Prophylactic transarterial embolization in patients with bleeding peptic ulcers following endoscopic control of bleeding.

Background: Bleeding peptic ulcer is a serious condition that often requires immediate endoscopic or surgical intervention to stop the bleeding (haemostasis). Following haemostasis, patients are at risk of rebleeding, leading to reintervention and risk of morbidity or mortality. In order to prevent rebleeding and associated complications, prophylactic measures have been developed and investigated. Prophylactic transarterial embolization (TAE), where the blood vessel leading to the site of the bleeding ulcer is closed via embolization (e.g. using coils to stop blood flow), has emerged as a potential therapeutic approach to address this challenge. However, a comprehensive evaluation of its efficacy and impact on patient outcomes is essential.

Objectives: To assess the effects of prophylactic transarterial embolization after successful endoscopic treatment compared with endoscopic haemostasis only on the risk of rebleeding after bleeding peptic ulcer, in patients where endoscopic haemostasis has been successful.

Search methods: In August 2023 we searched CENTRAL, MEDLINE, Embase, PubMed Central, Clinicaltrials.gov and the International Clinical Trials Registry Platform (ICTRP). There were no language or publication status constraints.

Selection criteria: This review included prospective randomized controlled trials that evaluated prophylactic TAE in patients with bleeding peptic ulcers. The selection process involved meticulous screening, full-text reviews, and considerations of study design, intervention, and patient populations.

Data collection and analysis: Two review authors extracted data and conducted risk of bias assessments. The outcomes of interest were rebleeding within 30 days, need for reintervention within 30 days, 30-day mortality, complications within 30 days, duration of hospitalization and success rate of the embolization. We contacted authors of included studies for missing and more detailed data, allowing us to carry out sensitivity analyses. We used GRADE to assess the certainty of evidence.

Main results: The review includes two studies involving 346 participants. Prophylactic TAE may not reduce the odds of rebleeding within 30 days (odds ratio (OR) 0.58, 95% confidence interval (CI) 0.18 to 1.83; 2 studies, 346 participants; low-certainty evidence). There may be little or no effect on reintervention rates per event (OR 0.68, 95% CI 0.35 to 1.35; 2 studies, 346 participants; low-certainty evidence) or per participant (OR 0.65, 95% CI 0.25 to1.69; 2 studies, 346 participants; low-certainty evidence), and there may be no reduction in 30-day mortality (OR 0.41, 95% CI 0.14 to 1.21; 2 studies, 346 participants; low-certainty evidence). Unfortunately, we were unable to analyze complications other than rebleeding, reintervention and mortality, as data for these outcomes were not available in the included studies. The duration of hospitalization may be shorter for participants undergoing prophylactic TAE (mean difference (days) -2.41, 95% CI -4.06 to -0.76; 2 studies, 346 participants; low-certainty evidence). Overall, the risk of bias in the included studies was low, but there was a high risk of performance bias and detection bias as none of the included studies were blinded. Further, one study had a high risk of selection bias as the randomization lists were created by the primary investigator.

Authors' conclusions: In conclusion, there is low-certainty evidence that prophylactic TAE may not reduce the odds of rebleeding, reintervention or mortality for participants following peptic ulcer bleeding. It may, however, reduce the duration of hospitalization. Ultimately, due to the limited number of studies and participants, further research with larger populations is warranted to validate these findings and explore additional outcomes, including adverse events other than rebleeding, reintervention and mortality.