EUS-guided transesophageal treatment of gastric fundal varices with combined coiling and cyanoacrylate glue injection (with videos)

doi:10.1016/j.gie.2011.06.030

Gastrointestinal Endoscopy

Volume 74, Issue 5, November 2011, Pages 1019-1025

https://doi.org/10.1016/j.gie.2011.06.030 Get rights and content

Background

There have been numerous reports of glue embolization after endoscopic cyanoacrylate (CYA) glue treatment of gastric fundal varices (GFV), with some cases fatal. Coils with attached synthetic fibers may decrease or eliminate this risk and may decrease the amount of CYA needed to achieve obliteration.

Objective

Assess the feasibility, safety, and outcomes of transesophageal EUS-guided therapy of GFV with combined coil and CYA injection.

Design

Retrospective query of a prospectively maintained database.

Setting

Tertiary care medical center.

Patients

Patients with hemorrhage from large GFV.

Intervention

A standardized approach by using EUS-guided coil and CYA treatment.

Main Outcomes Measurements

Hemostasis, rebleeding rate, complications.

Results

Thirty patients with GFV were treated between March 2009 and January 2011. At index endoscopy, 2 patients had active hemorrhage and 14 had stigmata of recent hemorrhage. EUS-guided transesophageal treatment of GFV was successful in all. Mean number of GFV treated was 1.3 per patient, and the mean volume of 2-octyl-CYA injected was 1.4 mL per varix. Hemostasis of acute bleeding was 100%. Among 24 patients with a mean follow-up of 193 days (range 24-589 days), GFV were obliterated after a single treatment session in 23 (96%). Rebleeding occurred in 4 patients (16.6%), with none attributed to GFV. There were no procedure-related complications and no symptoms or signs of CYA embolization.

Limitations

Single-center, pilot study.

Conclusion

Transesophageal EUS-guided coil and CYA treatment of GFV is feasible and deserves further study to determine whether this novel approach can improve safety and efficacy over standard endoscopic injection of CYA alone.

Section snippets

Patients

Our center has offered CYA injection for bleeding GFV since March 2002 under a U.S. Food and Drug Administration investigational device exemption and is a regional referral center for this type of therapy. After encountering one CYA failure in which emergent EUS-guided coiling (performed with consultative input from our interventional radiology service) was needed for hemostasis,¹⁷ we have offered combined EUS-guided coil and CYA treatment for patients referred for gastric variceal hemorrhage.

Results

Thirty patients with bleeding from GFV were treated between March 2009 and February 2011. Patient characteristics and endoscopic findings are summarized in Table 1. In 93% of patients, only 1 coil was used. Patients with acute or recent (<1 week) bleeding were hospitalized and taking octreotide at time of treatment; the remaining were outpatients (n = 10). Fifteen patients (48%) were taking beta-blockers and maintained this therapy during the follow-up period.

GFV were well visualized

Discussion

Endoscopic CYA injection of GFV has demonstrated higher hemostasis and lower rebleeding rates compared with band ligation or sclerotherapy.2, 3, 20 Delivery of CYA under EUS guidance has been previously reported and has the advantages of enabling precise delivery of glue into the varix lumen and confirmation of vessel obliteration with Doppler.6, 7 Romero-Castro et al⁷ reported on EUS-guided injection of CYA into gastric varices in 5 patients. The authors targeted the perforating vein by using

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: DISCLOSURE: The authors disclosed no financial relationships relevant to this publication.

: If you would like to chat with an author of this article, you may contact Dr. Binmoeller at [email protected].

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Original articleClinical endoscopyEUS-guided transesophageal treatment of gastric fundal varices with combined coiling and cyanoacrylate glue injection (with videos)

Background

Objective

Design

Setting

Patients

Intervention

Main Outcomes Measurements

Results

Limitations

Conclusion

Section snippets

Patients

Results

Discussion

Am J Gastroenterol

Hepatology

Gastrointest Endosc

Gastrointest Endosc

Baillieres Best Pract Res Clin Gastroenterol

Gastrointest Endosc

Mayo Clin Proc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Original article
Clinical endoscopy
EUS-guided transesophageal treatment of gastric fundal varices with combined coiling and cyanoacrylate glue injection (with videos)