Arteriography for Diagnosis and Treatment of Gastrointestinal Bleeding

1. Upper Gastrointestinal Bleeding

   Patients should initially undergo endoscopy to help with the differential diagnosis. If bleeding varices are identified, then TIPS can be considered if banding and/or sclerotherapy fail. If diffuse gastritis is present, arteriography and treatment with left gastric artery embolization may be helpful. If a bleeding gastric or duodenal ulcer is present which cannot be treated endoscopically, the patient should proceed to arteriography and embolization to treat this. If upper endoscopy is negative, search for a lower gastrointestinal source should be considered as discussed below.
   
   

2. Lower Gastrointestinal Bleeding

   The initial radiographic procedure of choice is a nuclear medicine scan. This is up 10 times more sensitive in demonstrating active bleeding than arteriography. If the scan is positive, it will help direct arteriography. If the scan is negative, emergent arteriography is not indicated. With appropriate preparation, elective arteriography may be helpful to detect vascular malformations. Embolization of lower gastrointestinal bleeding was previously limited to rectal sources, however recent advances have allowed embolization of colonic and small bowel sources in certain patients. Please note that oral contrast from upper GI, barium enema or CT scans severely limits arteriographic detection of bleeding, thus appropriate planning and patient preparation are critical.
   
   

3. Variceal Bleeding

   Patients with known variceal bleeding should be stabilized in preparation for TIPS. TIPS is not performed emergently in this institution because of the poor results and high mortality of this procedure in actively bleeding unstable patients. Keep in mind that in addition to trying to correct or at least partially correct any coagulopathy, patients will need ultrasound/Doppler evaluation of their portal system prior to undergoing TIPS. See IU TIPS guidelines.

Venous Thromboembolic Disease

All patients with suspected pulmonary emboli, except as outlined below under pulmonary embolectomy, must have a ventilation perfusion scan prior to arteriography. Theoretically, all patients with indeterminate scans should undergo arteriography although clinical considerations may alter the diagnostic algorithm. If the patient has a contraindication to anticoagulation, then arteriography should be performed emergently with placement of an inferior vena caval filter if the arteriogram is positive. If the patient does not have a contraindication to anticoagulation, heparin therapy should be instituted and a pulmonary arteriogram scheduled for the next morning.

It should be noted that pulmonary arteriography using modern techniques has an exceedingly low complication rate, uses relatively little contrast and can be performed in a very rapid fashion. If a patient has a left bundle branch block, they will need a temporary internal or external pacer and this should be kept in mind when requesting the study. Pulmonary hypertension is no longer considered even a relative contraindication to pulmonary arteriography using nonionic contrast agents.



1. Pulmonary Embolectomy

   A variety of new devices are available which allow the percutaneous fragmentation and/or fenestration of pulmonary emboli in certain patient populations. This procedure is limited to those patients with hemodynamically significant saddle emboli and thus these are very sick patients and the procedure needs to be performed as quickly as possible. In these instances, the interventional radiology staff may elect to bypass the ventilation perfusion scan and go directly to pulmonary arteriography.
   
   

2. Inferior Vena Caval Filters

   The primary indication for an inferior vena caval filter is a contraindication to anticoagulation in a patient with a DVT or PE as well as failure of anticoagulation such as recurrent pulmonary emboli despite a therapeutic Coumadin level. Other indications are handled on a case-by-case basis. Inferior vena caval filtration is safe and effective but does have an approximately 5% recurrent pulmonary embolization rate and approximately 10-20% inferior vena caval thrombosis rate though only 5% will be symptomatic.
   
   

3. Venous Thrombolysis

   See IU Thrombolysis Guidelines

Drainage Procedures

1. Biliary

   Biliary sepsis is an absolute indication for emergency biliary drainage. Patients should ideally have antibiotics running at the time of the procedure. Sterile biliary obstruction should be drained electively.
   
   

2. Urinary

   Urosepsis in conjunction with hydronephrosis should be considered pyonephrosis until proven otherwise and is considered an absolute indication for emergency nephrostomy. Sterile hydronephrosis can be drained electively. Again, antibiotics should be running at the time of the procedure.
   
