Bariatric embolization An emerging minimally invasive therapy


for patients with obesity By Frank Yuan, MD, Clifford R. Weiss, MD, FSIR


S


subcutaneous adiposity, suppress fundal ghrelin-producing cellular expression and increase levels of glucagon-like peptide 1 (GLP-1), peptide YY (PYY), and leptin (anorexigenic hormones) in both animal and human studies.13–23


ince the late 1970s, the prevalence of obesity in the United States has been growing at an alarming rate. Based on


the latest epidemiological data reported by the Centers for Disease Control and Prevention, an estimated 42.4% of adults and 18.5% of children in the U.S. are obese.1,2


Obesity is a multiorgan,


systemic metabolic disease and patients face increased risk for over a dozen severe chronic co-morbidities, including type-2 diabetes mellitus (T2DM), cardiovascular disease, degenerative joint disease, stroke, fatty liver disease, renal microvascular diseases, obstructive sleep apnea, polycystic ovarian syndrome, psychiatric disturbances and some forms of cancers.3–12


Historically, therapeutic strategies for patients with obesity have consisted of behavioral, pharmacologic and surgical approaches to induce and sustain weight loss. With advancements in imaging technology during the past decade, endovascular and endoscopic techniques have emerged that demonstrate promising weight-loss efficacy in animals and early-phase human clinical trials.


1969


The catheter-delivered stenting technique and prototype stent is created.


What is bariatric embolization? Bariatric embolization (BE) is an emerging, minimally invasive weight- loss procedure for patients with obesity. During BE, embolic microspheres are delivered under imaging guidance via a catheter directly into the arteries supplying the gastric fundus, an area where most ghrelin-producing X/A-like endocrine cells reside. The vascular supply to the gastric fundus from the left gastric artery (LGA) and left gastroepiploic artery (LGEA) are distinct and identifiable and are accessed using a percutaneous approach.


Embolization induces fundal oxyntic mucosal ischemia, suppresses orexigenic hormone (ghrelin) production and presumably reduces feeding behavior to induce weight loss. The upper gastrointestinal tract’s rich collateral supply allows for continued but lowered perfusion to the gastric fundus, preventing necrosis and perforation. Although the exact mechanism is unknown, decreased perfusion is believed to partially defunctionalize the stomach, possibly reducing ghrelin production. Similar to bariatric surgery, bariatric embolization has been reported to induce weight loss, decrease


1970


• Percutaneous removal of common bile duct stones


• Occlusive coils. 1971 This year marked the introduction of:


The origin of BE and embolic development The concept of using LGA embolization to achieve weight loss originated from observational studies of patients with gastrointestinal bleeding, who were treated with LGA embolization and had follow-up evaluations demonstrating varying degrees of weight loss.22–25


In the early 2000s, Arepally et al. conducted the first pre-clinical study of BE by injecting a liquid embolic agent into the gastric arteries of growing swine and reported suppression of serum ghrelin levels and a postprocedural reduction in animal weight gain not observed in control animals. Since precise targeting of the liquid embolic agent was clinically unachievable, subsequent pre-clinical studies focused on the use of particle embolics to minimize risks associated with nontarget embolization.


Bawudun et al.13 investigated


BE-induced weight loss in obese canines by comparing mixed sclerosant (bleomycin/lipiodol) vs. a large-particle embolic (500–700 m PVA). After BE with the particle embolic, dogs showed decreases in body weight and plasma ghrelin levels, with a reduction in subcutaneous adiposity as assessed by computed tomography (CT). To achieve distal penetration comparable to the original liquid sclerosant, Paxton et al.26


investigated 1972


Selective arterial embolization for GI bleeding is adapted to treat massive bleeding in other arteries in the body and to block blood supply to tumors.


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