Distal embolization and local vessel wall ulceration after gastric variceal obliteration with N-butyl-2-cyanoacrylate: a case report and review of the literature

Risk Factors for Rebleeding After Endoscopic Injection of Cyanoacrylate Glue for Gastric Varices: A Systematic Review and Meta-Analysis

BACKGROUND

Rebleeding is a significant complication of endoscopic injection of cyanoacrylate in gastric varices in cirrhotic patients.

AIM

This systematic review and meta-analysis aimed to evaluate the efficiency of endoscopic cyanoacrylate injection and summarized the risk factors for rebleeding.

METHODS

Databases were searched for articles published between January 2012 and December 2022. Studies evaluating the efficiency of endoscopic injection of cyanoacrylate glue for gastric varices and the risk factors for rebleeding were included.

RESULTS

The final analysis included data from 24 studies. The hemostatic rates ranged from 65 to 100%. The pooled rate of gastric varices recurrence was 34% [95% CI 21-46, I2 = 61.4%], early rebleeding rate was 16% [95% CI 11-20, I2 = 37.4%], late rebleeding rate was 39% [95% CI 36-42, I2 = 90.9%], mild and moderate adverse events rate were 28% [95% CI 24-31, I2 = 91.6%], 3% [95% CI - 2 to 8, I2 = 15.3%], rebleeding-related mortality rate was 6% [95% CI 2-10, I2 = 0%], all-cause mortality rate was 17% [95% CI 12-22, I2 = 63.6%]. Independent risk factors for gastric variceal rebleeding included portal venous thrombosis, ascites, cyanoacrylate volume, fever/systemic inflammatory response syndrome, red Wale sign, previous history of variceal bleeding, active bleeding and paragastric veins. The use of proton pump inhibitors could be a protective factor.

CONCLUSIONS

Endoscopic cyanoacrylate glue injection is an effective and safe treatment for gastric varices. Cirrhotic patients with the above risk factors may benefit from treatment aimed at reducing portal hypertension, antibiotic prophylaxis, and anticoagulation if they meet the indications.

EUS-guided coil injection therapy in the management of gastric varices: the first U.S. multicenter experience (with video)

BACKGROUND AND AIMS

Despite the significant morbidity associated with gastric variceal bleeding, there is a paucity of high-quality data regarding optimal management. EUS-guided coil injection therapy (EUS-COIL) has recently emerged as a promising endoscopic modality for the treatment of gastric varices (GV), particularly compared with traditional direct endoscopic glue injection. Although there are data on the feasibility and safety of EUS-COIL in the management of GV, these have been limited to select centers with particular expertise. The aim of this study was to report the first U.S. multicenter experience of EUS-COIL for the management of GV.

METHODS

This retrospective analysis included patients with bleeding GV or GV at risk of bleeding who underwent EUS-COIL at 10 U.S. tertiary care centers between 2018 and 2022. Baseline patient and procedure-related information was obtained. EUS-COIL entailed the injection of .018 inch or .035 inch hemostatic coils using a 22-gauge or 19-gauge FNA needle. Primary outcomes were technical success (defined as successful deployment of coil into varix under EUS guidance with diminution of Doppler flow), clinical success (defined as cessation of bleeding if present and/or absence of bleeding at 30 days' postintervention), and intraprocedural and postprocedural adverse events.

RESULTS

A total of 106 patients were included (mean age 60.4 ± 12.8 years; 41.5% female). The most common etiology of GV was cirrhosis (71.7%), with alcohol being the most common cause (43.4%). Overall, 71.7% presented with acute GV bleeding requiring intensive care unit stay and/or blood transfusion. The most common GV encountered were isolated GV type 1 (60.4%). A mean of 3.8 ± 3 coils were injected with a total mean length of 44.7 ± 46.1 cm. Adjunctive glue or absorbable gelatin sponge was injected in 82% of patients. Technical success and clinical success were 100% and 88.7%, respectively. Intraprocedural adverse events (pulmonary embolism and GV bleeding from FNA needle access) occurred in 2 patients (1.8%), and postprocedural adverse events occurred in 5 (4.7%), of which 3 were mild. Recurrent bleeding was observed in 15 patients (14.1%) at a mean of 32 days. Eighty percent of patients with recurrent bleeding were successfully re-treated with repeat EUS-COIL. No significant differences were observed in outcomes between high-volume (>15 cases) and low-volume (<7 cases) centers.

