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

Abstract Purpose of Review Gastric varices (GV) are an important complication of portal hypertension, and the current recommendation for management is beta-blocker therapy for primary prophylaxis and transjugular intrahepatic portosystemic shunt (TIPS) for active bleeding or secondary prophylaxis. Direct endoscopic injection of cyanoacrylate (CYA) glue has been investigated but has drawbacks including limited endoscopic characterization of GV and possible distal glue embolism. To this end, endoscopic ultrasound (EUS) has been pursued to help in characterization of GV, visualization of treatment in real time, and confirmation of obliteration with Doppler. Recent Findings In this paper, we review treatments for GV involving EUS, including EUS-guided injection of CYA and coils, either alone or in combination. We also discuss less common methods, including EUS-guided injection of thrombin and absorbable gelatin sponge. We then review literature comparing EUS-guided methods with direct endoscopic therapy and comparing individual EUS-guided methods with one another. We conclude by highlighting drawbacks of EUS in this field, including the unproven benefit over conventional therapy, lack of a standardized approach, and limited availability of expertise and necessary materials. Summary Novel EUS-based methods offer a unique opportunity to directly visualize and access gastric varices for treatment and obliteration. This may provide key advantages over current endoscopic or angiographic treatments. Comparative studies investigating the benefit of EUS over conventional therapy are needed.

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Endoscopic Ultrasound-Guided Angiotherapy for Gastric Varices—A Small Retrospective Study

Journal of Digestive Endoscopy ◽

10.1055/s-0040-1717823 ◽

2020 ◽

Vol 11 (03) ◽

pp. 201-204

Author(s):

Kapil Sharma ◽

Mamta Sharma ◽

Sanchit Singh

Keyword(s):

Endoscopic Ultrasound ◽

Case Series ◽

Gastric Varices ◽

Secondary Prophylaxis ◽

Limited Data ◽

Technical Success ◽

Ultrasound Guided ◽

Retrospective Case ◽

Technical Success Rate ◽

Complete Obliteration

Abstract Introduction Conventional n-butyl-cyanoacrylate (CYA) recommended for secondary prophylaxis of gastric varices (GV) is associated with significant rebleeding and glue embolism. Limited data are available on more successful and less risky endoscopic ultrasound-guided coils and CYA (EUS-Coils-CYA) injection in GV. Methods We present a retrospective case series of 12 patients with GV bleeding managed successfully with EUS-Coils-CYA injection leading to variceal eradication in 11 patients. Results From January 2018 to June 2019, 12 cases of GV, which were either bleeding or bled recently, were included. Complete obliteration was achieved in 91.6% of patients with 100% technical success. Mean number of deployed coils and volume of injected CYA glue were 1.16 and 1.58 mL, respectively. Conclusions EUS-guided angiotherapy is an effective and safe intervention for managing GV bleeding with high technical success rate.

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Endoscopic Ultrasound-Guided Treatment of Gastric Varices With Coil Embolization and Absorbable Hemostatic Gelatin Sponge

The American Journal of Gastroenterology ◽

10.14309/00000434-201810001-02031 ◽

2018 ◽

Vol 113 (Supplement) ◽

pp. S1158

Author(s):

Ahmad Najdat Bazarbashi ◽

Thomas J. Wang ◽

Phillip S. Ge ◽

Christopher C. Thompson ◽

Marvin Ryou

Keyword(s):

Endoscopic Ultrasound ◽

Coil Embolization ◽

Gastric Varices ◽

Gelatin Sponge ◽

Ultrasound Guided

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Endoscopic ultrasound-guided treatment of gastric varices with coil embolization and absorbable hemostatic gelatin sponge: a novel alternative to cyanoacrylate

Endoscopy International Open ◽

10.1055/a-1027-6708 ◽

2020 ◽

Vol 08 (02) ◽

pp. E221-E227 ◽

Cited By ~ 2

Author(s):

Ahmad Najdat Bazarbashi ◽

Thomas J. Wang ◽

Christopher C. Thompson ◽

Marvin Ryou

Keyword(s):

Endoscopic Ultrasound ◽

Coil Embolization ◽

Case Series ◽

Gastric Varices ◽

Gelatin Sponge ◽

High Morbidity ◽

Technical Success ◽

Radiographic Findings ◽

Systemic Embolization

Abstract Background and study aims Bleeding from gastric varices (GV) carries high morbidity and mortality. Current endoscopic therapies are premised on cyanoacrylate injection which is technically challenging and carries risk of embolization. We present a case series of endoscopic ultrasound (EUS)-guided coil injection in combination with hemostatic absorbable gelatin sponge (AGS) for treatment of bleeding gastric varices. Patients and methods This was a retrospective review of EUS-guided coil injection for bleeding GV since November 2017. After EUS-guided needle puncture, hemostatic coils were serially injected until significant reduction of Doppler flow. Under fluoroscopic guidance, test contrast was injected to confirm absence of run-off, at which time AGS, converted into a liquid slurry, was injected as hemostatic reinforcement. Results Ten consecutive patients underwent EUS-guided coil embolization reinforced by AGS. Technical success, defined as uncomplicated injection of coils and sponge was achieved in 100 % (10/10). Mean follow-up was 6 months 73–397 days; No patients rebled or required reintervention on GV. The complication rate was 10 % (1/10; severe abdominal pain without radiographic findings); otherwise, there were no cases of systemic embolization. Nine of 10 patients (90 %) had follow-up EUS (mean 80 days); 100 % (9/9) revealed near-obliteration of GV. Conclusion EUS-guided coil embolization in combination with hemostatic AGS is a novel method for management of bleeding GV with high clinical and technical success rates, low risk for complications and favorable safety profile when compared to cyanoacrylate. This technique theoretically minimizes embolic complications and need for re-intervention. Further studies are required to compare this modality.

