Background: This study was conducted to evaluate the technical and clinical success of trans-arterial embolization (TAE) as a treatment of gastrointestinal bleeding (GIB) in Coronavirus Disease 2019 (COVID-19) patients and to describe its safety; moreover, we describe the characteristics of these patients. Methods: Thirty-four COVID-19 hospitalized patients presented with GIB. Risk factors, drugs administered for COVID-19 infection, and clinical and biological parameters were evaluated. Furthermore, intraprocedural data and outcomes of embolization were analyzed. Results: GIB was more frequent in male. Overweight, hypertension, diabetes, previous cardiac disease, and anticoagulation preadmission (48.5%) were frequently found in our population. Previous or actual COVID Acute respiratory distress syndrome (ARDS) and a high level of D-dimer were encountered in most cases. Upper GIB was more frequent than lower GIB. Technical and clinical success rates of embolization were 88.2% and 94.1%, respectively. The complication rate was 5.9%. Conclusions: Our study highlights the most frequent characteristics of COVID-19 patients with GIB. Embolization is feasible, effective, and safe.
Coronavirus disease 2019 (COVID-19) is caused by a transmissible respiratory virus (SARS-CoV-2), detected in China in December 2019 and declared an official pandemic by the World Health Organization (WHO) on 11 March 2020 [1]. At the time of writing, there have been approximately 177,108,695 diagnosed infections and 3,840,223 deaths [1]. The clinical spectrum is wide, ranging from asymptomatic infection to severe viral pneumonia with respiratory failure, systemic involvement, and death [2,3,4]. Patients may have an increased susceptibility to develop coagulopathy, resulting in thromboembolism and disseminated intravascular coagulation (DIC) [5,6,7].
Recent studies have shown that COVID-19 patients treated with antithrombotic drugs are at increased risk of bleeding [8]. Among other mechanisms related to GI bleeding, stress ulcer formation from hospitalization [9] and hemorrhagic colitis possibly secondary to SARS-CoV-2 [10] have been mentioned.
Common GI symptoms include abdominal pain, nausea, vomiting, diarrhea [2,3,11], and sporadic gastrointestinal bleeding (GIB). Etiology is multifactorial, but not yet fully understood [2,3,11,12,13]. The rate of GIB events ranges between 1.5% and 13% [2,14].
The first-line treatment for GIB is endoscopy; however, this exposes staff to an increased risk of aerosol transmission of the virus [13] and patients to an increased risk of respiratory worsening during the procedure, with a possible need for respiratory support and transfer to the intensive care unit, often already saturated [4]. The risks of staff exposure need to be weighed against the benefits of endoscopy on a case-by-case basis using clinical judgement. Decisions could be better made using prognostic tools such as the Glasgow Blatchford score for the pre-endoscopic risk stratification of patients [15]. Moreover, recent studies have shown that some upper GIB can possibly be managed conservatively without endoscopy as patients responded within 24 h [16].
In COVID-19 patients, to avoid the aforementioned problems and in cases of persistent bleeding after endoscopy and preexisting hemodynamic instability, interventional radiology could play an important role [17,18].
The aim of our study was to describe the characteristics of patients with GIB and to evaluate the technical and clinical success, as well as the safety profile, of trans-arterial embolization (TAE) in the treatment of these hemorrhagic emergencies.
This was a multicenter retrospective observational study including 34 COVID-19 patients admitted to hospital between January 2020 and March 2021 with acute respiratory symptoms who developed GIB during hospitalization.
The study was approved by the ethics committee of the Coordinator Center (RadCovid 05-2020-467-2020).
We included all adult patients for a total of 34 patients (M:F, 22:12) hospitalized after a positive test by real-time polymerase chain reaction for COVID-19 infection. As mentioned above, all patients developed GIB during hospitalization. GIB was defined as evidence of hematemesis, coffee-ground emesis, melena, maroon stools, hematochezia, or a hemoglobin drop by 2 g·dL−1 in a 24 h period, decreasing in systolic blood pressure or hemodynamic instability.
Risk factors were assessed for each patient, especially body mass index (BMI) and comorbidities (hypertension, diabetes, cancer, cardiac disease, cirrhosis, etc.), as presented in Table 1. Moreover, drugs used for COVID-19 infection were reported, including prophylactic heparin (Table 2). More relevant clinical data and biologic parameters at hospital entry and the day of embolization were studied (Table 3 and Table 4). Moreover, intraprocedural data (Table 5) and outcomes of the embolization are reported (Table 6).
Most patients were evaluated by an emergency angio-CT to investigate the presence of active bleeding.
Indication for the procedure of embolization was established after a multidisciplinary consensus among gastroenterologist, radiologist, and surgeon on the basis of CT and/or endoscopic findings in association with clinical and laboratory data. In some cases, embolization was proposed after an unconclusive endoscopy or when endoscopy was not feasible [19,20].
Staff involved had to follow a high-standard infection protection protocol during the procedures [21].
Technical success was defined as the disappearance of contrast extravasation on post-procedural angiography or the completion of embolization of the desired artery (when an extravasation was not observed), while clinical success was established as the achievement of hemostasis, associated with hemodynamic stability, with no signs of rebleeding or related mortality within 30 days of embolization.
During follow-up, we monitored all patients’ symptoms and laboratory data every 6 h in the first 48 h and 1 week after the endovascular procedure.
Re-embolization was considered when clinical stability was not achieved during follow-up and/or evidence of persistent or new GI bleeding was demonstrated on a new angio-CT.
Safety was defined as procedure related morbidity and was evaluated according to the Society of Interventional Radiology guidelines [22].
All procedures were performed in the AngioSuite equipped for the treatment of COVID-19 patients, under local anesthesia, sedation, or general anesthesia with anesthesiologic assistance.
Access for endovascular angiography is usually gained via the common femoral artery; angiography is able to identify vessel(s) responsible for bleeding, and selective catheterization is carried out to prepare for embolization. In all hospitals, dedicated devices were used.
Given the small sample size and the observational nature of the study, only descriptive statistics were obtained for all variables assessed in the study population. Mean and standard deviation (SD) are provided for normally distributed variables, median and interquartile range (IQR) are provided for non-normally distributed variables, and number and percentage are provided for categorical variables. Normality was assessed by the Shapiro-Wilk test.
Questo sito è rivolto in primis a chi vuole saperne di più sulla Radiologia Interventistica, branca della Medicina in continua evoluzione, che ha rivoluzionato l’approccio di molte patologie, talvolta semplificandolo; i campi di applicazione spaziano dalla diagnosi alla terapia.