CONCLUSIONS

This U.S. multicenter experience on EUS-COIL for GV confirms high technical and clinical success with low adverse events. No significant differences were seen between high- and low-volume centers. Repeat EUS-COIL seems to be an effective rescue option for patients with recurrent bleeding GV. Further prospective studies should compare this modality versus other interventions commonly used for GV.

EUS-guided coil and glue injection versus endoscopic glue injection for gastric varices: International multicentre propensity-matched analysis

BACKGROUND

Gastric varices (GVs) are conventionally managed with endoscopic cyanoacrylate (E-CYA) glue injection. Endoscopic ultrasound (EUS)-guided therapy using combination of coils and CYA glue (EUS-CG) is a relatively recent modality. There is limited data comparing the two techniques.

METHODOLOGY

This international multicentre study included patients with GV undergoing endotherapy from two Indian and two Italian tertiary care centres. Patients undergoing EUS-CG were compared with propensity-matched E-CYA cases from a cohort of 218 patients. Procedural details such as amount of glue, number of coils used, number of sessions required for obliteration, bleeding after index procedure rates and need for re-intervention were noted.

RESULTS

Of 276 patients, 58 (male 42, 72.4%; mean age-44.3 ± 12.1 years) underwent EUS-CG and were compared with 118 propensity-matched cases of E-CYA. In the EUS-CG arm, complete obliteration at 4 weeks was noted in 54 (93.1%) cases. Compared to the E-CYA cohort, EUS-CG arm showed significantly lower number of session (1.0 vs. 1.5; p < 0.0001) requirement, lower subsequent-bleeding episodes (13.8% vs. 39.1%; p < 0.0001) and lower re-intervention (12.1% vs. 50.4%; p < 0.001) rates. On multivariable regression analysis, size of the varix (aOR-1.17; CI 1.08-1.26) and technique of therapy (aOR-14.71; CI 4.32-50.0) were significant predictors of re-bleeding. A maximum GV size >17.5 mm had a 69% predictive accuracy for need for re-intervention.

CONCLUSION

Endoscopic ultrasound-guided therapy of GV using coil and CYA glue is a safe technique with better efficacy and lower re-bleeding rates on follow-up compared to the conventional endoscopic CYA therapy.

Comparing large-volume band ligators and cyanoacrylate injection for gastric variceal eradication: A prospective study

BACKGROUND

The role of endoscopy in the ligation of gastric varices (GV) remains controversial. This study aimed to evaluate the efficacy of endoscopic band ligation (EBL) using large-volume ligators for the management of non-bleeding GV in patients with cirrhosis.

METHODS

One hundred fifty-eight patients with non-bleeding GV due to cirrhosis were divided randomly into 2 groups: the EBL group and the endoscopic variceal obturation (EVO) group. The EBL group underwent EBL with large-volume ligators and the EVO group underwent tissue glue injection for the treatment of GV. Follow-up endoscopy was performed 3 to 4 weeks after endoscopic treatment. Patients were followed up for ≥6 months after treatment. Eradication, complication, and recurrence rates were evaluated and compared between groups.

RESULTS

The type and size of GV were similar in both groups. No significant difference was found in the mean number of treatment sessions or eradication and recurrence rates after 6 months. Ulcer bleeding occurred in 2 EBL patients (2.50%) after ligation, whereas 8 EVO patients (10.25%) experienced bleeding due to glue extrusion. The bleeding rate after endoscopic treatment significantly differed between the groups. In the EVO group, 1 patient developed renal embolism after injection and 2 patients developed sepsis. The prevalence of postoperative fever was significantly higher in the EVO group than in the EBL group.

CONCLUSION SUBSECTIONS

Large-volume band ligators have similar efficacy to tissue glue for eradicating GV, however, the former is safer. Nevertheless, multicenter studies are needed to further confirm these results.

Variceal Bleeding: Beyond Banding

Despite advances in the management of complications of portal hypertension, variceal bleeding continues to be associated with significant morbidity and mortality. While endoscopic variceal band ligation remains first line therapy for treating bleeding and high-risk non-bleeding esophageal varices, alternate therapies have been explored, particularly in cases of refractory bleeding. The therapies being explored include stent placement, hemostatic powder use, over-the-scope clips and others. For gastric variceal bleeding, endoscopic ultrasound-guided therapies have recently emerged as promising interventions for hemostasis. The aim of this article is to highlight these alternative therapies and their potential role in the management of gastric and esophageal variceal bleeding.

