고신대학교 복음병원 영상의학과

윤종혁
 혈관계 인터벤션
 비정맥류성 위장관출혈의 치료
 정맥류성 위장관 출혈의 치료

 비혈관계 인터벤션
 위장관계 풍선확장술
 위장관계 스텐트 삽입술
 위루설치술
 암의 치료 혹은 장기의 제거목적으로
 간동맥화학색전술(TACE)
 수술전 신장암의 혈관색전

 출혈의 치료목적으로
 내과적으로 지혈하기 힘든 환자의 비수술적 지
혈
 수술받기 전까지 시간의 확보
 수술받을 수 있는 상태로 환자상태 개선을 위
해
 Celiac trunk

 Superior mesenteric artery

 Inferior mesenteric artery

 2nd portion of duodenum- transverse
colon

 To the small intestine

 Inf, PDA. Jejunal A, Ileal A

 To the large intestine

 Ileocolic, Right colic, Mid colic A
 Left colic artery

 Sigmoid artery
 Angiographically detectable bleeding
rate
 0.5ml/min

 The goal of embolotherapy

 Reduce the pressure in the bleeding artery
 Maintain collateral flow to preserve viability
 Risk of postembolic ischemia is minimal
due to rich collateral flow
 Transcatheter embolotherapy is more preferred
method

 Embolic agent
 Temporary embolic agents
• Gelfoam, autologous blood clots
 Permanent embolic agents
• Coils, glue, absolute ethanol, PVA particle
 Coil

Gelfoam
 Angiographic findings of GI bleeding
 Contrast extravasation
 Pseudoaneurysm
 Contrast accumulation within mucosal fold
(Pseudovein sign)
 Cause of bleeding
 Peptic ulcer > M-W syn > malignancy

 85% of bleeding foci : LGA

 Selective left gastric arteriography should be
performed
 If, negative angiography
• blind embolization of LGA
 Dual blood supply of duodenum
 Sup, PDA from GDA ( Celiac trunk )
 Inf, PDA from SMA

 Ideal technique
 Embolization across bleeding site
 Cause
 Diverticulum
 Angiodysplasia
 Polypectomy, tumor bleeding
 Inflammatory ds, Vasculitis
 Balloon dilatation

 Stent placement
 식도, 위장의 스텐트설치술
 대장의 스텐트설치술

 Gastrostomy / Jejunostomy
Benign diseases Malignant diseases
 Post op stricture  Esophageal cancer
 Corrosive stricture  Lung cancer
 Achalasia  Mediastinal tumor
 Peptic stenosis  Gastric ca with EGJ
 Congenital stenosis invasion
 Esophageal web
Benign diseases
 Bougienage
• Longitudinal force on the wall
• Increase risk of perforation
(8%)
 Balloon dilatation
• Axial stationary force on lesion
• Lower risk of perforation (2%)
Malignant diseases
 External beam radiation
 Nd-YAG LASER
 Brachytherapy
 Photodynamic therapy
 Ethanol injection
 Plastic tube insertion
 Self expandable metallic
stent
 Indication
 Swallowing difficulty in patients with post op
stricture, corrosive stricture, peptic stricture,
achalasia, etc

 Treatment goal
 Asymptomatic intake of a regular diet
 Esophageal luminal diameter: More than 12
mm
 Results
 Success rate: 67-97%
• Post operative stricture > Corrosive stricture
 Recurrence rate, Perforation rate
• Corrosive stricture > Others

 Complications
 Pain, Bleeding, Perforation
 Cause
 Esophageal cancer, gastric cancer /c EGJ
invasion, lung cancer, mediastinal tumor

 Symptoms
 Dysphagia, esophagorespiratory (ER) fistula

 Operability
 30 - 40% in esophageal cancer
 Symptom Palliation
 Surgical Palliation
• Morbidity rate: 36 - 71%
• Mortality rate: 13 - 22%
 Non-surgical Palliation
• Bougienage, rigid plastic stent, external beam
radiation, Nd-YAG LASER
 Metallic stent placement
00.8.29 00.9.30 00.10.4
 Results
 Technical success rate: 97 - 100%
 Improvement of dysphagia: 83 - 100%
 Comparative studies
• Metallic stent > RTx & CTx
– Cwikiel W, et al. Acta Oncol 1993
• Metallic stent > Plastic stent
– Knyrim K, et al. NEJM 1993
• Metallic stent > Laser therapy
– Adam A, er al. Radiology 1997
 Incidence
 5 - 15% of esophageal ca
 <1% of lung ca

