Provocative Mesenteric Angiography: Safety and Efficacy in Occult GI Bleeding

Provocative Mesenteric Angiography: Safety and Efficacy in Occult GI Bleeding

This episode tackles one of the most frustrating clinical challenges in Interventional Radiology: the patient with a recurrent occult GI bleed who has failed endoscopy and standard imaging. We analyze the largest retrospective cohort study to date (22 years of data) on TPA-based Provocative Mesenteric Angiography (PMA) to determine when to use this aggressive diagnostic maneuver.

• The Safety Surprise: Despite intentionally provoking bleeding with TPA and Nitroglycerin, the study revealed zero major bleeding adverse events, thanks to "first-pass hepatic metabolism" clearing the drugs before they hit the systemic circulation.

• The "Secret Sauce" for Selection: We identify the two independent predictors that increase the odds of a positive study by nearly sevenfold:

  • Hematochezia (bright red/maroon stool).

  • A Prior Positive Radiologic Study (CTA or Tagged RBC), even if the bleed appeared to stop.

• The Hard Stop: The data provides a clear exclusion criterion: zero patients with Melena (black tarry stool) and negative prior imaging had a positive PMA result, suggesting these procedures are likely futile.

• Technical Mastery: Success relies on super-selectivity. Injecting from a distal, third-order vessel yielded a 63.6% positivity rate, compared to just 21.5% from a proximal injection.

Tune in to learn how to safely provoke the bleed on your terms and identify the source when all other methods fail.

Find the Article Here: https://www.jvir.org/article/S1051-0443(25)00444-0/abstract