Endoscopic Treatment of Gastric and Ectopic Varices

Gastric variceal bleeding has a high mortality. Endoscopic cyanoacrylate injection is the standard therapy; however, rebleeding and unexpected adverse events, such as injection sites ulcers and distal glue embolisms, are pitfalls of this therapy. Endoscopic ultrasound (EUS)-guided endovascular therapies offer a safer and more practical alternative for the treatment of gastric varices. EUS-guided combined therapy with coiling and cyanoacrylate injection is the most promising alternative with high obliteration rates and fewer adverse events reported. The authors reviewed the latest available data for all endoscopic therapies proposed for the management of gastric varices in patients with chronic liver disease.

Clip-Assisted Endoscopic Cyanoacrylate Injection: A Novel Technique for Acute Gastroesophageal Variceal Bleeding

Background and Aim: Endoscopic injection sclerotherapy is effective for the treatment of gastric variceal bleeding, but may cause fatal ectopic embolism. Spontaneous portosystemic shunts are one of the risk factors for ectopic embolism. This present study aims to evaluate the efficacy and safety of clip-assisted endoscopic cyanoacrylate injection for the treatment of acute gastroesophageal variceal bleeding. Methods: The medical records of patients with gastroesophageal varices (GOVs) who underwent clip-assisted cyanoacrylate injection at the Ningbo First Hospital from March 2017 to August 2020 were reviewed. The outcomes were immediate hemostasis rate, early rebleeding rate, late rebleeding rate, and procedure-related complications. The gastrorenal and splenorenal shunts were evaluated by the computed tomography angiography. Results: A total of 9 patients with GOVs (GOV1 and GOV2) were analyzed, and 4 of the patients had spontaneous portosystemic shunts. The average number of clips used in each patient was 2.11 ± 1.96, and an average of 5.11 ± 1.76 mL of cyanoacrylate was injected into each patient. All patients completed immediate hemostasis. Two patients experienced rebleeding, including 1 case of early rebleeding and 1 case of late rebleeding (both due to cyanoacrylate extrusion) during a median follow-up of 367 days (interquartile range 270-855 days). Five patients underwent follow-up endoscopy; eradicated gastric varices (GVs) were revealed in 1 patient, and shrunken GVs were found in 4 patients. No serious complications, including ectopic embolism, were observed. Conclusion: The present study showed the efficacy and safety of clip-assisted endoscopic cyanoacrylate injection in acute GOV bleeding, but these results require verification by randomized controlled studies with larger sample numbers.

Endoscopic Ultrasound-Guided Coil Embolization With Absorbable Gelatin Sponge Appears Superior to Traditional Cyanoacrylate Injection for the Treatment of Gastric Varices

Gastric variceal (GV) bleeding is a feared complication of cirrhosis. Traditional endoscopic treatment with cyanoacrylate (CYA) injection can be challenging. Alternatively, endoscopic ultrasound (EUS)-guided delivery of hemostatic coils has shown high therapeutic success without the complications profile of CYA alone. Our aim was to compare the clinical outcomes of EUS-guided coil embolization with endoscopic CYA injection for the treatment of GV.

Cost-effectiveness of endoscopic ultrasound-guided coils plus cyanoacrylate injection compared to endoscopic cyanoacrylate injection in the management of gastric varices

BACKGROUND

Cyanoacrylate (CYA) injection can be performed using a standard upper endoscopy technique or under endoscopic ultrasound (EUS) guidance alone or in combination with coils. There is little information available on the economic impact of these treatment methods.

AIM

To compare the cost-effectiveness of treating gastric varices by CYA injection via upper endoscopy vs coils plus CYA guided by EUS.

METHODS

This was an observational, descriptive, and retrospective study. Patients were allocated into two groups: A CYA group and coils plus CYA group. The baseline characteristics were compared, and a cost analysis was performed.

RESULTS

Overall, 36 patients were included (19 in the CYA group and 17 in the coils + CYA group). All patients in the CYA group had acute bleeding. They underwent a higher mean number of procedures (1.47 vs 1, P = 0.025), and the mean volume of glue used was 2.15 vs 1.65 mL, P = 0.133. The coils + CYA group showed a higher technical success rate (100% vs 84.2%), with a complication rate similar to the CYA group. The majority of CYA patients required hospitalization, and although the mean total per procedure cost was lower (United States $ 1350.29 vs United States $ 2978), the mean total treatment cost was significantly different (United States $ 11060.89 for CYA vs United States $ 3007.13 for coils + CYA, P = 0.03).

CONCLUSION

The use of EUS-guided coils plus cyanoacrylate is more cost-effective than cyanoacrylate injection when the total costs are evaluated. Larger, randomized trials are needed to validate the cost-effectiveness of the EUS-guided approach to treat gastric varices.

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

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.

