Management of Treatment-refractory Gastric Antral Vascular Ectasia (GAVE) with HALO-90 Radiofrequency Ablation

Abstract

Purpose: Gastric antral vascular ectasia (GAVE) is rare but an important cause of transfusion-dependent iron deficiency anemia. Various ablative techniques such as bipolar cautery, heater probe, and argon plasma coagulation (APC) have been used with good success, but some cases are refractory to these methods. We reviewed radiofrequency ablation with the HALO-90 device (BÂRRX Medical, Inc., Sunnyvale, CA) in several of these treatment-refractory (TFGAVE) cases with positive results. Methods: Retrospective review of radiofrequency ablation with HALO-90 device (BÂRRX Medical, Inc, Sunnyvale, CA) in six cases of treatment-refractory gastric antral vascular ectasia (TF-GAVE). Results: Six patients with GAVE had received prior ablative treatments with APC (1 patient also had bipolar cautery) but did not respond despite multiple treatments. Inadequate response was defined as continued need for frequent blood transfusion despite therapy. Three patients were male and 3 female with a mean age 66 (range 63-77 yrs). All patients had endoscopic appearance of vascular ectasia in the antrum while in one patient lesions also involved the gastric body and cardia. Average hemoglobin prior to HALO 90 therapy was 7.1 with a range from 4 to 10. All patients were transfusion dependent. HALO-90 treatment was done in the manner first reported by Gross, et al., (Gastrointest Endosc, 2008; 67(2):324-7) with 4 pulses applied per site. Pulses applied per session averaged 66 (range 44-160). Hemoglobin levels after HALO-90 showed average count of 10.0 with a range from 9.4 to 11.8. Fours patients did not need further blood transfusions after HALO 90 treatment sessions. One patient was transfusion-free for 9 months, but GAVE recurred and retreatment was necessary. A second patient with refractory anemia was diagnosed with myelodysplastic syndrome. Treatments were tolerated well, and there were no complications. Conclusion: Despite general effectiveness of ablative therapy of GAVE, some cases will remain refractory to treatment. APC is the most commonly used, but presents challenges to obtain a uniform coagulation zone to avoid “skip areas”. In addition, edema and bleeding induced by APC makes the treatment more difficult to perform when GAVE is extensive. In TF-GAVE patients, radiofrequency mucosal ablation with the HALO-90 system was successful in four out of six patients (66%) in terms of hemoglobin improvement and decreased need for transfusion. The procedure was technically straightforward, and well-tolerated by the patients. This encouraging data suggests that HALO-90 may be the preferred treatment of TF-GAVE. In addition, extensive GAVE lesions may be better managed with HALO-90 rather than APC, although further clinical trials should be done to prove this.