Mayo Clinic gastroenterologist Michael J. Levy, M.D., of the Rochester, Minnesota, campus, discusses endoscopic ultrasound (EUS)-guided angiotherapy for the treatment of gastrointestinal bleeding. Dr. Levy presents five case studies that illustrate the potential role, utility and limitations of this modality.
well, I want Mike Levy, a gastro neurologist and Mayo Clinic specializing in pancreatic biliary disease by areas of clinical expertise, include pancreatic disorders, endoscopic ultrasound, endoscopic, retrograde, Colangelo Pan create, Ah, graffiti and tumor ablation. Today I'll be sharing the latest information on the U. S. Guided and Joe therapy when we managed gastrointestinal bleeding. There several options. Most undergo standard endoscopic intervention when there's re bleeding or failed the detection of the lesions. We sometimes have to pursue interventional, radiological or surgical alternatives. There's now a new alternative, which is US guided. Angio therapy. This list includes the type of patients that we've treated all at Mayo Clinic and include various is from a number of different sites. Asafa deal another Luminal Cancers drew a fall lesions stromal tumors Luminal and ask demotic bleeding ulcers of various sites. Brunner's gland ham, martoma, duodenal metastases, pseudo aneurysms of various sites and a number of vascular abnormalities, as well as a prostate cancer that eroded into the rectal wall. I should note that the US was almost never the initial modality in these patients. We pursued it after standard techniques failed or there were significant re bleeding. What I like to do is take you through five cases five patients in their care, and I think it highlights the potential role the utility as well as limitations of the US in this setting. The first was a 70 year old gentlemen with diabetes, hypertension, obesity, hyper lipid, denia, hypothyroidism, GERD and Barrett's esophagus. It had two prior bleeds. One was clinically significant and had received seven units of packed red blood cells. His prior evaluation included a negative exams to E. G. D s one colonoscopy and a C t of the abdomen. He was undergoing his 30 g d, which was negative. Except for the finding of parents, as expected, that was undergoing four quadrant biopsy. There was an unexpected, clinically significant bleed. The endoscopy was not able to perform a pin effort, injection or banning because no vascular abnormality was identified. He attempted gold probe and sent the patient to the intensive care unit. He performed or asked me to perform in the US, which demonstrates blood flow in the left ventricle as Agus and aorta is expected but unexpected were very large columns of various is and multiple Paris's great skill, color, power and pulse Doppler, all show the vascular flow, and then coils were placed into the barracks. This is an anarcho core black appearing vessel. That's how they typically appeared. This is the needle, and then through the needle, a coil is advanced and you look at this, one might think, is this coil to small correct size or two large Not going to show an ideal example? I'm actually showing a less than ideal, which is the insertion of too small of a coil. We know it's too small, because once it's injected, it appears and has the same shape as it does outside of the patient. Ideally, that should not be the case. If it's too small, is a risk of embolization. Happy to say this did not occur in this patient, that there would be a risk and placing too small of a coil. And in fact, what you want to do is place a coral. It's about 1.2 to 1.6 times the diameter of the vessel. Therefore, it's a little difficult to insert and assumes that geographic or three dimensional shape and doing so, it's more likely to stay in place and not m belies. We're really concerned about immobilization. We can place a little bit of the coil distal to the wall as well as most within the vessel and some in the proximate and intervening tissues that shows a nice treatment response, pre and post therapy, very active flow and absence of flow following therapy. Gentlemen did well. It was discharged two days later following the U. S. And has had no recurrence more than six months following intervention. Now one should take care of a second patient, a 26 year old gentleman with the central from both psychosis. He has thrombosis of his portal vein Superior medicine. Terek Vein and Splenic Vein embarrasses both the sake Jilin biliary, resulting in a biliary stricture. It had numerous prior beliefs and numerous transfusions of popular blood cells. E r C P was performed on several occasions with covered metal stent placement, hoping to Tampa non the blood vessels. Unfortunately, that did not work well. You can see here This is not only air, but it's also blood clots with them. Sean surgery was considered but considered technically not feasible in this gentleman. He was a candidate at for transplant, but not at that time. They were looking for temporizing measure and therefore asked me to perform