Transradial coil embolization of a bleeding duodenal ulcer in a patient with Raynaud’s syndrome

Clinical History

A 64-year-old women with longstanding systemic lupus erythematosus (SLE) and significant peripheral vascular disease developed an upper gastrointestinal bleed from a duodenal ulcer which re-bled after two upper endoscopies. Her comorbidities posed a challenge obtaining femoral vascular access for interventional management in the acute setting.

Imaging Findings

Non-contrast abdominal CT demonstrated subtotal occlusion of the infracoeliac aorta with dense calcified plaque, which precluded access and selection of the coeliac axis from the transfemoral route.
Catheter angiogram was performed using the left radial artery for vascular access. A 5F radial sheath and 5F 125 cm Bernstein catheter (Merit Medical, Salt Lake City, UT) was used to negotiate the aortic arch and descending thoracic aorta, followed by cannulation of the coeliac axis. A 2.4F 150cm microcatheter/wire combination (Direxion/Fathom, Boston Scientific, Natick, MA) was used to superselect the gastroduodenal artery (GDA). Digital subtraction angiography (DSA) demonstrated active contrast extravasation of the proximal GDA, which correlated with the site of the bleeding duodenal ulcer. A series of 4mm detachable Concerto Helix coils (Coviden, Dublin, Ireland) were deployed in branch vessels of the GDA. Post-delivery DSA demonstrated successful superselective coil embolization, with preservation of flow within the GDA.

Discussion

Background:
Vascular access for interventional embolization has been traditionally obtained using a transfemoral route. Studies in the cardiology literature have explored the use of a transradial approach as a suitable alternative, with lower complication rates, comparable efficacy rates, and faster time to ambulation and discharge [1–3]. Overall, lower rates of local vascular complications are reported with the radial approach, including fewer large haematomas and pseudo aneurysms compared to femoral or brachial access [2, 4].
Reported cases of transradial approach are in the interventional radiology literature, with the largest retrospective review of 1004 transradial interventional procedures, which showed a 0.3% prevalence of major adverse events requiring additional management [1].
We describe a case using a transradial access technique to treat life-threatening gastrointestinal haemorrhage in a patient with severe peripheral vascular disease, infrarenal aortic occlusion, and complications following bilateral common femoral endarterectomies which precluded transfemoral access.

Clinical Perspective:
The patient’s situation was exacerbated by Raynaud’s syndrome in the context of SLE, causing marked vasoconstriction of her distal upper limb vessels in cold environments, making vascular access challenging. Barbeau test was performed by compressing the radial artery (preferred over brachial access to reduce ischaemic complications), recording waveform from plethysmography and pulse oximetry probe on the thumb [4], revealing a Type B waveform.
The upper left arm was warmed by a surgical air warmer to facilitate arterial dilation and perfusion. Perivascular local anaesthetic was administered prior to gaining access, consisting of 9mL 1% lidocaine and 100 mcg of nitroglycerin, of which 2-3ml was administered subcutaneously a few centimetres above the radial artery entry site. Arterial access was obtained via the left radial artery with a 5F vascular sheath (PreludeEASE, Merit Medical, Salt Lake City, UT). Following the introduction of the sheath, a combination of 200mcg Nitroglycerin, 2.5mg Verapamil, and 2000 units of Heparin was administered through the sheath. The infusion was performed by aspirating blood into a 20mL syringe containing the medication mixture, then re-injecting the haemodiluted medication (in our experience this decreases hand pain, often encountered following intra-arterial injection of Verapamil).

Outcome:
The patient was successfully managed by coiling the gastroduodenal artery using the left radial artery for vascular access. The patient’s haemoglobin levels stabilized post-embolization with no further episodes of melaena.

Take Home Message:
Transradial access for acute life-threatening gastrointestinal haemorrhage is a safe procedure, and demonstrates utility in many patients, particularly those with severe peripheral vascular disease where transfemoral access is extremely challenging or not possible.

Differential Diagnosis List

Final Diagnosis

Peptic ulcer disease

URL:	https://www.eurorad.org/case/13047
DOI:	10.1594/EURORAD/CASE.13047
ISSN:	1563-4086