Combination therapy versus monotherapy for EUS-guided management of gastric varices: A systematic review and meta-analysis

Cyanoacrylate (CYA), coil embolization, and/or combination thereof are available EUS-guided therapies for the treatment of gastric varices (GV). The primary aim of this study was to perform a structured systematic review and meta-analysis to evaluate the comparative effectiveness of EUS-guided interventions for the treatment of GV. Individualized search strategies were developed for PubMed, EMBASE, and Cochrane Library databases, from inception through November 2018 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This cumulative meta-analysis was performed using calculating pooled proportions. Measured outcomes included technical success, clinical success, adverse events, and rate of rebleeding or reintervention. Comparative subgroup analyses were performed for three treatment cohorts (EUS-guided CYA injection, EUS-guided coil embolization + CYA injection, and EUS-guided coil injection alone). Heterogeneity was assessed with I² statistics. Eleven studies (n = 536 patients; 62.20% of males) were included. The mean age was 58.21 ± 4.15 years with an average follow-up of 12.93 ± 7.69 months. Overall technical success, clinical success, and adverse events for EUS treatments was 100% ([95% confidence interval [CI] 98–100]; I² = 30.54%), 97% ([95% CI 92–100]; I² = 59.99%), and 14% ([95% CI 6–23]; I² = 82.23%), respectively. On subgroup analysis, EUS-guided CYA + coil embolization resulted in a better technical and clinical success compared to CYA alone (100% vs. 97%; P < 0.001 and 98% vs. 96%; P < 0.001) and coil embolization alone (99% vs. 97%; P < 0.001 and 96% vs. 90%; P < 0.001). CYA + coil embolization also resulted in lower adverse event rates compared to CYA alone (10% vs. 21%; P < 0.001), and comparable rates to coil embolization alone (10% vs. 3%; P = 0.057). EUS-guided treatment overall appears to be an effective and safe modality for GV. Among a variety of EUS-therapies available, EUS combination therapy with coil embolization + CYA injection appears to be a preferred strategy for the treatment of GV over EUS-based monotherapy.

Gastric variceal bleeding

PURPOSE OF REVIEW

There are no well-established guidelines for the management of gastric variceal bleeding. Endoscopic management of acute gastric variceal bleeding has been premised on the injection of sclerosants and synthetic glue. However, these therapies are associated with various complications including systemic embolization and recurrent bleeding. Recently, endoscopic ultrasound (EUS)-guided interventions including coil injection have emerged as promising modalities with high technical and clinical success rates and low rates of recurrence.

RECENT FINDINGS

In this review we discuss the classification, natural history, prognosis, and treatment options of gastric variceal. Discussion of treatment is further subdivided into primary and secondary prophylaxis and the management of acute gastric variceal bleeding with a focus on emerging endoscopic interventions.

SUMMARY

Cyanoacrylate injection may have a role in the primary and secondary prophylaxis of gastric variceal. Endoscopic band ligation should be considered for GOV1. EUS-guided injection of synthetic glues like cyanoacrylate is superior to direct injection. However, EUS-guided coil injections with or without cyanoacrylate should be considered first-line endoscopic treatment in all bleeding gastric variceal except for GOV1. Balloon retrograde transvenous obliteration (BRTO) and transjugular intrahepatic portosystemic shunts (TIPS) remain important interventional radiologic therapeutic options as primary therapy in centers without EUS expertise or as salvage therapy.

Insights into the role of endoscopic ultrasound-guided vascular therapy

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.

Endoscopic ultrasound-guided placement of coils and cyanoacrylate embolization in refractory gastric variceal bleeding: a pediatric case report

Background and study aims  Gastric variceal bleeding management is challenging, especially in the pediatric population. Endoscopic cyanoacrylate glue injection is considered the standard for management of gastric varices but it is associated with a high rebleeding rate. Endoscopic ultrasound (EUS)-guided placement of coils with cyanoacrylate is a newly available technique with a lower rebleeding rate but there are no reported cases using this technique in pediatric patients. We report on a 12-year-old child with liver cirrhosis and gastric variceal hemorrhage who was refractory to the endoscopic cyanoacrylate injection and in whom hemostasis was achieved without rebleeding following EUS-guided coiling and cyanoacrylate injection. Neither rebleeding nor varix reappearance was noted on 12-month follow-up. EUS-guided coiling and cyanoacrylate injection is safe and feasible in pediatric patients and could be considered as rescue therapy for treatment of refractory gastric variceal bleeding.