the U. S at the U. S. You can see the hyper a Coke or bright white struts of the metal step, and it's surrounded by a feeding and the numerous Perry Kohli, Dokle Paris's. There were so many embarrasses. I did not want to treat all of them. I thought that might make the stricture even worse. So I performed introductory ultrasound. And here's the small probe in the Bible dog trying to identify the vessels that were most likely to be resulting in the bleeding and are magnified view. You can see the entire Lumen is obliterated by a very large derricks using both the US and fluoroscope E. The guy treatment targeted that vessel and it was successful. Fortunately, transplant could be delayed 15 months to at which time he waas an appropriate candidate. Yeah, show the care of a third patient, a seven year old female with PSE and cirrhosis. She had had several clinically significant bleeds have been managed with Samantha Staten, non selective beta blockers and topical silver nitrate. US was performed by placing the probe actually on the skin of the patient And here you can see Perry Stonewall Paris's coils were then inserted with the probe not only on the skin, but slightly in Azaz. Well and placement of the coils. Unfortunately, in the follow up period of eight months, she developed No, we believes three there Insufficient data, I would say, for a U. S guided angio therapy. Not enough centers have done a large enough volume to put together meaningful data for most indications and applications. But there are data for gastric Paris's. The technical success of using the U. S. Guided angio therapy is approximately 80 to 100%. Based on the literature. The treatment success after one treatment session is approximately 50 to 80% and it's approximately 90 to 95% for all treatment sessions. The re bleeding rates a little difficult to discern because the studies have somewhat limited follow up period, and it's often been used for primary prophylaxis. There a number of adverse events that have been reported. What we worry most about is glue embolization. This was a small study, but they evaluated 19 patients who underwear glue injection for gastric. Barris is detained. A chest C t in all 19. And although all patients were asymptomatic, nine developed a cult embolization. Occasionally there is a clinical sick quality. So this is something we always keep in mind when considering this therapy the remains. So uncertainties, while it is at least, is good, a standard endoscopy. How much better still remains to be determined? Indications are somewhat uncertain in some centers in terms of patient selection, lesion selection and timing. The technique has not been standardized in terms of the use of coil and or glue, and the number of coils and volume of glue. The cost must be considered for both US and Flora Skopje and again, while the efficacy and safety appear to be at least is good a standard endoscopy MAWR data needed to determine how much better US guided approaches are. We're gonna take you through the care of two final patients to so show some unique uses. 37 year old gentleman who's an alcoholic had recurrent acute and chronic pancreatitis diagnosis in 2012 and multiple episodes of human suckers, pancreatic ous attempts to control with interventional radiology. At least four attempts at a referring hospital, one in our institution, C T shows a densely calcified pancreas here and interventional radiology revealed the black. The bleeding lesion. Yeah, they placed coils thinking this would result in a cessation of bleeding. Unfortunately, this was not the case and follow up imaging. Both C T and M R revealed the enhancing the blood flow within the pseudo aneurysm, and these were the corals that have been placed. Us was then performed again. Here's the pseudo aneurysm, with vigorous blood flow shown on power and pulse Doppler and under US guidance, Anita was advanced into the Mass and a coil place. You can see that soon thereafter. Sure, aneurysm was full of client, and this was successful therapy, as demonstrated on follow up interventional radiology and the absence of bleeding a re bleeding over the 15 month follow up. And finally there was a 63 year old gentlemen with alcohol induced cirrhosis. He had more than five episodes of chemo suckers. Pancreatic ous had received more than 18 units of packed red blood cells, and again he had had four or more. Somewhere at referring hospitals attempt at interventional radiology control. C T shows the pseudo aneurysm here, as well as seen on us and under US guidance, multiple coils were placed in the pseudo aneurysm. There's now clot formation and cessation of bleeding. Okay, so the presented cases demonstrate the utility of the U. S. Guided angio therapy in the appropriate clinical setting, I would say, for patients were evaluated the Mayo Clinic. We approach them in a multi disciplinary manner and consider whether standard endoscopy U. S I R. Surgery is the most appropriate. And I think this optimizes patient care and outcome. Thank you.