Therapeutic transcatheter arterial embolization in the management of intractable haemorrhage from pelvic urological malignancies: preliminary experience and long-term follow-up

Authors


Abstract

OBJECTIVE

To evaluate the feasibility, efficacy and complications of internal iliac artery embolization as a palliative measure in the control of intractable haemorrhage from advanced pelvic urological malignancies.

PATIENTS AND METHODS

Six patients (mean age 80 years, range 76–87) with advanced pelvic malignancies (three each with bladder carcinoma and prostate carcinoma) underwent embolization between September 1997 and July 2001, using permanent coils in the anterior division of internal iliac artery bilaterally.

RESULTS

All patients had undergone conservative treatment before embolization for a mean of 2 days. The mean requirement for transfusion before embolization was 3.2 units. All patients except one were successfully embolized in a single setting with no complications. Bleeding was successfully controlled in one patient at the second attempt of embolization. There were minor complications, e.g. nausea, vomiting or fever, for a mean of 2 days, responding well to conservative treatment. At a mean follow-up of 22 months, no patient had a recurrence of bleeding.

CONCLUSION

Internal iliac artery embolization is a feasible, effective and minimally invasive option in managing advanced pelvic urological malignancies presenting with intractable bleeding; it should be bilateral and permanent.

INTRODUCTION

Massive and potentially life-threatening haemorrhage from pelvic urological malignancy is often a genuine therapeutic challenge. The advanced disease, poor general condition of the patient and lack of convincing evidence for the efficacy of any therapeutic measure are some of the difficulties faced in managing these patients. The benefits of any interventional therapeutic measure must be balanced against the quality of life of these patients with terminal cancer. In the past the failure of conservative treatment could even necessitate open surgical bilateral ligation of the internal iliac arteries as a final option. However, such a procedure in a terminally ill patient would carry an unacceptable morbidity. There has been a continuing search for a minimally invasive, less morbid procedure to offer to these patients before they have exsanguinated. Since the introduction of internal iliac embolization in 1974 by Hald and Myging [1] there have been significant advances in the development of technique, imaging agents, experience and embolization materials. The growing expertise in this area has enabled the precise placement of embolization agents into the anterior division of iliac artery, thereby avoiding the complications reported earlier [2,3]. Permanent embolotherapy is now carried out with new, more thrombogenic coils made of either platinum or titanium. We evaluated the role of transcatheter arterial embolization (TAE) of bilateral internal iliac arteries, using permanent coils, in managing uncontrollable haemorrhage as an alternative, less-invasive therapeutic method in six patients. The feasibility, efficacy, complications of TAE and follow-up of these patients are presented.

PATIENTS AND METHODS

From September 1997 to June 2001, six patients (mean age 80 years, range 70–87) presenting with intractable haemorrhage underwent bilateral internal iliac artery embolization; three each had advanced TCC of the urinary bladder and advanced adenocarcinoma of the prostate (Table 1). All the patients had conservative treatment before TAE, which included continuous bladder irrigation using a three-way catheter and attempts to control bleeding endoscopically. Three patients (two with TCC and one with prostate adenocarcinoma) had palliative radiotherapy to control the bleeding. The haematuria recurred in all three at a mean (range) of 7 (6–9) months. In one patient the bladder tumour had recurred after radical radiotherapy and two were too sick to transport for any palliative radiotherapy. The mean requirement for transfusion before and after TAE was recorded. All the patients had complete coagulation profiles assessed to exclude any coagulopathy.

Table 1. The clinical staging, pre-embolization treatment methods and final outcome of the six patients
VariablePatient
123456
  1. ASA. American Society of Anesthesiologists; PC, prostate cancer; CBI, continuous bladder irrigation; EEC, endoscopic electrocoagulation; BC, bleeding controlled.

No./age, years1/762/813/784/875/706/83
DiseaseTCC bladderPCTCC bladderPCPCTCC bladder
Clinical stageT3BN0M0T3N2M0T4BN0M0M1, D2T3N0M1T3BN2M0
ASA Grade  3  3  3  2  2  3
Initial treatmentCBICBI + EECCBICBICBICBI + EEC
Previous radiotherapyPalliativeRadicalPalliativePalliative
Time from initial treatment to TAE, days  5  8  4  2  3  2
Final outcomeBCBC 2nd attemptBCBCBCBC
Follow-up, months131718126012

Pelvic angiography was performed with a pigtail catheter (5 F angiographic catheter, Cook UK Ltd). The internal iliac arteries were selectively catheterized using pre-curved catheters. The anterior division of internal iliac artery was embolized using tungsten/platinum coils of appropriate size, irrespective of whether bleeding was detected or not on the angiographic study (Figs 1 and 2). Angiography was used after embolization, under fluoroscopic guidance, to ensure complete occlusion of blood flow (Fig. 3). The same procedure was repeated on the opposite side using an ipsilateral or contralateral puncture. After embolization patients were followed for symptoms of embolization syndrome, other complications of the procedures and the efficacy of the procedure in controlling haematuria, requirement for blood transfusion and improvement in haematocrit.