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594 – Endoscopic Ultrasound-Guided Treatment of Gastric Varices with Coil Embolization and Absorbable Gelatin Sponge: A Novel Alternative to Cyanoacrylate

Gastroenterology ◽

10.1016/s0016-5085(19)37085-4 ◽

2019 ◽

Vol 156 (6) ◽

pp. S-116-S-117 ◽

Cited By ~ 1

Author(s):

Ahmad Najdat Bazarbashi ◽

Thomas J. Wang ◽

Phillip S. Ge ◽

Kelly Hathorn ◽

Christopher C. Thompson ◽

...

Keyword(s):

Endoscopic Ultrasound ◽

Coil Embolization ◽

Gastric Varices ◽

Gelatin Sponge ◽

Ultrasound Guided

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Insights into the role of endoscopic ultrasound–guided vascular therapy

Therapeutic Advances in Gastrointestinal Endoscopy ◽

10.1177/2631774519878282 ◽

2019 ◽

Vol 12 ◽

pp. 263177451987828

Author(s):

Roberto Oleas ◽

Carlos Robles-Medranda

Keyword(s):

Gastrointestinal Bleeding ◽

Endoscopic Ultrasound ◽

Endovascular Therapy ◽

Combined Therapy ◽

Treatment Options ◽

Gastric Varices ◽

Ultrasound Guided ◽

Endoscopic Injection ◽

Life Threatening

Gastroesophageal variceal bleeding is a life-threatening complication in patients with liver cirrhosis and portal hypertension. The endoscopic injection of cyanoacrylate is considered as the first-line alternative for gastric varices treatment; however, the incidence of adverse events supports the endoscopic ultrasound–guided approach. Endoscopic ultrasound–guided interventions are a safe and feasible technique for the injection of sclerosants, cyanoacrylate, thrombin, and the deployment of coils into targeted vessels. This review article aims to offer an overview of the role of endoscopic ultrasound–guided vascular therapy and present the available data regarding endoscopic ultrasound–guided management of gastrointestinal bleeding and other vascular therapies. The available data have shown the superiority of endoscopic ultrasound–guided endovascular therapy over the endoscopic technique, which supports the implementation of endoscopic ultrasound–guided therapy in therapeutical algorithms and guidelines. Regarding whether injecting cyanoacrylate, the deployment of coils, or combined therapy, we recommend the endoscopic ultrasound–guided combined therapy in patients with gastric varices due to the high eradication rate with lower rebleeding and reintervention rates. Multicenter worldwide studies are required to confirm the actual clinical applicability of endoscopic ultrasound–guided endovascular therapy and establish treatment algorithms. Endoscopic ultrasound offered a safe and effective alternative in the management of variceal and nonvariceal gastrointestinal bleeding, with the implementation of new diagnostic and treatment options for various gastrointestinal conditions, representing a new territory for research and development.

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Plug-Assisted Retrograde Transvenous Obliteration

Digestive Disease Interventions ◽

10.1055/s-0038-1632364 ◽

2017 ◽

Vol 01 (04) ◽

pp. 293-301

Author(s):

Eung Kim ◽

Dong Gwon

Keyword(s):

Hepatic Encephalopathy ◽

Clinical Success ◽

Treatment Options ◽

Clinical Effectiveness ◽

Gastric Varices ◽

Gelatin Sponge ◽

Success Rates ◽

Endoscopic Injection ◽

Balloon Catheters ◽

Portosystemic Shunts

AbstractGastric fundal varices and portosystemic hepatic encephalopathy are major complications of portal hypertension in patients with liver cirrhosis. Many treatment options have been used for gastric varices, including endoscopic injection and transjugular intrahepatic portosystemic shunts (TIPS), but the clinical effectiveness of these treatments remains contentious. Today, balloon-occluded retrograde transvenous obliteration (BRTO) has become the treatment of choice because of its excellent clinical effectiveness and outcomes; however, the associated use of sclerosants and temporary indwelling balloon catheters can cause specific complications. Vascular plugs are another option that has been shown to be safe, feasible, and effective when used as an embolic material in vascular disease. Recently, a technique has been developed that uses such vascular plugs with a gelatin sponge to embolize gastrorenal shunts. This technique is known as plug-assisted retrograde transvenous obliteration (PARTO), and it is also associated with high technical and clinical success rates. Moreover, it appears to be a much safer and more feasible procedure than BRTO. In this review, we introduce PARTO and outline its strengths and potential for use as the treatment of choice in gastric varices and hepatic encephalopathy.

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