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246 TECHNICAL NOTES
January 1980
Transcatheter Embohization of an Esophageal Artery
for Treatment of a Bleeding Esophageal Ulcer1
John A. Michal, III, M.D., W illiam R. Brody, M.D.,
Joseph W alter, M.D., and Lewis W exier, M.D.
Angiographic detection and control of bleeding into a distal
esophageal ulcer is described in a 16-year-old girl with acute
leukemia. Catheterization of an esophageal artery arising di-
rectly from the distal thoracic aorta allowed successful control
of the hemorrhage. The arterial anatomy of the esophagus is
described in detail.
INDEX TERMS: Embolism, therapeutic, 9.129 #{149} Esophagus, hemorrhage #{149}
Esophagus, ulcers, 7[1j.250 #{149} (Vessels of GI system, hemorrhage,
9151.7 10)
Radiology 134:246, January 1980
Major esophageal hemorrhage is most commonly caused by
4-
vanices related to portal hypertension; occasionally arterial
hemorrhage secondary to esophagitis, the Mallory-W eiss syn-
drome, or esophageal trauma is encountered. This technical note
describes the angiographic detection of esophageal arterial
bleeding from a large esophageal ulcer by selective catheter-
ization of an artery arising directly from the lower thonacic
aorta.
CASE REPORT
Fever and dysphagia developed in a 16-year-old girl with acute leu-
kemia. She had oral thrush, and an esophagogram demonstrated a 3-cm
distal esophageal ulcer (Fig. 1). Three days after she was started on oral
nystatin and intravenous amphotericin B, massive upper gastrointestinal
hemorrhage developed. Bleeding continued after transfusion and in-
travenous vasopressin administration.
Selective celiac, left gastric, and inferior phrenic arteriograms
demonstrated no definite bleeding site. Because of the previous dem-
onstration of the distal esophageal ulcer, the lower thoracic aorta was
explored and a small arterial branch arising anterolaterally at the 1-10
level catheterized. An arteriogram demonstrated free extravasation
of contrast material into the distal esophageal lumen (Fig. 2). The artery
was embolized with Gelfoam particles, and hematemesis ceased im-
mediately.
Five days later, massive hematemesis recurred, and a second ar-
teriogram demonstrated the bleeding site to be the same esophageal
artery. Re-embohization combined with intra-arterial vasopressin
infusion for 1 2 hours again controlled the bleeding. An esophagogram
four weeks later showed that the ulcer had healed.
DISCUSSION
W hile embolization of the left gastric and inferior phrenic
arteries for control of distal esophageal arterial hemorrhage has
been described (1), the role of other esophageal arteries has not
been discussed, to our knowledge.
The arterial blood supply of the cervical esophagus is derived
from descending branches of the inferior thyroid arteries: the
midthoracic portion by branches of the bronchial arteries and
one on two esophageal arteries arising directly from the aorta,
and the distal portion by branches of the left gastric or left inferior
phrenic arteries (2). Variations in the arterial supply of the
esophagus may be useful to note (3). In the cervical region, there
may be branches of the subclavian, thyroidea ima, common
carotid, and superior thyroid arteries which supply the esopha-
Fig. 1 . Barium eosphagogram demonstrating a 3 X 1-cm oval
esophageal ulcer crater 6 cm proximal to the esophagogastric junc-
tion.
Fig. 2. Selective arteriogram of an esophageal branch arising di-
rectly from the aorta, seen in the late arterial phase, in the left posterior
oblique projection. Contrast medium fills the esophageal artery (arrow),
opacifies a 4-mm round pseudoaneurysm, and extravasates into the
distal esophageal lumen, filling the esophageal veins.
gus. In the thoracic portion, the right third and/on fourth inter-
costal arteries occasionally supply the esophagus. The number
and location of bronchial arteries vary widely. In the distal
esophagus, cehiac, splenic, short gastric, and left hepatic origins
have been described.
To our knowledge, the only previous mention of the angio-
graphic usefulness of an esophageal artery arising directly from
the aorta is a report of the visualization of an esophageal
leiomyoma (4). Our case illustrates that esophageal arteries
arising directly from the aorta can be occluded safely without
resulting in significant esophageal ischemia or injury to the spinal
cord.
REFERENCES
1 . Carsen GM, Casarella W J, Spiegel RM: Transcatheter embohi-
zation for treatment of Mallory-W eiss tears of the esophagogastric
junction. Radiology 128:309-313, Aug 1978
2. Swigart LL, Siekert RG, Hambley W C, et al: The esophageal ar-
teries. An anatomic study of 150 specimens. Surg Gynecol Obstet
90:234-243, Feb 1950
3, Michels NA: Underlying Blood Supply and Anatomy of the Upper
Abdominal Organs, with a Descriptive Atlas. Philadelphia, Lip-
pincott, 1955, pp 266-270
4. Ben-Menachem Y, Akhtar M, Duke JH Jr, et al: Angiographic
characteristics of esophageal leiomyoma. Am J Roentgenol
128:479-482, Mar 1977
1 From the Department of Radiology, Stanford University School of
Medicine, Stanford, CA. Received Jan. 25, 1979; revision requested
April 18; received May 18 and accepted May 21 . (Reprint requests to
W .R.B., Department of Radiology, Stanford University Medical Center,
Stanford, CA 94305.)