Figure 1.

Angiography showing increased vascularity in the pelvic area (arrow).

Figure 2.

X-ray showing embolization on one side with complete obliteration of blood flow using coils (arrow).

Figure 3.

Complete bilateral embolization using coils (arrowheads).

RESULTS

Before embolization, the patients had required a mean (range) of 15 (2–4) emergency admissions, and required 3.2 (2–6) transfusion units. TAE was successful in all six patients, with complete control of bleeding in all except one, in whom the bleeding was successfully embolized at a second attempt. At a mean (range) follow-up of 22 (10–60) months the haemorrhage was permanently controlled in all patients. No patient required transfusion after TAE. The mean (range) haematocrit before and after TAE was 28 (22–34)% and 36 (26–44)%, giving a mean improvement of 8 (2–10)%, and the respective haemoglobin values were 84 (72–92) and 96 (92–110) g/L.

There were minor complications, e.g. nausea, vomiting and fever in three patients, for a mean of 2 days; there was no major complication. At a mean follow-up of 22 months all the patients had good control of bleeding with no further requirement of emergency admission for control of haematuria.

DISCUSSION

Embolization has been used successfully for managing intractable bleeding in advanced pelvic malignancies, particularly gynaecological tumours [2]. Pisco et al.[4], in a large review, reported complete control of bleeding in 69% of cases with pelvic malignancies by embolizing the anterior division of anterior iliac artery. However, there was no separate mention of the type of conservative treatment undertaken, requirement for transfusion, improvement in haematocrit or follow-up of urological malignancies in that study. Understandably, the threshold for embolization of gynaecological tumours is low, as there are few options for intracavitary irrigation or balloon tamponade using a Foley catheter as a conservative measure. In practice, most haematuria episodes are controlled by an effective continuous normal saline irrigation using three-way catheters, and by endoscopy in urological malignancies. When these measures fail to control bleeding, the urologist faces a difficult clinical problem. Therapeutic embolization offers an alternative to surgical intervention in these patients. There are reports of the successful control of haematuria after embolization in bladder and prostate cancers [4–11]. However, to our knowledge, a prospective evaluation of therapeutic TAE for the control of intractable bleeding in urological malignancies has not been reported.

The anterior division of the internal iliac artery should be embolized bilaterally irrespective of whether the bleeding point is detectable on angiography or not [12]. This prevents the recurrence of bleeding from collaterals. The partial physiological alterations in mean pressure, pulse volume and blood flow even after bilateral internal iliac embolization obviates the fear of ischaemic infarction [13]. We used coils to permanently embolize the anterior division of internal iliac arteries. The long-term follow-up showed no complications, e.g. increased risk of tissue necrosis or recurrence of bleeding, and is evidence that TAE should be bilateral and permanent, using coils rather than particulate materials [14]. TAE is a less invasive palliative measure to control bleeding in terminally ill patients than any surgical intervention. TEA not only effectively controls the bleeding, but also decreases the requirement for blood transfusion rates and improves the haematocrit. There were no major complications, in contrast to previously reported series [2,3,12–14]. Careful radiographic visualization of the anterior division of internal iliac artery, precise placement of the coils and the use of coils instead of particulate embolizing agents, to preserve tissue perfusion as these remain proximal to arterioles and do not interfere with capillary circulation [13–15], are probably important in minimizing complications. Mild self-limiting symptoms like nausea, vomiting or fever were easily controlled conservatively.

In conclusion, the long-term results of managing bleeding from advanced pelvic cancers (which had not responded to conservative treatment) using TAE with permanent coils suggests that this technique is feasible, safe and effective. Permanent TAE of the internal iliac artery should be considered as an alternative less-invasive palliative measure and the treatment of choice in these situations. Internal iliac artery embolization not only controls the immediate problem of severe and life-threatening haemorrhage, but also achieves sustained control of haematuria, and is important in the palliative care and quality of life of these patients.

Abbreviations
TAE

transcatheter arterial embolization.

Ancillary