Transcript
Incomplete Hemostasis of High-Risk Adverse Outcome Bleeding Lesions After Placement of the Over the Scope Clip: Causes and Solutions
High-Risk Adverse Outcome (HR_AO) bleeding lesions:
Large vessels or high-risk stigmata within deep or fibrotic ulcer in the distribution of major arteries.
High risk for adverse events during or after endoscopic treatment
Endoscopic treatment of HR-AO has a high-risk of failure. Rebleeding has high morbidity and mortality.
New data showed the safety and efficacy of the over the scope clip, but there is a 5% failure.
We wish to share cases that illustrates the causes and solutions of failures
Based on our collective experience, we found three general patterns of causes of failure:
- Delayed clip closure
- Shallow clip deployment
- Misplaced clip placement
We will now shareexamples of delayed closure of a large artery bleeding.
This patient with bleeding gastric Dieulafoy’s was referred to us after standard therapy was unsuccessful.After removal of the previously placed clips, we deployed the over the scope clip way under the vessel. Although deployment was ideal, the bleeding did not stop. Viewing of the bleeding artery showed a large-diameter artery. In this case, we decided to use additional hemostasis technique using coaptive coagulation. Bleeding was controlled more than 5 minutes clip placement. There was no further bleeding.
We will now share examples of shallow clip deployment
After encountering the fresh fibrin clot in the bulb, we rapidly equipped our therapeutic endoscope with the over the scope clip. The ulcer was large but appeared pliable enough to be suctioned into the cap. We thus decided to deploy the clip without additional accessory such as the triprong.It was however not adequate. There was continuing bleeding after deployment of the clip. Evaluation showed that the clip was placed too shallow. The bleeding artery could be seen under the artery. In this case, we injected diluted epinephrine in order to slow down the bleeding. We then sprayed hemostatic powder. There was no further bleeding.
Here is another case of shallow clip deployment due to inadequate suction. A large fibrin clot was found in the duodenal bulb of this patient with massive bleeding. The therapeutic endoscope was equipped with the over the scope clip. The cap appeared the right size and was easily positioned over the clot.
Suction was applied. The clot however was dislodged and went into the suction channel. Thus, there was a temporary decrease in vacuum. The clip was released at this time. Clipping was placed too superficially.
The bleeding artery could be seen behind or below the clip. The clip was unlikely to be effective and was therefore removed using a rat tooth. The endoscope was equipped with a new over the scope clip and the bleeding artery was suctioned well into the cap. The clip was released. There was no further bleeding.
Clip can be misplaced because of difficult anatomy, poor visualization and unstable endoscope position.
This elderly patient presented with hematemesis and melena after taking a large amount of NSAIDS. A large fibrin clot with an underlying pulsating vessel was found in the duodenal bulb. The distal bulb appeared narrowed and prevented the cap to be approximated to the ulcer base. We thus used the triprong. The triprong was opened and the ulcer base was pulled towards the endoscope. Suction was applied. The clip was released. Massive bleeding however ensued.
Pulsating bleeding could be appreciated from below the clip.
We kept suctioning the blood while preparing a regular therapeutic endoscope to be equipped with an over the scope clip. This medium sized clip could be passed beyond the narrowed area. And, we deployed the second clip slightly distally to the first one and using it to guide our position. Clip placement was ideal and there was no further bleeding.
In conclusions, hemostasis after the over the scope clip may be incomplete because of a number of reasons. The artery could be too large; the ulcer base could be too fibrotic; the clip could be placed too shallow or even misplaced. A number of techniques can be useful to mitigated incomplete hemostasis.