Endoscopic-ultrasound-guided coil and cyanoacrylate embolization for gastric varices and the roles of endoscopic Doppler and endosonographic varicealography in vascular targeting

OBJECTIVE

To report the results of endoscopic ultrasound-guided injection of coils with cyanoacrylate (CYA) using a less-expensive coil with an emphasis on the roles of Doppler and endosonographic varicealography (EV) in identifying the feeder vessel in gastric varix treatment.

METHODS

An observational, descriptive study with prospectively collected data. Patients with gastric varices (GV) were included and were treated by endoscopic ultrasound-guided injection of CYA and a less-expensive coil. Technical success, complete and immediate variceal obliteration, rebleeding, complication and survival rates were evaluated.

RESULTS

Thirty patients with GV with a mean age of 62 years (range: 44-76 years) were treated. Median number of coils used was 2 (range: 1-3), and median volume of CYA was 1.8 mL (1.2-2.4 mL). Technical success rate was 100%. EV technical success was observed in 26/30 patients. Complete variceal obliteration was observed in 96.6% of patients, and immediate disappearance of the varix was observed in 24 (80%) patients. The complication rate was 6.7%.

CONCLUSIONS

Endoscopic-ultrasound guidance for gastric varix treatment with the addition of EV and the use of a less-expensive coil is a safe and effective technique that results in the immediate disappearance of GV after targeting the feeding vessel.

Thromboembolic Events Secondary to Endoscopic Cyanoacrylate Injection: Can We Foresee Any Red Flags?

BACKGROUND

Gastric varices (GV) are associated with high morbidity and mortality in patients with portal hypertension. Endoscopic cyanoacrylate injection is the first-line recommended therapy for GV obliteration. This study aims to explore the reason behind related adverse events and better prevent its occurrence.

METHODS

A retrospective case series study was conducted from January 1, 2013, to December 31, 2016, to identify patients who experienced severe adverse events secondary to endoscopic cyanoacrylate injection. A literature review of similar cases was performed on two medical databases, Medline and Embase.

RESULTS

A total of 652 patients underwent cyanoacrylate injection at our center within the study duration. Five cases of severe adverse events related to the use of tissue adhesives were identified. Detailed clinical presentation, patient treatment, and outcomes were reviewed and analyzed. Twenty-seven similar cases were identified based on the literature review providing further insight into the study.

CONCLUSION

Although rare in incidence, systemic embolism associated with cyanoacrylate injection is often fatal or debilitating. This report may raise awareness in treatment protocol, including the necessity of preoperative angiographic studies, to avoid similar adverse events in clinical practice.

The Efficacy and the Safety of Prophylactic N-Butyl-2-Cyanoacrylate Injection for Gastric Varices Using a Modified Injection Technique

BACKGROUND

Primary prophylactic N-butyl-2-cyanoacrylate (NBC) injection for nonbleeding gastric varices (GVs) remains controversial. In addition, there is still no consensus concerning the technique, its safety, and long-term results.

AIM

To analyze the safety and the efficacy of NBC for primary prophylaxis of GVs using a modified injection technique.

METHODS

Between February 2004 and June 2014, a total of 72 patients with GVs with a high risk of bleeding, who received undiluted NBC injection using a modified "sandwich" method for primary prophylaxis in General Hospital of Chengdu Military Command, were enrolled in this retrospective study. All patients were followed up at 1 to 2 weeks, 3 months, 6 months, and thereafter every 6 months or whenever required, using endoscope detection. The rate of obliteration, bleeding, recurrence, and complications was evaluated.

RESULTS

According to the standard Sarin classification, 28 patients were IGV1 and 44 patients were GEV2. Hepatitis B virus infection was the major cause of portal hypertension. The mean number of sessions were 1.4 (1 to 3) and the mean volume of NBC per session was 3.5 mL (1 to 6 mL). One injection per session was used in 41 patients (56.9%) and 2 or more injections were used in the remaining 31 patients (43.1%). During the follow-up (27 mo; range, 12 to 67 mo), complete obliteration of GVs was achieved in 93.1% of the patients (67/72). One session of NBC injection was enough to obliterate GVs in 49 patients (68.1%), and 2 or more sessions were needed in 23 patients (31.9%). In addition, the bleeding and the recurrence rate were 11.1% (8/72) and 15.3% (11/72), respectively, during the follow-up. The cumulative bleeding-free rate at 1, 3, and 5 years was 95.8%, 91.7%, and 88.9%, respectively. Worsening of esophageal varices was observed in 13 patients (9 in GEV2 and 4 in IGV1). No serious complications, such as distal embolism, were observed in all patients.

