Transcatheter Embolization Of Hypogastric Branch Arteries in the Management of Intractable Bladder Hemorrhage

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Abstract
Transcatheter embolization with inert material was an effective means to control hemorrhage from the bladder and other pelvic organs. Hemorrhage in the 14 patients studied was attributable to a variety of traumatic, neoplastic and congenital conditions. Superselective catheter techniques permit selective engagement of branch vessels, i.e., the superior vesical artery, and limit embolization to the supply area of 1 branch. In patients with multiple demonstrable bleeding points supplied from different branch vessels embolization is best done by releasing the infarct particles in midstream of the appropriate division of the hypogastric artery and relying on the siphoning effect of the bleeding lesion to channel particles into the appropriate branches. To facilitate superselective engagement of branch vessels an approach via the axillary artery or the contralateral femoral artery is favored. Fluoroscopic monitoring and fractional embolization with decreasing volumes of embolic material for the 2nd and subsequent embolization attempts are imperative to limit embolization to the desired region and preclude inadvertent regurgitation of embolic material into the main vessels with attendant embolization of distant capillary beds. An excellent collateral network in the bladder muscularis assures an acceptable capillary flow to any segment in which the principle vascular supply was embolized and prevents tissue necrosis. The reduced pressure gradient in the embolized system allows adequate clot formation at bleeding points. Transcatheter embolization should be done only after bleeding points have been identified (extravasation of contrast medium on the diagnostic arteriogram). In cases with hemorrhage from the bladder due to carcinoma or to direct extension of other pelvic neoplasms specific bleeding points may not be identifiable. Embolization of the entire vascular supply of the vesical component of such neoplasms is most effective in control of this type of hemorrhage and usually can be accomplished by midstream injection of absorbable gelatin sponge into the anterior division of the hypogastric artery. The propensity of arteriovenous malformations to refill and reform via collaterals may necessitate repeat embolization for permanent obliteration.