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/lp/springer-journals/transarterial-embolization-of-acute-non-neurologic-bleeding-using-9lhoM7ZOzI
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- Springer Journals
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- Copyright © The Author(s) 2023
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- 2520-8934
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- 10.1186/s42155-023-00347-0
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Abstract
Background To evaluate feasibility, safety and effectiveness of transarterial embolization of acute non-neurologic hemorrhage with Ethylene Vynil Alcohol Copolymer (EVOH). Methods Between January 2018 and June 2021, 211 patients (male 123, mean age 69.7 y + 17.9) who underwent transarterial embolization with Onyx for acute non-neurologic arterial bleeding were retrospectively reviewed. Most frequent etiology of bleeding was post-operative (89/211, 42.2%), trauma (62/211, 29.4%) and tumor (18/211, 8.5%). Technical success was defined as the angiographic evidence of target vessel complete occlusion. Clinical success was defined as resolution of bleeding. Any rebleeding within the primitive site, requiring a new intervention during the first 30-days following embolization, was considered a clinical failure. Occurrence of procedure-related complication and mortality within 30 days of the embolization were examined. Results A total of 229 embolization procedures was performed in 211 pts.; technical success rate was 99.5% (210/211 pts). Clinical success rate was 94.3% (199/211 pts). In 11 patients (5.2%) a reintervention was needed because of a rebleeding occurring within the primitive site, whereas in five patients (2.4%) rebleeding occurred within a site differ - ent from the primitive. Factors more often associated with clinical failure were coagulopathy/ongoing anticoagulant therapy (5/11, 45.4%), and post-operative etiology (3/11, 27.3%). EVOH was used as the sole embolic agent in 214/229 procedures (93.4%), in association with coils in 11 cases (4.8%), and with microparticles in 4 cases (1.7%). In the pre- sent series, major complications occurred in 6 cases (2.8%): respectively, four cases (1.9%) of colonic ischemia and two groin hematomas (0.9%) with active extravasation were observed. 26 (12.3%) patients died during the follow-up. Conclusion Embolization of acute arterial bleeding with EVOH as a first-line embolic agent is feasible, safe and effective. Keywords Acute arterial hemorrhage, Embolization, Ethylene vinyl alcohol copolymer, Onyx, EVOH Introduction Acute arterial hemorrhage requiring urgent treatment may be related to several conditions such as trauma, tumor or post-surgical complications (Powerski et al. *Correspondence: 2018). In the last decades transcatheter embolization Paolo Rabuffi (TE) has been succesfully used to treat arterial bleed- prabuffi@hsangiovanni.roma.it Unit of Interventional Radiology, Azienda Ospedaliera San Giovanni ing, resulting from different etiologies, in various Addolorata, Via dell’Amba Aradam 9, 00184 Rome, Italy anatomic locations and it is nowadays proposed as a © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. Rabuffi et al. CVIR Endovascular (2023) 6:2 Page 2 of 8 first-line treatment in the management of acute hemor - Table 1 Baseline characteristics rhage (Chen et al. 2009, Wang et al. 2015). During TE, Gender Frequency Percent- the effectiveness of the desired hemostasis must be bal - age anced to the risk of ischemia or rebleeding. Since there Male 123 58.29 are no established guidelines, the choice of the embolic Female 88 41.71 agent depends on multiple factors, such as the operator Total 211 100 preferences, the diameter or tortuosity of the target ves- Age classes sel and the presence of a pseudoaneurysm rather than 16-|37 14 6.64 an active extravasation. Onyx (Medtronic; Irvine, CA) 37-|57 35 16.59 is a liquid embolic agent which has been first intro - 57-|77 75 35.55 duced for the treatment of cerebral vascular malforma- 77-|97 87 41.23 tions, but, thanks to its peculiar characteristics, in the Total 211 100 last two decades it has also been increasingly used in Etiology the peripheral vascular district (Bommart et al. 2012, Bronchiectasis 1 0.47 Guimaraes et al. 2011, Saeed Kilani et al.2015). This Coagulopathy 4 1.9 retrospective study was designed to determine the fea- Diverticular disease 8 3.79 sibility, effectiveness and safety of TE with EVOH as a Vascular malformation 12 5.69 primary embolic agent for the treatment of acute non- Pancreatitis 5 2.37 neurologic hemorrhage. Post-operative 89 42.18 Early 28 13.27 Methods Late 61 28.9 The study was approved