2.1 Patient characteristics.
This retrospective study was conducted in Shanghai Eastern Hepatobiliary Surgery Hospital. The ethics committee approved the study (approval number: EHBHKY2022-K-024). Because of the retrospective nature of this study, no patient informed consent was required. Between September 2015 and June 2021, 19 patients who underwent angiography to manage suspected DAH after operation for cholangiolithiasis were identified in our prospective database. DAH was identified in 15 patients on angiogram, and these patients were enrolled in this study.
2.2 Interventional procedures.
Diagnostic. Endovascular procedures were performed by one of six experienced abdominal interventional radiologists. A 5F introducer sheath (Terumo Corp., Tokyo, Japan) was inserted through the common femoral artery under local anaesthesia. Angiography of the coeliac trunk and the superior mesenteric artery (SMA) was then routinely performed to detect bleeding using a 5F angiographic catheter (RH: Hanaco Medical Co., Tianjin, China; Yashiro: Terumo Corp., Tokyo, Japan). The branches of the celiac axis were selectively catheterized using a 5F catheter or a 2.8-F microcatheter (Boston Scientific, Natick, MA, USA) when no bleeding was found. Signs of the target vessel on the angiogram included contrast media extravasation, a pseudoaneurysm, and stenosis/irregularity.
Covered stent implantation. After localization of the site of hemorrhage, the diameter of the affected vessel was measured. With appropriate technique, the 5F sheath was replaced by a 8F vascular sheath (Terumo Corp., Tokyo, Japan), then covered stent (Fluency Plus, C.R. Bard Company, Franklin Lakes, NJ, USA) was negotiated into the target artery over a 0.035-inch/260-cm stiff guidewire (Boston Scientific, Marlborough, MA, USA). Proper localization of the stent was determined immediately before stent deployment with control angiograms and the graft was deployed. The stent graft was advanced through the vascular sheath and centered on the site of the target artery.
Embolization. Embolization was performed after selective catheterization with the above mentioned microcatheter. Microcoils (Tornado Embolization Microcoil™, Cook Medical, Bloomington, IN, USA), interlock microcoils (Interlock™ Fibered IDC™ Occlusion System, Boston Scientific, Cork, Ireland), gelatin sponge particles ( Gel Foam, Alicon Pharm., Hangzhou, China), microspheres (Embosphere, Merit Medical Systems, South Jordan, UT, USA), and/or N-butyl cyanoacrylate ( NBCA, Compoint medical devices company, Beijing, China; mixed with ethiodized oil at a ratio of 1:1-1:3) were used as embolic agents. Their selection was mainly based on preference of the operator, and many other factors, such as microcatheter location, vessel size, and coagulation profile of the patient influenced the selection of the agents.
At the end of the covered stent placement or embolization, repeat angiography was performed to confirm cessation of bleeding of the targeted artery. The puncture site was closed with an arterial closure devise or manually compressed.
2.3 Definitions.
Technical success was defined as the exclusion of the bleeding focus with no evidence of active bleeding on a completion angiogram. Clinical success was defined as the cessation of signs or symptoms of abdominal bleeding and no requirement for additional procedures (e.g., surgery, endoscopy, or EVT) within 30 days of the EVT. Major complications of EVT were classified as a serious adverse event (grades 3–6) according to the reporting standards of the Cardiovascular and Interventional Radiological Society of Europe. Hepatic failure was defined as jaundice (serum bilirubin ≥85umol/L) and coagulopathy (international normalized ratio [INR]≥1.5 or prothrombin activity≤40%) complicated by ascites and/or encephalopathy.15