EUS-Guided Therapy of Bleeding Gastric Varices

Abstract

Introduction: The treatment of gastric varices (GV) is challenging due to their large size and bleeding severity. Endoscopic cyanoacrylate (CYA) glue obliteration has demonstrated a higher hemostasis and lower rebleeding rate compared with ligation or sclerotherapy. Treatment delivery under endoscopic ultrasound (EUS) guidance may improve results and offers new treatment approaches. EUS enables precise treatment delivery into the varix lumen and feeding veins. Obliteration can be confirmed on Doppler study. Furthermore, ultrasound visualization is not impaired by blood in the stomach. Coils that are currently used for intravascular embolization treatments, can be delivered under EUS-guidance and offer a new approach that may be an alternative or complementary therapy to glue injection. Aim: To assess the feasibility, safety and outcomes of EUS guided therapy with tissue adhesives, coils or a combination of both for the treatment of bleeding gastric varices. Methods: Patients with GV bleeding (active bleeding or stigmata of prior bleeding) treated by EUS-guided therapy between October 2007 and November 2008 were identified in a prospectively collected database. A linear array echoendoscope was used to deliver treatment. A 22G needle was inserted under EUS guidance. Either CYA, coils (InterLock®, Boston Scientific) or a combination of both was used. After each intervention EUS was used to assess obliteration and determine the need of further intervention. Rebleeding was assessed by clinical follow-up. EUS was used to evaluate GV obliteration during surveillance. Results: Eleven GV were treated in 9 patients (4M: 5F;mean age 56). Five varices were active bleeding while the other six had stigmata of prior bleeding. CYA alone (mean volume: 2.3mL; range1-5mL) was injected in 6 varices. Coils alone (1coil per varix) were inserted in 3 varices. A combination of coils (1 or 2 coils per varix) and CYA (mean volume: 2mL; range: 1-3mL) was used in 2 varices. No complications, including symptoms or signs of embolization, were observed. No rebleeding has been reported on follow-up. EUS surveillance was available in 4 patients and showed complete obliteration of GV. Conclusions: Endoscopic treatment of gastric varices under EUS guidance may improve results due to improved targeting of therapy within the varix. The delivery of coils under EUS guidance is a novel approach with promising results. Further studies are warranted.