Endoscopic ultrasound-guided angiotherapy in refractory gastrointestinal bleeding from large isolated gastric varices: a same-session combined approach

A 36-year-old Asian man with severe portal hypertension due to hepatitis B virus-related cirrhosis had been previously treated for acute gastrointestinal bleeding from a large isolated gastric varix (IGV-1) by injection of endoscopic cyanoacrylate glue at a local hospital ([Fig. 1]). Following an episode of massive recurrent hematemesis, the patient was hemodynamically stabilized and referred to our institute. Radiological evaluation revealed the presence of numerous collaterals in the gastric fundus with a large-caliber splenorenal shunt.

Fig. 1 Endoscopic view of a large isolated gastric varix (IGV-1) with signs of recent glue injection.

With the patient under general anesthesia, it was found that the portal gradient did not decrease significantly with a transjugular intrahepatic portosystemic shunt (TIPS) positioned across the left hepatic and left intrahepatic veins [1], confirming that blood outflow was predominantly diverted towards the shunt ([Fig. 2 a]). We then decided to use a same-session combined technique involving balloon-occluded retrograde transvenous obliteration (B-RTO) of the left renal vein [2] and selective endoscopic ultrasound (EUS)-guided variceal embolization [3] [4] by coils and n-butyl-2-cyanoacrylate (CYA) injection.

Fig. 2 Radiographic images showing: a contrast medium injected via a catheter inserted through the transjugular intrahepatic portosystemic shunt (TIPS) into the splenic vein, which confirmed portal outflow in the direction of a large splenorenal shunt (asterisk); b a balloon-occlusion catheter (asterisk) that had been advanced through the internal jugular access and positioned in the left renal vein to give protective closure of the efferent limbs of gastric varices; c EUS-guided selective embolization, with spiral coils (from 4 – 8 cm in length) having been selectively released according the size and axis of the gastric varix.

A B-RTO was performed to obliterate the left renal vein before EUS-guided selective treatment in order to protect the pulmonary circulation from systemic embolization ([Fig. 2 b]). Gastric varices (IGV-1) were then visualized from the stomach with a linear-array echoendoscope. Selective EUS-guided intravascular puncture was performed with a 22-gauge fine needle aspiration (FNA) needle (EZ Shot 3 Plus; Olympus Europe) and three 0.018-inch coils (MReye Embolization Coil; Cook Medical) were released through the needle under EUS and fluoroscopic control ([Video 1]), the endovascular coils being advanced into the targeted vessel using the pushing action of the stylet. Following the complete deployment of each coil, 1 mL of CYA, 3 mL of Lipiodol, and 10 mL of 5 % glucose solution were injected through the needle into the varix creating a full thrombosis. We released a total of three coils ([Fig. 2 c]) with complete variceal embolization as confirmed by a negative color Doppler scan. No adverse events or rebleeding had been reported at 12 months of follow-up.

Video 1 Refractory bleeding from isolated gastric varices is successfully treated in a same-session combined approach using transjugular intrahepatic shunt (TIPS) placement, balloon-occluded retrograde transvenous obliteration (B-RTO), and endoscopic ultrasound (EUS)-guided variceal embolization by coils and cyanoacrylate glue injection.

EUS-guided coil placement with CYA injection is a feasible and effective additional procedure following TIPS placement in selected patients with severe portal hypertension and refractory bleeding from large IGV-1 varices.

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• References

• 1 Garcia-Tsao G, Abraldes JG, Berzigotti A. et al. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology 2017; 65: 310-335
• 2 Sabri SS, Saad WE. Balloon-occluded retrograde transvenous obliteration (BRTO): Technique and intraprocedural imaging. Semin Intervent Radiol 2011; 28: 303-313
• 3 Bhat YM, Weilert F, Fredrick RT. et al. EUS-guided treatment of gastric fundal varices with combined injection of coils and cyanoacrylate glue: a large U.S. experience over 6 years (with video). Gastrointest Endosc 2016; 83: 1164-1172
• 4 Weilert F, Binmoeller KF. Cyanoacrylate glue for gastrointestinal bleeding. Curr Opin Gastroenterol DOI: 10.1097/MOG.0000000000000294.