title: Mesenteric angiography for acute gastrointestinal bleed: predictors of active extravasation and outcomes.
abstract: BACKGROUND
  Ongoing gastrointestinal bleeding (GIB) following endoscopic therapy and deciding between mesenteric angiography and surgery often challenge surgeons. We sought to identify predictors of positive angiographic study (active contrast medium extravasation) and characterize outcomes of embolization for acute GIB.
  
  
  METHODS
  We retrospectively analyzed angiographies for GIB at 2 teaching hospitals from January 2005 to December 2008. The χ2, Wilcoxon rank sum and t tests determined significance. A Cox proportional hazards model was used for multivariate analyses.
  
  
  RESULTS
  Eighteen of 83 (22%) patients had active extravasation on initial angiography and 25 (30%) were embolized. Patients with active extravasation had more packed red blood cell (PRBC; 5.3 v. 2.8 units, p < 0.001) and fresh frozen plasma (4.8 v. 1.7 units, p = 0.005) transfusions 24 hours preangiography and were more likely to be hemodynamically unstable at the time of the procedure (67% v. 28%, p = 0.001) than patients without active extravasation. Each unit of PRBC transfused increased the risk of a positive study by 30% (hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.2-1.6 per unit). Embolization did not decrease recurrent bleeding (53% v. 52%) or length of stay in hospital (28.1 v. 27.5 d, p = 0.95), but was associated with a trend toward fewer emergency surgical interventions (13% v. 26%, p = 0.31) and greater 30-day mortality (33% v. 7%, p = 0.006) than nonembolization. Blind embolization was performed in 10 of 83 (12%) patients and was found to be an independent predictor of death in patients without active extravasation (HR 9.2, 95% CI 1.5-55.9).
  
  
  CONCLUSIONS
  The number of PRBC units transfused correlates with greater likelihood of a positive study. There was a significant increase in mortality in patients who underwent angioembolization. Large prospective studies are needed to further characterize the indications for angiography and blind embolization.
authors.affiliation: The Department of Surgery, McGill University, Montréal, Que.
authors.forename: Lawrence
authors.initials: L
authors.lastname: Lee
authors.forename: Sameena
authors.initials: S
authors.lastname: Iqbal
authors.forename: Sara
authors.initials: S
authors.lastname: Najmeh
authors.forename: Paola
authors.initials: P
authors.lastname: Fata
authors.forename: Tarek
authors.initials: T
authors.lastname: Razek
authors.forename: Kosar
authors.initials: K
authors.lastname: Khwaja
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000792:Angiography; D015897:Comorbidity; D004621:Embolization, Therapeutic / Q000401:mortality; D017707:Erythrocyte Transfusion; D005119:Extravasation of Diagnostic and Therapeutic Materials / Q000000981:diagnostic imaging* / Q000401:mortality; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000000981:diagnostic imaging / Q000209:etiology* / Q000401:mortality / Q000628:therapy*; D006784:Hospitals, Teaching; D006801:Humans; D008297:Male; D008638:Mesenteric Arteries / Q000000981:diagnostic imaging*; D017537:Mesenteric Artery, Inferior / Q000000981:diagnostic imaging; D017538:Mesenteric Artery, Superior / Q000000981:diagnostic imaging; D008875:Middle Aged; D015999:Multivariate Analysis; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012189:Retrospective Studies