CONCLUSIONS

Prophylactic endoscopic NBC injection using a modified injection technique may be a safe and effective treatment for gastric fundal varices with a high risk of bleeding.

Endoscopic management of bleeding gastric varices with N-butyl, 2-cyanoacrylate glue injection in children with non-cirrhotic portal hypertension

Background and study aims: In view of the paucity of literature, we carried out this audit to evaluate the safety and efficacy of N- butyl, 2-cynoacrylate glue injection therapy in secondary prophylaxis of gastric varices in children. Patients and methods: Consecutive children (≤ 18 years) with non-cirrhotic portal hypertension who presented with bleeding from gastric varices and who had undergone cyanoacrylate glue injection therapy were included. They were evaluated for safety, efficacy and complications. Their long-term outcomes and follow-up were recorded. Results: Over 11 years, 28 children with median age 13 (range, 8 to 18) years (68 % boys), underwent cyanoacrylate glue injection for bleeding gastric varices. In 25 (89 %) cases, extrahepatic portal venous obstruction was the etiology and isolated gastric varices were the source of the bleeding. Primary and secondary gastric variceal bleeding was seen in 11 (39 %) and 17 (61 %) children, respectively. A total 36 sessions with median volume of 2 (range, 1 - 5) mL of glue injections were required (2 sessions in 8 children). Hemostasis was achieved in all and 57 % had gastric variceal obliteration. Two children had early (< 1 month) rebleeding and 2 children had late rebleeding. One child had gastric ulcer. Over a median follow-up of 24 (8 - 98) months, 14 children underwent surgery (12 porto-systemic shunt), 2 were lost to follow-up, 1 died and there was no recurrence of bleeding in the remaining 11. Conclusions: Cyanoacrylate glue injection is highly effective mode of secondary prophylaxis of bleeding gastric varices in children with non-cirrhotic portal hypertension. Rebleeding occurred in 14 % but treatment-related complications were uncommon. However, a large controlled clinical trial is required to confirm our findings.

Cyanoacrylate therapy for the treatment of gastric varices: a new method

OBJECTIVE

Cyanoacrylate (CYA) injection is recommended for bleeding gastric varices (GV) but with significant adverse effects. Transesophageal endoscopic ultrasound-guided therapy of large GV with a combined coil and CYA injection has shown promising results. However, it is expensive and requires technical expertise. In this study, we aimed to compare the safety and efficacy of a new method with UCYA [undiluated CYA (UCYA) followed by lipiodol-diluated CYA (DCYA)] in the management of large bleeding GV.

METHODS

Fifteen consecutive patients with bleeding from large GV (>1 cm) were prospectively treated with DCYA and another 15 patients treated with UCYA retrospectively. All patients in the DCYA group underwent thoracic computed tomography scan to identify glue embolism.

RESULTS

Baseline characteristics were similar between the two groups. Rates of GV obliteration and rebleeding were 100% vs 93.3% (P = 0.309) and 6.7% vs 33.3% (P = 0.06) in the DCYA and UCYA groups, respectively. One patient in the UCYA group had needle fixation which led to fatal bleeding after forceful needle extraction. In DCYA group none had glue embolism.

CONCLUSIONS

Both UCYA and DCYA are effective in treating bleeding from large GV. DCYA has lower rebleeding rates and tends to have fewer adverse events than UCYA injection, although the differences are not statistically significant. Large-sample-sized prospective randomized trials are required.

Can proton pump inhibitors reduce rebleeding following Histoacryl sclerotherapy for gastric variceal hemorrhage?

BACKGROUND/AIMS

To evaluate the efficacy of proton pump inhibitors (PPIs) in reducing rebleeding and bleeding-related death rates after endoscopic gastric variceal obliteration (GVO) using N-butyl-2-cyanoacrylate (NBC).

METHODS

This study enrolled 341 patients who were consecutively diagnosed with and treated for bleeding gastric varices. The patients were divided into PPI and non-PPI groups, and their endoscopic findings, initial hemostasis outcomes, rebleeding and bleeding-related death rates, and treatment-related complications were analyzed.

RESULTS

The rate of initial hemostasis was 97.1%. rebleeding occurred in 2.2% of patients within 2 weeks, 3.9% of patients within 4 weeks, 18.9% of patients within 6 months, and 27.6% of patients within 12 months of the GVO procedure. A previous history of variceal bleeding (relative risk [RR], 1.955; 95% confidence interval [CI], 1.263 to 3.028; p = 0.003) and use of PPIs (RR, 0.554; 95% CI, 0.352 to 0.873; p = 0.011) were associated with rebleeding. Child-Pugh class C (RR, 10.914; 95% CI, 4.032 to 29.541; p < 0.001), failure of initial hemostasis (RR, 13.329; 95% CI, 2.795 to 63.556; p = 0.001), and the presence of red-colored concomitant esophageal varices (RR, 4.096; 95% CI, 1.320 to 12.713; p = 0.015) were associated with bleeding-related death.