   

3. Fluid Collection Aspiration/Drainage

   Fluid collections under 3 cm in diameter generally are not amenable to placing a catheter but can be aspirated under appropriate imaging guidance as necessary. This procedure is performed by the abdominal imaging service. Catheter drainage of suspected abscesses is emergent if the patient is showing signs of sepsis. Broad-spectrum antibiotics should be running at the time of the procedure.
   
   

4. Thoracentesis/Pleural Drainage

   For large pleural fluid collections, thoracentesis should be attempted at the bedside before consulting radiology. For smaller but still readily drainable collections, asking ultrasound to mark the collection and performing it at the bedside may be a cost effective alternative which provides house-staff with experience in thoracentesis while minimizing patient discomfort.

   Diagnostic thoracentesis should be referred to the abdominal imaging service.

   Therapeutic thoracentesis and other thoracic drainage procedure such as empyema drainage should be referred to interventional radiology.
   
   

5. Paracentesis

   For large volume paracentesis, if more than 5 liters of fluid is going to be removed then patient should be administered IV albumin. The recommendation is 8g of albumin for every liter over 5 liters removed, with maximum dose of 25g.

Venous Access Procedures

1. PICC Lines

   Please see the accompanying PICC line policy for further details. Please note that PICC lines are not performed as emergencies and therefore this service is not available at night or on weekends. All PICC line requests should initially go to Home Care, if Home Care fails the patient will automatically be referred to interventional radiology. Requests for PICC lines received by interventional radiology before noon will be accommodated the same day and those received after noon will be accommodated by the next day at the latest. If line placement is needed sooner than that offered by interventional radiology, this should be taken up with the interventional radiology staff.
   
   

2. Central Lines

   Patients in need of central lines should have an attempt at the bedside unless coagulopathy or thrombocytopenia makes this a contraindication. If bedside placement is unsuccessful, interventional radiology should be contacted to place the line. This service is available round the clock and on weekends.
   
   

3. Tunneled Catheters

   Hickman catheters, dialysis catheters and ports do not constitute emergency procedures and are therefore not performed at night or on weekends. However, removal of an infected Hickman catheter will be performed at any time. Please see accompanying PICC line policy which outlines the type of venous access indicated depending on the duration of therapy anticipated.

Central Venous Angioplasty in Hemodialysis Patients

Do not perform PTA of central venous stenosis in hemodialysis patients unless there is a clinical indicator for that PTA, i.e., in almost all cases, arm swelling.

Rationale:  Central venous stenosis almost never causes access dysfunction.  While PTA in a patient with extremity swelling is appropriate, the dismal patency rates concomitant to central PTA (perhaps 30% at 6 months), mitigate against its performance in almost any other case.  Do not perform central PTA unless you are certain that the stenosis is physiologically and clinically significant.

Liver Biopsy

When a liver biopsy is requested, ascertain that the plt count is 50 or greater.  If it is less than 50, suggest a transjugular liver biopsy.  Even though you are planning to do a transjugular biopsy, request that platelets be transfused to get the platelet count over 50.  If there is a compelling reason that the referring service does not want to give, or cannot give platelets, do not mandate that they be given.  E.g., they may state that the patient is consuming platelets, and the count will never get above 50.  However, it is still likely to be better to have platelets running during the procedure, even if it's unlikely to get the count up.  Do NOT request a platelet transfusion, get the count above 50, and then decide to do a percutaneous biopsy. 

Magnetic Resonance Arteriography

Also see MRA Questionnaire.  MRA has emerged as a viable diagnostic imaging alternative to look at the renal arteries as well as the peripheral vessels.  This study is ideal for patients with severe contrast allergies, elevated Creatinine, and uncorrectable coagulopathy.  Requests for Magnetic Resonance Arteriography of the renal, iliac and infrainguinal arteries should be directed to interventional radiology.

Percutaneous Gastrostomy, Gastrojejunostomy and Transgastric Jejunostomy

This is an elective procedure.  Inpatients may have a nasogastric tube placed by the referring service before the procedure, but a 5F Berenstein catheter placed in the IR angio room may be less traumatic.  In general, if the tube is for feeding it is preferable to place a transgastric jejunostomy rather than a simple gastrostomy because of the risk of aspiration with gastric feeding.

Proximity Injury Arteriograms and Other Semi-Emergent Procedures

When these are scheduled for the next morning, it is imperative that these procedures be done as the first case.  These patients should be fully worked up by the resident-on-call with the assistance of the on-call VIR fellow as needed.