by the local institutional review Trauma 62 29.38 board. Informed consent was obtained before treat- Penetrating 8 3.79 ment from each patients. All bleeding diagnosis were Blunt 54 25.59 confirmed by multidetector CT before patients under - Tumor 18 8.53 went angiography. A database of patients suffering Gastro-duodenal ulcer 12 5.69 from peripheral acute arterial bleeding, who under- Total 211 100 went TE in an emergency setting between January 2018 Anatomic district and June 2021, was retrospectively analyzed and 211 Head & Neck 15 6.6 patients (male 123, female 88, 16–97 years old) treated Musculoskeletal (MSK) 109 47.6 with EVOH were found. The demographics of patients, Gastroenteric 54 23.6 etiology, anatomic location of hemorrhage and nomen- Splancnic 51 22.3 clature of treated vessels are listed in Tables 1 and 2. Total 229 100 Indication for embolization procedure was determined by an interdisciplinary team, including anesthesiolo- gists, surgeons, and the emergency medical team, based all cases after detection of bleeding at angiography; no on variuous factors and including the hemodinamic empirical embolization was performed in any patient. condition of the patient. Patients who underwent embo- First, selective catheterization of the target artery was lization in the present study were hemodynamically performed with traditional diagnostic angiographic stable (158/229, 69%) or showed a condition of mild to catheter or guiding catheter, according to the vessel moderate hypotension which was successfully managed diameter. Subsequently, a dimethyl sulfoxide (DMSO) with the use of vasoactive agents (71/229, 31%). Onyx compatible microcatheter (Carnelian, Tokai, The Hague, is a gelling solution composed of ethylene-vinyl alco- Netherlands; Excelsior SL-10, Stryker Neurovascular, hol copolymer (EVOH) and DMSO solvent. In order to Fremont, CA, USA) was superselectively inserted and polymerize, EVOH needs to be injected after the dead placed in the desired position. Since injection of DMSO space of the microcatheter has been filled with DMSO; is painful, all patients systematically were administered ™ ™ Onyx is available in two formulations, Onyx 18 (6% Fentanyl (100–150 mcg) 10 minutes before the embo- EVOH) and Onyx 34 (8% EVOH, which has almost lization, plus Propofol 1 mg/kg by intravenous route. double viscosity), that differ in terms of EVOH con - All procedures were performed in the presence of an centration and distal penetration. TE was performed in anesthesiologist. R abuffi et al. CVIR Endovascular (2023) 6:2 Page 3 of 8 Table 2 Treated vessels as the angiographic evidence of target vessels complete occlusion. Clinical success was defined as resolution of Treated arteries Frequency bleeding, without need of reintervention in the follow- external carotid artery 1 ing 30 days. The parameters used to assess clinical suc - bronchial artery 1 cess of embolization were the absence of further decrease femoral circumflex artery 5 in haemoglobin levels or new bleeding episodes after iliac circumflex artery 7 the procedure. Any rebleeding within the primitive site colic artery 11 occurring during the first 30-days following emboliza - hemorrhoidal artery 8 tion, and requiring a new intervention, was considered a hepatic artery 7 clinical failure. Coagulopathy was defined in presence of inferior epigastric artery 27 one or more of the following: thrombocytopenia (plate- ascending pharingeal artery 1 let counts lower than 50,000/mm ), a prothrombin time profunda femoris artery branches 11 lower than 50% of the coagulation activity of normal superficial femoral artery branches 1 reference plasma or an activated partial thromboplastin left gastric artery 6 time of 50 seconds or more. In all cases, coagulopathy gastroduodenal artery 15 was treated with platelets or fresh blood plasma infusion, gastroepiploic artery 1 or anticoagulants antidotes (such as vitamin K, or DOAC genicular artery 1 specific reversal agents) according to its etiology. Proce - gluteal artery 13 dure-related complications were defined based on the ileocolic artery 1 European Society of Cardiovascular and Interventional iliolumbar artery 5 Radiology (CIRSE) standard of practice committee clas- intercostal artery 7 sification system (Filippiadis et al. 2017). Follow-up was peroneal artery 1 conducted for 30 days after the intervention, by retro- lingual artery 3 spectively reviewing clinical data in our electronic medi- lumbar artery 14 cal record system and by telephone calls. internal mammary artery 4 internal maxillary artery 3 Statistical analyses superior mesenteric artery 2 Univariate and bivariate analyses were performed to humeral artery branches 2 