CONCLUSIONS

The prophylactic use of PPIs reduces rebleeding after GVO using NBC in patients with gastric variceal hemorrhage. However, prophylactic use of PPIs does not reduce bleeding-related death.

Endoscopic ultrasound-guided intravascular therapy

The gastrointestinal tract provides a unique "window" to access vascular structures in the mediastinum and abdomen. The advent of interventional endoscopic ultrasound (EUS) has enabled access to these structures with a standard fine-needle aspiration (FNA) needle. Sclerosants, cyanoacrylate, and coils can be delivered through the lumen of the FNA needle. EUS-guided treatment of gastric varices has theoretical advantages over conventional endoscopy-guided treatment. Controlled studies are needed to determine the role of EUS-guided treatment for primary and secondary prevention of variceal bleeding. There is a growing list of novel indications for EUS-guided vascular therapy that include portal vein angiography and pressure measurements, intrahepatic portosystemic shunt placement, and micro coil embolization of vascular structures. Additionally, access and therapy of the heart and surrounding structures appears feasible.

Endoscopic management of esophagogastric varices in Japan

Esophagogastric varices are the most common complication in patients with portal hypertension, and endoscopy plays an important role in their diagnosis and in the prevention of acute bleeding from these structures. Recently, new modalities such as endoscopic ultrasonography (EUS) and narrow-band imaging have been introduced for the diagnosis of esophagogastric varices. In Japan, endoscopic therapy has become the first choice for the treatment of acutely bleeding esophageal or gastric varices. The two principal methods used to treat esophageal varices are endoscopic injection sclerotherapy (EIS) and endoscopic variceal ligation (EVL). Recently, combinations of EIS plus EVL and EVL plus argon plasma coagulation were reported to be more effective than EVL or EIS alone. Additionally, endoscopic cyanoacrylate injection is superior to EIS and EVL for the treatment of acutely bleeding gastric varices.

EUS-guided coil versus cyanoacrylate therapy for the treatment of gastric varices: a multicenter study (with videos)

BACKGROUND

Therapy of gastric varices (GV) is still challenging. Cyanoacrylate (CYA) injection is the recommended treatment for bleeding GV, but has a known adverse event rate, which could be reduced if EUS is used for guidance. Otherwise, EUS-guided coil application (ECA) may be an alternative.

OBJECTIVES

To compare CYA and ECA embolization of feeding GV for feasibility, safety, and applicability.

DESIGN

Retrospective analysis of a prospectively maintained database.

SETTING

Multicenter study, tertiary referral centers.

PATIENTS AND INTERVENTIONS

Thirty consecutive patients with localized GV who received either CYA injection or ECA were included with follow-up for 6 months after treatment.

RESULTS

There were 11 patients in the coil group and 19 patients in the CYA group. The GV obliteration rate was 94.7% CYA versus 90.9% ECA; mean number of endoscopy sessions was 1.4 ± 0.1 (range 1-3). Adverse events occurred in 12 of 30 patients (40%) (CYA, 11/19 [57.9%]; ECA, 1/11 [9.1%]; P < .01); only 3 were symptomatic, and an additional 9 (CYA group) had glue embolism on a CT scan but was asymptomatic. No further adverse events occurred during follow-up. Six patients (20%) died unrelated to the procedures or bleeding.

LIMITATIONS

Nonrandomized; EUS expertise necessary.

CONCLUSIONS

EUS-guided therapy for GV by using CYA or ECA is effective in localized GV. ECA required fewer endoscopies and tended to have fewer adverse events compared with CYA injection. Larger comparative studies are needed to prove these data.

EUS-Guided Vascular Procedures: A Literature Review

Endoscopic ultrasound (EUS) is continuously stepping into the therapeutic arena, simultaneously evolving in different directions, such as the management of pancreatic and biliary diseases, celiac neurolysis, delivering local intratumoral therapy, and EUS-guided endosurgery. EUS-guided vascular procedures are also challenging, considering the variety of vascular pathology, proximity of the vascular structures to the GI tract wall, high resolution, and real-time guidance offering an attractive access route and precise delivery of the intervention. The literature on vascular therapeutic EUS demonstrates techniques for the management of upper GI variceal and nonvariceal bleeding, pseudoaneurysms, and coiling and embolization procedures, as well as the creation of intrahepatic portosystemic shunts. The paucity of studies, diversity of study designs, and the number of animal model studies hamper a systematic approach to the conclusion and decision making important to clinicians and healthcare policy makers. Nevertheless, theoretical benefits and findings up to date concerning technical feasibility, efficacy, and safety of the procedures drive further research and development in this rather young therapeutic arena.

