Endoscopic ultrasound-guided treatment of gastric varices with coil embolization and absorbable hemostatic gelatin sponge: a novel alternative to cyanoacrylate

Abstract

Background and study aims Bleeding from gastric varices (GV) carries high morbidity and mortality. Current endoscopic therapies are premised on cyanoacrylate injection which is technically challenging and carries risk of embolization. We present a case series of endoscopic ultrasound (EUS)-guided coil injection in combination with hemostatic absorbable gelatin sponge (AGS) for treatment of bleeding gastric varices.

Patients and methods This was a retrospective review of EUS-guided coil injection for bleeding GV since November 2017. After EUS-guided needle puncture, hemostatic coils were serially injected until significant reduction of Doppler flow. Under fluoroscopic guidance, test contrast was injected to confirm absence of run-off, at which time AGS, converted into a liquid slurry, was injected as hemostatic reinforcement.

Results Ten consecutive patients underwent EUS-guided coil embolization reinforced by AGS. Technical success, defined as uncomplicated injection of coils and sponge was achieved in 100 % (10/10). Mean follow-up was 6 months 73–397 days; No patients rebled or required reintervention on GV. The complication rate was 10 % (1/10; severe abdominal pain without radiographic findings); otherwise, there were no cases of systemic embolization. Nine of 10 patients (90 %) had follow-up EUS (mean 80 days); 100 % (9/9) revealed near-obliteration of GV.

Conclusion EUS-guided coil embolization in combination with hemostatic AGS is a novel method for management of bleeding GV with high clinical and technical success rates, low risk for complications and favorable safety profile when compared to cyanoacrylate. This technique theoretically minimizes embolic complications and need for re-intervention. Further studies are required to compare this modality.

• References

• 1 Garcia-Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med 2010; 362: 823-832
• 2 Wani ZA, Bhat RA, Bhadoria AS. et al. Gastric varices: Classification, endoscopic and ultrasonographic management. J Res Med Sci 2015; 20: 1200-1207
• 3 Soehendra N, Nam VC, Grimm H. et al. Endosopic obliteration of large esophagogastric varices with bucrylate. Endoscopy 1986; 18: 25-26
• 4 Ramond MJ, Valla D, Gotlib JP. et al. Endoscopic obturationof esophagogastric varices with bucrylate. I. Clinical study of 49 patients. Gastroenterol Clin Biol 1986; 10: 575-579
• 5 Iwase H, Maeda O, Shimada M. et al. Endoscopic ablation with cyanoacrylate glue for isolated gastric variceal bleeding. Gastrointest Endosc 2001; 53: 585-592
• 6 Sarin SK, Jain AK, Jain M. et al. A randomized controlled trial of cyanoacrylate versus alcohol injection in patients with isolated fundic varices. Am J Gastroenterol 2002; 97: 1010-1015
• 7 Cheng LF, Wang ZQ, Li CZ. et al. Treatment of gastric varices by endoscopic sclerotherapy using butyl cyanoacrylate: 10 years' experience of 635 cases. Chin Med J (Engl) 2007; 120: 2081-2085
• 8 Fry LC, Neumann H, Olano C. et al. Efficacy, complications and clinical outcomes of endoscopic sclerotherapy with N-butyl-2-cyanoacrylate for bleeding gastric varices. Dig Dis 2008; 26: 300-303
• 9 Dhiman RK, Chawla Y, Taneja S. et al. Endoscopic sclerotherapy of gastric variceal bleeding with N-butyl-2-cyanoacrylate. J Clin Gastroenterol 2002; 35: 222-227
• 10 Kok K, Bond RP, Duncan IC. et al. Distal embolization and local vessel wall ulceration after gastric variceal obliteration with N-butyl-2-cyanoacrylate: a case report and review of the literature. Endoscopy 2004; 36: 442-446
• 11 Rickman OB, Utz JP, Aughenbaugh GL. et al. Pulmonary embolization of 2-octyl cyanoacrylate after endoscopic injection therapy for gastric variceal bleeding. Mayo Clin Proc 2004; 79: 1455-1458
• 12 Robles-Medranda C, Valero M. et al. Endoscopic-ultrasound guided coil and cyanoacrylate embolization for gastric varices and the roles of endoscopic Doppler and endosonographic varicealography in vascular targeting. Dig Endosc 2019; 31: 283-290
• 13 Bhat YM, Weilert F, Fredrick RT. et al. EUS-guided treatment of gastric fundal varices with combined injection of coils and cyanoacrylateglue: a large U.S. experience over 6 years (with video). Gastrointest Endosc 2016; 83: 1164-1172
• 14 Lôbo MRA, Chaves DM, DE Moura DTH. et al. Safety and efficacy of EUS-guided coil plus cyanoacrylate versus conventional cyanoacrylate technique in the treatment of gastric varices: a randomized controlled trial. Arq Gastroenterol 2019; DOI: 10.1590/S0004-2803.201900000-08. [E-pub ahead of print]
• 15 Lee EW, Saab S, Gomes AS. et al. Coil-assisted retrograde transvenous obliteration (CARTO) for the treatment of portal hypertensive variceal bleeding: preliminary results. Clin Translat Gastroenterol 2014; 5: e61
• 16 Council on Pharmacy and Chemistry. Absorbable Gelatin sponge — new and nonofficial remedies. JAMA 1947; 135: 921
• 17 Jenkins HP, Senz EH, Owen H. et al. Present status of gelatin sponge for control of hemorrhage. JAMA 1946; 132: 614-619
• 18 Sarin SK, Lahoti D, Saxena S. et al. Prevalence, classification and natural history of gastric varices: A long-term follow-up study in 568 portal hypertension patients. Hepatology 1992; 16: 1343-1349
• 19 Seewald S, Leong T, Imazu H. et al. A standardized injection technique and regimen ensures success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices. Gastointest Endosc 2008; 68: 447-454
• 20 Wang YM, Cheng LF, Li N. et al. Study of glue extrusion after endoscopic N-butyl-2-cyanoacrylate injection on gastric vari- ceal bleeding. World J Gastroenterol 2009; 15: 4945-4951
• 21 Joo HS, Jang JY, Eun SH. et al. Long-term results of endo- scopic histoacryl (N-butyl-2-cyanoacrylate) injection for treat- ment of gastric varices: a 10-year experience. Korean J Gastroenterol 2007; 49: 320-326
• 22 Ge PS, Bazarbashi AN, Thompson CC. et al. Successful EUS-guided treatment of gastric varices with coil embolization and injection of absorbable gelatin sponge. VideoGIE 2018; 4: 154-156
• 23 Bazarbashi AN, Ryou M. EUS-guided coil injection therapy for bleeding gastric variceal bleeding not amenable to IR guided therapies. ACG Case Re 2019; 6: 1-4