determine both the clinical success and the predictive obturatory artery 8 factors associated with it. The results of univariate analy - pancreatica magna artery 1 sis were tested for significance using hypothesis testing pancreaticoduodenal artery 7 for proportion. The Chi-square test was used to deter - popliteal artery 1 mine whether two variables are likely to be related or not. prostatic artery 5 For all statistical tests, p-values < 0.01 were considered internal pudendal artery 12 significant. All statistical analyses were performed by segmental renal artery 12 using software R (version 4.2.). scapular circumflex artery 2 sphenopalatin artery 4 Results sigmoid artery 1 A total of 229 embolization procedures was performed in splenic artery 2 211 pts. TE with EVOH in the present series was tech- adrenal artery 1 nically successful in 99.5% of patients (210/211). Clini- superior thyroid artery 2 cal success rate was 94.3% (199/211 pts). EVOH was uterine artery 2 used as the sole embolic agent in 214/229 procedures vesical artery 1 (93.4%), in association with coils in 11 cases (4.8%), and costocervical trunk 2 with microparticles in 4 cases (1.7%). EVOH 6% formu- Total 221 lation was used exclusively in 168 cases (73.4%), EVOH 8% in 41 cases (17.9%); a combination of the two EVOH concentrations was injected in 20 cases (8.7%) (Table 3). Study endpoint and definitions The mean number of 1.5-ml vials of EVOH injected Bleeding was defined as the angiographic evidence of was 1.4 per procedure. 16 patients (7.6%) underwent extravasation or staining of contrast media, or in case a new embolization for a bleeding recurrence. In 11 of a vascular injury such as a pseudoaneurysm, necessi- patients (5.2%) a reintervention was needed because of tating urgent treatment. Technical success was defined Rabuffi et al. CVIR Endovascular (2023) 6:2 Page 4 of 8 Table 3 EVOH concentration, volume injected, use of other 72.7% of clinical failure cases and in 73.4% of the remain- embolic agents in association ing general population, so there was no significative dif - ference regarding EVOH formulation between clinical EVOH concentration Frequency Percentage success and clinical failure cases. In the present series, EVOH 8% 41 17,9 major complications occurred in 6 cases (2.8%): respec- EVOH 6% 168 73,4 tively, four cases (1.9%) of colonic ischemia and two EVOH 6% + 8% 20 8,7 groin hematomas (0.9%) with active extravasation were Total 229 100 observed. 26 patients (12.3%, mean age 74.1 y, 28–94) EVOH 6% 1.5 ml vials injected died during the follow-up. One patient, who underwent 1 125 74,4 colectomy because of colonic ischemia following TE, died 2 33 19,6 for multiorgan failure after 7 days. The other 25 patients 3 4 2,4 died for the consequences of trauma (7/25), or because of 4 5 3 the severity of their underlying disease (18/25). 5 1 0,6 Total 168 100 Discussion EVOH 8% 1.5 ml vials injected Overall clinical success of TE with EVOH in the present 1 29 70,73 series was 94.6%; the highest clinical success rate was 2 7 17,07 observed within the subgroup of patients suffering from 3 3 7,32 post-traumatic bleeding (98.3%), whereas the lowest effi - 4 2 4,88 cacy rate was recorded within the subgroup of patient Total 41 100 suffering from coagulopathy or under anticogulant ther - Other embolic agents apy (91.9%). Clinical success rate among the patients suf- No 214 93,4 fering from upper and lower gastro-intestinal bleeding Coils 11 4,8 (UGIB and LGIB, 52/211, 24.6% of total cases) was 96.1%. Microspheres 4 1,7 The choice of the appropriate embolic agent is still a con - Total 229 100 troversial matter. The ideal embolic agent should be safe, compatible with most microcatheters, easy to prepare and control during injection and able to achieve an effi - a rebleeding occurring within the primitive site, whereas cient occlusion. Clinical efficay rate of coil embolization in five patients (2.4%) rebleeding occurred within a site for the treatment of acute arterial bleeding is 76–90% different from the primitive. Characteristics of rebleeding (Tan et al.2010, Khanna et al. 2005, Valek et al. 2013, Yap cases are listed in Table 4. Factors more often associated et al. 2013, Kickuth et al. 2008). However, the use of coils with clinical failure were coagulopathy/ongoing antico- is contraindicated in case of false aneurysms and may not agulant therapy (5/11, 45.4%), and post-operative etiol- be feasible within small, tortuous target arteries or in a ogy (3/11, 27.3%). The EVOH 8% formulation was used in vasospasm condition. Embolization of gastrointestinal Table 4 Rebleedings Age, sex Etiology Timing (days) Bleeding site EVOH Injected Other concentration volume (vials) embolics 79y, F pancreatitis 1 gastroduodenal 8% 1 No 86y, F coagulopathy (OAT ) 1 lumbar 6% 1 No 41y, M trauma 1 pudendal 6% 1 No 62y, M post-operative (robotic prostatectomy) 1 prostatic 6% 1 No 45y, F post-operative femoral puncture 4 femoral circumflex 6% 1 No 85y, F post-operative (femoral prosthesis) 15 iliac circumflex 6% 3 No 74y, M larynx tumor 30 external carotid 8% 1 No 79y, F coagulopathy (OAT ) 1 inferior epigastric 6% 1 No 88y, M coagulopathy (OAT ) 1 iliolumbar 8% 1 No 75y, M coagulopathy (OAT ) 7 scapular 8% 1 No 50y, M coagulopathy (cirrhosis) 12 intercostal 8% 1 No OAT Oral Anticoagulant Therapy R abuffi et al. CVIR Endovascular (2023) 6:2 Page 5 of 8 bleeding with N-butyl-cyanoacrilates (NBCA) has proven from 96.7% to 100%, were also reported using EVOH in to be effective, with clinical success rates ranging from the embolization of LGIB and renal acute arterial hemor- 70.4%–74.5% to 78%–88% for, respectively, upper and rhage (Urbano et al. 2014, Lenhart et al. 2010, Mahdjoub lower gastro-intestinal bleeding (UGIB and LGIB) (Hur et al. 2020). Compared to NBCA, EVOH injection can be et al. 2014, Hur et al., 2017). However, obtaining an effi - stopped and resumed during the embolization, since the cient distal distribution of NBCA requires great expe- copolymer is nonadhesive and solidifies in an “outside-in” rience and technical skill (Hill et al. 2018): infact, since fashion, allowing the operator to perform longer injec- NBCA has a short polymerization time, once the mixture tions with lesser ocurrance of microcatheter entrapment with Lipiodol is prepared, it must be injected immedi- or occlusion (Guimaraes et al. 2011, Poursaid et al. 2016, ately in order to avoid catheter lumen occlusion. Never- Loh et al. 2010). In the present series 6% EVOH formula- theless, reflux of glue during injection may happen, with tion was preferred in 73.4% of cases, because of its lower non-target embolization events reported in up to 16.7% viscosity and more distal penetration capacity, in com- of cases (Guimaraes et al. 2011, Mavili et al. 2007). parison to 8% EVOH (Figs. 1 and 2). The characteristics that made EVOH a popular embolic EVOH can be either used as a flow-dependent embolic agent within the neurovascular system allow its use also agent, relying on arterial pressure-driven fluidodynam - for the embolization of peripheral vascular arteries. In ics in order to navigate within the target vessel, or, as it fact, thanks to its 5 minutes-long polimerization time, is done in case of cerebral AVMs, after balloon-occlusion high radiopacity and easy diffusion within tortuous and of the artery from which the injection is performed, in small-caliber vessels, EVOH has proven to be a safe and order to neutralize the pressure gradient and achieve a efficient embolic agent for the treatment of hemoptysis more distal EVOH penetration. Another technique used and traumatic hemorrhage, with clinical success rates to maximize distal penetration of EVOH is to navigate of 94% and 100%, respectively (Ayx et al. 2017, Muller- superselectively the target vessel until the microcath- Wille et al. 2012). High clinical success rates, ranging eter occupy entirely the arterial lumen: in such situation Fig. 1 a–d CT MPR images in a patient suffering from lower gastrointestinal bleeding show active diverticular bleeding within the lumen of the descending colon (a). Selective inferior mesenteric artery angiography (IMA) shows a contrast extravasation from a branch of the sigmoid artery (b). After superselective catheterization of the target vessel with a 1.7 Fr microcatheter (c), selective IMA post-embolization angiography confirms selective occlusion of the target vessel (d) Rabuffi et al. CVIR Endovascular (2023) 6:2 Page 6 of 8 Fig. 2 a–d Selective left internal iliac artery angiography (IIA) in a patient suffering from pain and anemia after robotic prostatectomy shows the presence of a false aneurysm of the distal branch of the superior vescical artery (a). After superselective catheterization of the target vessel with a microcatheter (b), embolization is performed with Onyx 18. Filling of the pseudoaneurysmal sac, distal and proximal portion of the vescical artery is visible in c. IIA post-embolization angiography confirms effective occlusion of the target vessel the vessel flow is blocked and the embolic agent may be lesions before completing embolization with EVOH, in pushed very distally facing low resistances during injec- order to reduce the risk of vessel recanalization and pos- tion. In the present series no occurrance of rupture nor sible rebleeding in the following days. Another point in entrapment of the microcatheter tip were