Patient: The patient was a 45-year-old man with a body mass index of 19.8 kg/m2.
Past history: Dilated cardiomyopathy and placement of a cardiac resynchronization therapy-defibrillator (CRTD).
Oral medication history: Antihypertensive drug, diuretic.
During the previous several months, the patient had experienced epigastric discomfort. He had an episode of presyncope after a meal and was transported to our hospital by ambulance. On presentation, the patient's blood pressure was 82/64 mmHg, heart rate 140/min, SpO2 98% (room air), and consciousness level GCS E4V5M6. Ejection fraction (EF) was determined on an echocardiogram and found to be 20%. Although tachycardia and decreased blood pressure were seen, hemodynamics stabilized rapidly with a transfusion of <1,000 mL fluid that was administered on an emergency basis. A blood sample showed mild anemia (Hb, 11.5 g/dL) but no other significant findings. Although contrast computed tomography (CT) showed an irregularity in part of the wall of the descending portion of the duodenum, no perforation or extravasation was seen. There were no other significant findings in the head or chest. The patient was admitted to thoroughly investigate the presyncope episode, and the planned endoscopy was scheduled the following day.
Although the patient's vital signs were stable after admission, blood collected on the day after admission showed worsening anemia (Hb, 7.6 g/dL). Duodenal hemorrhage was suspected based on the patient's clinical course, and upper gastrointestinal endoscopy was scheduled the following day due to gastric fullness (Supplementary Figure 1). However, the patient had an episode of presyncope before the endoscopic examination was performed, and an emergency call was placed in the general ward. When examined by the physician, the patient was found to be in shock, and emergency transfusion was started immediately. However, the patient went into cardiac arrest. Although a spontaneous heartbeat was restored with cardiopulmonary resuscitation, the patient's hemodynamics were unstable. Because a large volume of bloody drainage was seen from the nasogastric tube that had been inserted, the cause of the cardiac arrest was concluded to be upper gastrointestinal hemorrhage, and a decision was made to perform emergency hemostasis. However, the emergency blood transfusion administered by pumping barely produced pulse pressure. Consequently, there was not sufficient time to proceed to a CT examination. Placement of a REBOA device was therefore planned to temporarily stabilize the patient's hemodynamics.
The patient was moved to a fluoroscopy room as resuscitation was continued. A REBOA device (Rescue Balloon ER , Tokai Medical Products, Kasugai, Japan) was then inserted via the left femoral artery and placed in zone I (region between the left subclavian artery and the celiac artery). Blood pressure increased transiently due to inflation of the REBOA balloon. Vascular embolization was planned as the hemostasis procedure, and it was determined that it would be performed in the fluoroscopy room. A 4-Fr sheath was placed contralaterally via the right femoral artery. Imaging was performed via the celiac and superior mesenteric arteries, and extravasation was seen from the gastroduodenal artery to within the duodenum (Figure 1A). Isolation of the hemorrhage site by coil embolization was then planned. The gastroduodenal artery was embolized using 11 ionization coils (Target Detachable Coil , Stryker, Tokyo, Japan). During the embolization procedure, the transfusion rate was adjusted to manage hemodynamics as appropriate, while ischemia distal to the REBOA device was prevented by deflating the REBOA balloon. Angiography performed after embolization showed that the extravasation had nearly disappeared (Figure 1B). Moreover, no marked decrease in blood pressure was seen when the REBOA balloon was completely deflated. After completion of the embolization procedure, imaging is performed via the superior mesenteric artery with the REBOA balloon deflated. The ischemic area associated with embolization was confirmed to be small (Figure 1C), and there were no significant complications. The procedure was therefore completed, and the patient was returned to the intensive care unit (ICU). The transfusion required to maintain circulation from resuscitation to the end of the embolization procedure used 26 units of RBCs and 16 units of fresh frozen plasma (FFP).
After the patient returned to the ICU, there were no findings suggestive of recurrent bleeding, and hemodynamics were stable. Although the patient had a past history of dilated cardiomyopathy and was therefore weaned from mechanical ventilation carefully, mechanical ventilation was withdrawn without incident on day 8 of his illness. Upper gastrointestinal endoscopy performed on day 11 of hospitalization showed an ulcer in the anterior wall of the duodenal bulb and coil extrusion but no bleeding (Figure 2). Oral food intake was subsequently started, and the patient was able to walk without assistance at discharge and had no neurological sequelae.