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

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.

Abbreviations: CYA, cyanoacrylate, FV-CLA, forward-view curved linear array, GFV, gastric fundal varices