observed. favor of embolization with EVOH is that the microcath- Coils were used in combination with EVOH in 11 cases, eter is not subject to overload nor friction during EVOH in the present experience. The rationale of using EVOH inection and delivery, whereas dislocation of the micro- in association with coils is to obtain a flow deceleration, catheter may happen during coil insertion and deploy- expecially in case of large vessel with very high flow, in ment due to the mechanical stress to which the device order to reduce the risk of non-target embolization. Also, is subjected. Finally, compared to particles that require in the present series, EVOH plus coil embolization was larger inner lumen microcatheter as the size of the used performed in case of target bleeding vessel too small to microsphere increases, 6% or 8% EVOH, despite their be catheterized (ie, small sidebranches of the gastroduo- different viscosity, may be injected through a microcath - denal artery): in such cases, after the main trunk of the eter of the same size. Recurrency of hemorrhage after TE parent artery, distally to the bleeding sidebranches, was with coils or gelfoam has showed, in recent publications, occluded with coils, EVOH was able to navigate up to the consistent rates at 30 days ranging from 23% to 27.8% coil plug, and then, through a retrograde filling, embo - for gastrointestinal bleeding and 20.8% for peripheral lize the target bleeding sidebranch. In this series, EVOH acute arterial bleeding (Yap et al. 2013, Sirvinskas et al. was used in combination with microspheres in 4 cases 2017, Beggs et al. 2014, Powerski et al. 2018). In com- (100–300 and 300–500 μm in 2 embolization of hepatic parison to traditional embolic agents, embolization with arteries for ruptured HCC, and 500–700 μm in 2 embo- NBCA for non-variceal gastrointestinal bleeding has lizations of uterine arteries for bleeding cercival cancer). been associated with lower rebleeding rates, of, respec- The rationale of using microspheres was to obtain, at tively, 12.5% and 15.7% for UGIB and LGIB (Chevallier first, an occlusion of the distal feeding vasculature of the et al. 2021). There is paucity of data regarding recurrence R abuffi et al. CVIR Endovascular (2023) 6:2 Page 7 of 8 of bleeding after embolization with EVOH: in the only conservative management. In two cases, following TE, a published meta-analysis available, a rebleeding rate of groin hematoma with active bleeding, requiring embo- 7.6% was described, which was higher in case of hemop- lization was observed. In the present study, the rate of tysis, compared to gastrointestinal hemorrhage (Kolber complication following TE ranged from 0% of post-trau- et al. 2015). In his experience of LGIB embolization with matic hemorrhage, to 7.1% of external carotid branches EVOH, Urbano reported a recurrence of the bleeding in embolization and 7.6% of gastrointestinal bleeding. 10% of cases, though the relevance of the data is prob- There are some aspects to take into consideration when ably overestimated, since two-thirds of the rebleeding using EVOH: DMSO must be injected slowly to prevent occurred in sites different from the primitive, and in no vasospasm and requires exclusive use of compatible case a reintervention was needed (Urbano et al. 2014). catheters. Also, the solvent injection is painful, there- In the present series 11 patients (mean age 69.4 years) fore the presence of an anesthesiologist is recommended needed a new embolization for a bleeding recurrence in in order to perform a proper analgesia. Moreover, to the primitive site (5.4% of cases), after a median time of ensure radiopacity, the EVOH vials need to be shaken for 6.7 days (1–30 days). Within this subgroup of patients, at least 20 minutes prior to its use, hence the dedicated five (45.4%) were suffering from coagulopathy or under vial-mixers should be activated as soon as the patient is anticoagulant therapy and three patients (27.3%) under- referred to the angio suite. Although embolization with went a surgical or endovascular intervention before (see EVOH requires a longer learning curve compared to Table 4). Only one patient out of 45 who underwent coils or other traditional embolic agent, this disadvantage embolization with EVOH in the present case series for is overcome by the major hemostatic power of EVOH, gastro-intestinal hemorrhage experienced a rebleeding which is not influenced by the coagulation status of the within the first 30 days from the intervention. Coagu- patient, and by the fact that EVOH is more controllable lopathy represents an independent predictor for clinical during injection with very low occurrance of non-target failure and recurrency