 Causes
 Local tumor invasion, surgery, stent
placement

 Devastating & life-threatening Cx

 Results of Stent Placement
 Clinical success rate: 67 – 100%
 Recurrent fistula: 8 – 35%
• Causes of recurrence
– Stent occlusion, migration, covering disruption
• Management of recurrent fistula
– Additional stent placement

 Increased mean survival

 Immediate therapy, initial clinical success
 Causes
 Malignancy of gastric antrum or duodenum
 Direct invasion or extrinsic compression of duodenum
from pancreatic or cholangiocarcinoma
 Metastatic involvement from distant primary neoplasm

 Symptoms
 Nausea, intractable vomiting, food fear, deterioration in
nutrition

 Operability
 60 % in gastric cancer, 5-20 % in pancreatic cancer
 Palliation
 Surgical palliation (gastrojejunostomy)
• Mortality: 8-18 % in gastric cancer, 10-14 % in
pancreatic cancer
• Remission of Sx: 50 % (-90%)
• Prolonged hospitalization (mean, 15 days)
 Non-surgical palliation with feeding tube
• Constant reminder of disease
 Metallic stent placement
  Technical and clinical results
Patients/reference
%
population n
Technical success (successful stent
589/606 97
placement and deployment)
Technical failure 17/606 3
Clinical success following technical
success group (relief of symptoms and/or 529/589 89
improved food intake)
Clinical failure following technical success 65/589 11
Time to final resolution of symptoms
3.7 (1-7)
(days; mean, range)
Mean survival (weeks) 12.1
Dormann A, et al. Endoscopy 2004
 Enteral or parenteral feeding
 Inadequate oral intake more than 7-14 days

 TPN
 Nasogastric tube
 Gastrostomy (gastrojejunostomy)
• Preferred method of nutritional support in
malnourished patients with an intact GI tract
 Enteric access for patients with
inadequate oral intake
 Surgical gastrostomy
• Verneuii in 1876
 Percutaneous endoscopic gastrostomy (PEG)
• Gauderer MWL and Ponsky JL in 1980
 Percutaneous radiologic gastrostomy (PRG)
• Preshaw RM in 1981
 Indication
 Nutritional support in pts who cannot ingest
nutrient normally
• Neurologic disease (stroke, traumatic brain injury)
• Ca. of head and neck
• Psychiatric disorder (anorexia nervosa, depression..)
• Debilitated patient with inadequate oral intake
• Amyotrophic lateral sclerosis
 Enteric decompression
• Gastric outlet obstruction, chronic GI obstruction
• Diabetic gastropathy
 Contraindication
 Absolute CIx
• Uncorrectable bleeding diathesis
• Gastric varix
• Ventriculoperitoneal shunt
• Short life expectant (<30 days)
 Relative CIx
• Ascites, GE reflux, Inflammation or tumor
Pigtail-retained catheter
(10-14 F)

Balloon-retained catheter
(14-18 F)

Mushroom-retained catheter
(>20F)
 Air insufflation by L-tube or angiographic catheter
(over 500cc) until adequate distension
 Distal body of the stomach
 Equidistance from greater and lesser curvature
 Lateral to the rectus muscle or midline
 Avoid epigastric artery puncture

★
★
 18-G puncture needle
 Puncture on lateral fluoroscopy
 Gastrostomy: vertically or toward the fundus
 Gastrojejunostomy: toward the pylorus
 Pigtail-retained catheter (12-14F)
 Pigtail-retained catheter (12-14F)
 After care
 Careful follow-up for bleeding, peritonitis
 Tube feeding 12-24 hrs after procedure
 Release anchor suture 2 weeks after catheter
insertion
 Tube exchange in pigtail-retained tube: every
6 months
 Results
 Technical success rate: 95%-100%
 Major complication: 0.5-6%
• Bleeding, peritonitis, aspiration, sepsis
 Minor complication: 2.9-12%
• Pain /s peritoneal sign, clogging of the tube,
catheter dislodgement, wound infection, benign
pneumoperitoneum
 Rare complication
• Cologastric fistula, liver laceration, deep puncture
(pancreas, spleen, aorta, ect)
 장점
 최소 침습적
 시술이 간단
 회복시간이 매우 짧다
 치료비 저렴
 재발시 재시술 혹은 수술