatic small bowel gastrointestinal stromal tumor (GIST, diagnosed 2008) status post multiple surgical resections admitted with two days of melena and hematemesis.
Past medical history:
Pulmonary embolus, IVC filter placement (rectal bleed while on warfarin therapy)
Hypertension, hypothyroidism
Past surgical history:
Small bowel / mesenteric tumor resection x 2
Prior hospitalizations:
Admission for melena 2 months prior to current presentation with Hgb of 6.5
Responded at that time to transfusion / medical management without intervention

3. Admitted to Medicine
Vitals: BP 100/58, P 83bpm, RR 18, SA02 97%, T 36.8C
Labs: Hgb 9.3 (baseline ~9), Plts 214, INR 1.03
CT imaging with IV contrast performed

4. CT Abdomen & Pelvis
Numerous large, confluent upper abdominal masses inseparable from the stomach, pancreas and bowel (arrows)
Few small satellite nodules
Hepatic metastases

5. Hospital course Multiple intermittent episodes of brisk melena
Vitals (over 48 hrs): BP / 58-92, P 80-84
Labs (over 48 hrs): Hgb 9.2  8.7  7.8  7.3  6.9
Transfused 2 units pRBC
GI and Surgery consulted:
GI: EGD considered low value with known gastric and duodenal tumor infiltration. Palliative XRT recommended.
Surgery: No surgical intervention. Recommended urgent IR consult due to active tumor-associated GI bleeding.

6. IR consulted, angiography performed
Proximal SMA branch injection
Distal SMA branch injection
5Fr catheter / microcatheter combo used for selective catheterization
Numerous hypertrophied, abnormally tortuous vessels supplying tumor originating from the superior mesenteric artery (arrows)
No active extravasation

7. Proximal SMA injection Middle colic injection
Adjust contrast of images
Hypertrophied, tortuous marginal arteries (arrows) arising from the middle colic artery supplying tumor

8. Splenic artery injection
Splenic artery branches supplying hypervascular tumor (arrowheads)
Adjust contrast of images

9. Left: Normal caliber, normal appearing (non-tortuous) vessels were not embolized
Right: Tumor-supplying branches of the superior mesenteric artery were selectively embolized with 500 micron polyvinyl alcohol (PVA) particles

10. Clinical Follow-up Follow-up in clinic 22 days post embolization
No further episodes of melena/hematemesis
Denied abdominal pain, no symptoms/signs of GI ischemia
Hgb stable at 9.0 without transfusion requirement
Tolerating systemic therapies well

11. Gastrointestinal stromal tumors (GIST)
Account for approximately 5% of sarcomas
20-45% small bowel GIST1: More aggressive, larger and higher recurrence rates vs. stomach GIST1,2
Bleeding (30%-40%) = most common symptom after abdominal discomfort (60%-70%) 3
Up to 50% of all GISTs have evidence of metastatic disease at the time of presentation4
Responds to imatinib mesylate (tyrosine kinase inhibitor)

12. Discussion
Angiography indicated due to intermittent melena and downtrending hemoglobin requiring transfusion
Patients with ongoing hemorrhage are not typically candidates for tyrosine kinase inhibitors, therefore GI bleeding must be controlled to allow for continued life-prolonging treatment
Is GI tumor embolization safe/effective?
Several studies suggest yes...
Successful embolization of small bowel GIST with gelfoam 1
Successful particle/sphere embo of RCC metastasis to GI tract with larger size embolics ( micron or larger PVA particles or micron embospheres) and microcoils: 75% with cessation of bleeding for at least 30 days (range 1-26 months) 5

13. Points to Remember Angiography for GI tumors:
Carefully review pre-procedure imaging for vascular territories involved
Aortography may be helpful to focus catheter interrogation (often in addition to visceral/splenic arteries)
Thoroughly examine angiograms to prevent uninvolved bowel embolization
Embolization
Perform selective embolization of tumor supplying branches
Not all tumor vessels require embolization to achieve clinical success
End-point: Sufficient target vessel occlusion to reduce bleeding without GI ischemia, non-target embolization
Limit potential for GI ischemia by using larger embolics...coils may prevent access for subsequent treatment access if required
Monitor for reflux during embolization to avoid non-target embolization

14. Conclusions
Selective larger particle embolization of GI tumor supplying vessels can be be performed for GI bleeding with at least short term efficacy, enabling continuation of systemic therapies
Attention to pre-procedure and intra-procedural vascular imaging and embolization technique will contribute to safety and efficacy

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Pena Brito, G