Endoscopic Ultrasound-Guided Treatment of Gastric Varices Using Coils and Cyanoacrylate Glue Injections: Results after 1 Year of Experience

Abstract

Background and Aims: Gastric varices (GVs) occur in 20% of patients with portal hypertension. GVs are associated with a 65% risk of bleeding over the course of 2 years and have a mortality rate of up to 20%. The standard treatment for GVs is obliteration with cyanoacrylate (CYA). This study presents our experience with combined therapy (vascular coils and CYA) under endoscopic ultrasound (EUS) guidance. Methods: 16 patients (9 male and 7 female) were included into our study. Etiology of portal hypertension included: portal vein thrombosis (PVT) (31.0%), isolated splenic vein thrombosis (SVT) (25.0%), alcoholic cirrhosis (12.5%), hepatitis C cirrhosis (19.0%), and alcoholic cirrhosis with PVT (12.5%). Varices type GOV-2 were diagnosed in 8 patients, type IGV-1 and IGV-2 in 6 and 2 patients, respectively. Indications for treatment were based on endoscopic and endosonographic evaluations of GVs. Inclusion and exclusion criteria were also specified. Technique depended on the size of varices (different size of coils + CYA additionally). The results were based on the achievement of technical success, therapeutic effects, and number of adverse events. Average follow-up period was 327 days. Results: From January to August 2017, 16 patients were treated with EUS-guided obliteration of GVs using vascular coils only or coils with CYA injections. 6 (37.5%) and 10 (62.5%) patients underwent primary and secondary prophylaxis for hemorrhage, respectively. Technical success was achieved in 15 patients (94.0%). Mean numbers of implanted coils and CYA volume during one procedure were 1.7 and 2 mL, respectively. Therapeutic success was achieved in all patients treated with the combination. There were no serious complications such as embolization or death due to the procedure. Three patients (19.0%) had transient abdominal pain and two (12.5%) had transient fever. 1 patient had clinical symptoms of gastrointestinal bleeding. Conclusions: Based on our retrospective research we have concluded, that EUS-guided implantation of intravascular coils combined with cyanoacrylate injections is an effective method of treatment with an acceptable number of complications.

Beyond the scope and the glue: update on evaluation and management of gastric varices

“…Further studies on EUS based therapy for prevention of bleeding in GV are lacking [ 23 ]. In the study by Koziel et al on EUS-guided obliteration of GVs using vascular coils only or coils with CYA injections for primary and secondary prophylaxis for GV haemorrhage, technical success was 94% without serious complications [ 24 ]. Nonetheless, this was a small series with retrospective methodology and inherent bias.…”

The Role of Endoscopic Ultrasound (EUS) in the Management of Gastric Varices

“…Recurrent bleeding was seen in 1 patient with successful repeat treatment [34]. Similarly, Koziel et al described EUScoil/CYA for secondary prophylaxis in 10 patients with complete obliteration in all patients [40]. Fujii-Lau et al also described EUS-coil/CYA for secondary prophylaxis in 3 patients, with no rebleeding episodes documented [36].…”

“…Coil migration is also a rare adverse event that can occur [36]. In cases where CYA is also administered, abdominal pain has been reported in anywhere from 3 to 43% of patients [22•, 40, 41••, 43], and fever has been reported in up to 13% of patients [40].…”

Role of Endoscopic Ultrasound in Liver Disease: Where Do We Stand?

“…The results showed a GV obliteration rate of 70-100%, with no re-bleeding complications, but one event of major bleeding during the procedure was detected. Several groups of authors encourage the use of glue injection and coils in combination (primary prophylaxis, acute GV bleeding, and secondary prophylaxis), believing in their synergistic activity of hemostasis and reducing the risk of re-bleeding and distal embolization [85,88,91,[96][97][98][99][100]. The overall GV obliteration rate was 40-100%, with up to a 20% re-bleeding rate.…”

“…Severe complications also included pulmonary embolism in up to 25% of cases [85,98]. All of the abovementioned results are summarized in Table 2 [85][86][87][88][89][90][91][93][94][95][96][97][98][99][100]. In addition to synthetic tissue adhesives, such as CYA, some of the biologic tissue adhesives that have been studied for GV obliteration include thrombin (converts fibrinogen to fibrin and promotes clot production) and AGS that is prepared from purified porcine gelatin and can absorb up to 45 times its weight in whole blood.…”