of bleeding after embolization embolization. (Loffroy et al. 2020, Kim et al. 2017). In case of coagu - lopathy, permanent liquid embolic agents such as EVOH Limitations and NBCA are preferred over coils or gelfoam because The present study has some limitations: it is retrospec - they act independently of the patient coagulation status tive, has no control group, and reflects a single-institu - (Hur et al. 2014, Hur et al., 2017). In fact, in this condition tion experience. clinical failure rate of TE with non-liquid embolic agents has been reported to be as high as 45–64%, whereas Conclusion embolization with NBCA showed a clinical failure rate Embolization of acute arterial bleeding with EVOH has of 33.8% (De Wispelaere et al. 2002, Defreyne et al. 2003, showed to be feasible, safe and effective, confirming the Loffroy et al. 2015). In the present series, the subgroup data reported from other authors who described similar of patients in whom coagulopathy was the primary patient series. Although the emergency setting of acute cause of bleeding accounted for 62 units (29.4% of total arterial bleeding makes it particularly difficult to set up population): in those patients, embolization with EVOH a prospective randomized study comparing the vari- showed a clinical success rate of 91.9% and a rebleeding ous embolic agents, certainly further studies with larger rate of 8.1%, which is significantly lower than previously populations are needed in order to confirm these results. reported using traditional embolic agents or NBCA. (Figs. 1 and 2). Major complications following TE with coils and other non-liquid embolic agents range may occur in up to 23% Abbreviations (Maleux et al. 2009, Ahmed et al. 2010, Navuluri et al. EVOH Ethylene Vynil Alcohol 2012) of patients. The use of NBCA for embolization of TE Transcathether Embolization non-variceal gastrointestinal bleeding has been associ- DMSO Dymethil Sulfoxide NBCA N-Butyl-Cyanoacrilates ated with a major complication rate of 8.6% (Chevallier LGIB Lower Gastrointestinal Bleeding et al. 2021), whereas major complication rate after embo- UGIB Upper Gastrointestinal Bleeding lization with EVOH has been described as low as 3.1% Acknowledgements (Kolber et al. 2015). In the present series 6 major com- Not applicable. plication were recorded (2.8%). Four patients experienced colonic ischemia after embolization with EVOH, due to Authors’ contributions All authors contributed equally to the article. unintended non-target vessel embolization: in one case a surgical colectomy was required, whereas in the other Funding three patient the ischemia resolved spontaneously after This study was not supported by any funding. Rabuffi et al. CVIR Endovascular (2023) 6:2 Page 8 of 8 Availability of data and materials Kim PH, Tsauo J, Shin JH, Yun SC (2017) Transcatheter arterial embolization All data and materials related to the study are available if requested. of gastrointestinal bleeding with N-butyl cyanoacrylate: a systematic review and metaanalysis of safety and efficacy. J Vasc Interv Radiol 28:522–531 Declarations Kolber M, Shukla PA, Kumar A, Silberzweig JE (2015) Ethylene vinyl alcohol copolymer (Onyx) embolization for acute hemorrhage: a systematic Ethics approval and consent to participate review of peripheral applications. J Vasc Interv Radiol 26(6):809–815 For this type of study formal consent is not required. Lenhart M, Paetzel C, Sackmann M et al (2010) Superselective arterial embo- lisation with a liquid polyvinyl alcohol copolymer in patients with Consent for publication acute gastrointestinal haemorrhage. Eur Radiol 20:1994–1999 For this type of study consent for publication is not required. Loffroy R, Favelier S, Pottecher P et al (2015) Transcatheter arterial emboliza- tion for acute nonvariceal upper gastrointestinal bleeding: indications, Competing interests techniques and outcomes. Diagn Interv Imaging 96:731–744 The authors declare that they have no conflict of interest. Loffroy R, Mouillot T, Bardou M, Chevallier O (2020 Oct) Current role of cyanoacrilate glue transcatheter embolization in the treatment of acute nonvariceal gastrointestinal bleeding. Expert review of gastroen- Received: 13 October 2022 Accepted: 4 January 2023 terology & hepatology 14(20):975–984 Loh Y, Duckwiler GR (2010) Onyx trial, a prospective, multicenter, rand- omized trial of the Onyx liquid embolic system and N-butyl cyanoacr- ylate embolization of cerebral arteriovenous malformations. 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Journal
CVIR Endovascular – Springer Journals
Published: Jan 26, 2023
Keywords: Acute arterial hemorrhage; Embolization; Ethylene vinyl alcohol copolymer; Onyx; EVOH