Clinical outcomes of transcatheter arterial embolization in patients with angiography-negative duodenal ulcer bleeding after failed endoscopic hemostasis

BACKGROUND: Duodenal ulcer bleeding is a common cause of non-variceal upper gastrointestinal bleeding. Although endoscopic hemostasis is recommended as the first-line treatment, a subset of patients experience failure of endoscopic therapy and require further intervention, for which transcatheter arterial embolization (TAE) has become a commonly used salvage treatment. In clinical practice, however, angiography may fail to demonstrate definite active bleeding, posing challenges for subsequent therapeutic decision-making. Under such circumstances, empiric embolization is frequently performed, yet its clinical outcomes have not been systematically evaluated. METHODS: This two-center retrospective observational study included 31 patients who underwent TAE for duodenal ulcer bleeding after failed endoscopic hemostasis between January 2017 and November 2024 and showed no definite evidence of active bleeding on angiography. Clinical characteristics, endoscopic findings, interventional procedures, and clinical outcomes were retrospectively reviewed. The primary outcome was initial clinical hemostasis following TAE, while secondary outcomes included early rebleeding, delayed rebleeding, 30-day bleeding-related mortality, 30-day non-bleeding-related mortality, and 90-day all-cause mortality. RESULTS: Among the 31 patients included, initial clinical hemostasis was achieved in 25 (80.6%). Early rebleeding occurred in 1 patient (3.2%), and delayed rebleeding was observed in 5 patients (16.1%). The 30-day bleeding-related and non-bleeding-related mortality rates were 12.9% (4/31) and 6.5% (2/31), respectively, and the 90-day all-cause mortality was 25.8% (8/31). No major embolization-related complications, such as bowel ischemia or pancreatitis, were observed. Subgroup analysis showed that the initial hemostasis rate was significantly higher in the coil-plus-cyanoacrylate group than in the coil-only group (95.0% vs. 54.5%, P = 0.013), while 30-day bleeding-related mortality was numerically lower (5.0% vs. 27.3%, P = 0.115), though this difference did not reach statistical significance. CONCLUSIONS: For patients with angiography-negative duodenal ulcer bleeding after failed endoscopic hemostasis, TAE appears to be a feasible and safe salvage option. These preliminary findings suggest that empiric embolization may achieve effective bleeding control even in the absence of definite angiographic evidence of active bleeding. An exploratory subgroup analysis suggested that the choice of embolic material may influence early hemostatic outcomes, warranting further prospective investigation.