Endoscopic ultrasound-guided angiotherapy in bleeding gastrointestinal stromal tumors with coil deployment and cyanoacrylate injection

Hemorrhage is the most frequent (30 – 40 %) and dangerous complication of gastrointestinal stromal tumors (GISTs), with surgery being the treatment of choice and emergency surgery having a significantly higher risk than elective procedures [1]. Conventional endoscopic treatment of tumoral lesions is challenging and efficacy limited because of the complex neoangiogenesis of these lesions, which are beyond the reach of endoscopic contact procedures [2]. Cases of endoscopic ultrasound (EUS)-guided therapy of bleeding GISTs with injection of cyanoacrylate (CYA) [3] [4] or ethanol [5] have been published. To the best of our knowledge, EUS-guided coil deployment has not been reported in this setting. We present two cases of bleeding GISTs successfully treated with EUS-guided combined coil deployment and further injection of CYA targeting the feeding artery ([Video 1]).

Video 1 Endoscopic ultrasound (EUS)-guided angiotherapy in two patients with bleeding GI stromal tumors with EUS-guided coil deployment and cyanoacrylate (CYA) injection targeting the feeding artery.

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Case 1: a 72-year-old man was admitted for melena and hemodynamic instability. An ulcerated fundic mass with a necrotic center and a 5-mm intratumoral artery was observed ([Fig. 1]). EUS-guided injection of CYA (Histoacryl; B. Braun, Melsulgen, Germany) into the feeding artery ([Fig. 2]) with a 22-gauge needle was the initial approach. However, a spurting bleed into the tumor cavity after punction was observed ([Fig. 3]). Hemostasis was achieved by deploying a 6-mm × 20-cm coil (Nester; Cook Medical, Limerick, Ireland) and injecting 2 mL of CYA with a 19-gauge needle ([Fig. 4]).

Fig. 1 Endoscopic view of the ulcerated bleeding GI stromal tumor (GIST).

Fig. 2 Endoscopic ultrasound (EUS) image displaying the feeding artery of the bleeding GI stromal tumor (GIST) (arrows) shown in [Fig. 1].

Fig. 3 Spurting bleed (arrows) after the endoscopic ultrasound (EUS)-guided punction with a 22-gauge needle.

Fig. 4 Endoscopic ultrasound (EUS)-guided deployed coil (arrows) with a 19-gauge needle.

Case 2: a 79-year-old woman was admitted for hematemesis and hypovolemic shock. An ulcerated fundic mass with a 4-mm artery was observed. EUS-guided therapy with a 19-gauge needle was performed employing a 6-mm × 14-cm coil, followed by injection of 2 mL of CYA.

The clinical outcome in both patients was uneventful, and scheduled surgery took place 4 weeks later.

EUS-guided combined angiotherapy targeting the culprit artery of bleeding GISTs maintained hemostasis until scheduled surgery. Moreover, although the follow-up in these two patients was short, EUS-guided angiotherapy may be a therapeutic option in patients with bleeding GISTs deemed unfit for surgery.

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• References

• 1 Liu Q, Kong F, Zhou J. et al. Management of hemorrhage in gastrointestinal stromal tumors: a review. Cancer Manag Res 2018; 10: 735-743
• 2 Venezia G, Asnaghi G, Manca A. et al. Successful use of Hemospray as a bridge to surgery in life-threatening bleeding from a gastrointestinal stromal tumor of the stomach. Endoscopy 2016; 48: E232-E233
• 3 Levy MJ, Wong Kee Song LM, Farnell MB. et al. Endoscopic ultrasound (EUS)-guided angiotherapy of refractory gastrointestinal bleeding. Am J Gastroenterol 2008; 103: 352-359
• 4 Kumbhari V, Gondal B, Okolo Iii PI. et al. Endoscopic ultrasound-guided angiotherapy of a large bleeding gastrointestinal stromal tumor. Endoscopy 2013; 45: E326-E327
• 5 Valdivielso Cortazar E, Fernandez-Urien I, Vila Costas JJ. et al. Endoscopic ultrasound-guided therapy of a gastrointestinal stromal tumor (GIST). Endoscopy 2015; 47: E262-E263