Factors influencing clinical outcomes of Histoacryl® glue injection-treated gastric variceal hemorrhage

AIM: To determine the factors associated with clinical outcomes and complications of Histoacryl^® glue injection for acute gastric variceal hemorrhage.

METHODS: Patients who presented to the Siriraj Gastrointestinal Endoscopy Center with active gastric variceal bleeding and were admitted for treatment between April 2008 and October 2011 were selected retrospectively for study inclusion. All bleeding varices were treated by injection of Histoacryl^® tissue glue (B. Braun Melsungen AG, Germany) through a 21G or 23G catheter primed with lipiodol to prevent premature glue solidification. Data recorded for each patient included demographic and clinical characteristics, endoscopic findings, clinical outcomes in terms of early and late re-bleeding, mortality, and procedure-related complications. Data from admission (baseline) and post-treatment were comparatively analyzed using stepwise logistic regression analysis to determine the correlation between factors and clinical outcomes.

RESULTS: A total of 90 patients underwent Histoacryl^® injection to treat bleeding gastric varices. The mean age was 55.9 ± 13.9 (range: 15-88) years old, and 74.4% of the patients were male. The most common presentations were hematemesis (71.1%), melena (12.2%), and coffee ground emesis (8.9%). Initial hemostasis was experienced in 97.8% of patients, while re-bleeding within 120 h occurred in 10.0%. The presence of ascites was the only factor associated with early and late re-bleeding [odds ratio (OR) = 10.67, 95%CI: 1.27-89.52, P = 0.03 and OR = 4.15, 95%CI: 1.34-12.86, P = 0.01, respectively]. Early procedure-related complications developed in 14.4% of patients, and were primarily infections and non-fatal systemic embolization. Late re-bleeding was significantly correlated with early procedure-related complications by univariate analysis (OR = 4.01, 95%CI: 1.25-12.87, P = 0.04), but no factors were significantly correlated by multivariate analysis. The overall mortality rate was 21.1%, the majority of which were related to infections. The factors showing strong association with higher mortality risk were elevated total bilirubin (OR = 16.71, 95%CI: 3.28-85.09, P < 0.01), a large amount of transfused fresh frozen plasma (OR = 1.001, 95%CI: 1.000-1.002, P = 0.03), and late re-bleeding (OR = 10.99, 95%CI: 2.15-56.35, P = 0.02).

CONCLUSION: Histoacryl^® injection is a safe and effective hemostatic method for treating gastric variceal hemorrhage. Patients with compromised liver, including ascites, have a higher risk of re-bleeding.

Atrial embolism caused by portal vein embolization: Treatment by percutaneous withdrawal and stenting

Hepatectomy remains the only curative treatment for many primary and secondary liver cancers. Portal vein embolization (PVE) has been used to increase the volume of the future liver remnant and thus lower the risk of small-for-size syndrome and postoperative liver failure. This technique has proven its safety, with a low post-procedure morbidity rate. Here, we describe a very rare case in which a young patient suffered a glue embolism to the right atrial cavity following PVE in preparation for a major hepatectomy for colorectal metastasis. The foreign body was withdrawn from the heart with a femoral, percutaneous device and trapped against the wall of the femoral vein with a self-expanding metal stent. Our report shows that this previously unknown complication of PVE can be resolved without recourse to sternotomy and open heart surgery.

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.

Undiluted N-butyl cyanoacrylate is safe and effective for gastric variceal bleeding

BACKGROUND

Gastric variceal bleeding is associated with significant morbidity and mortality in patients with portal hypertension. N-butyl cyanoacrylate (NBC), mixed with lipiodol, has been shown to be effective in controlling bleeding, but is associated with the risk of distal embolization.

OBJECTIVE

To study the efficacy and safety of undiluted NBC in the management of gastric varices (GV).

DESIGN

Prospective cohort study.

SETTING

Single tertiary care center.

PATIENTS

170 consecutive patients with GV.

INTERVENTION

Standardized technique of undiluted NBC injection for management of GV.

MAIN OUTCOME MEASUREMENTS

Achievement of initial hemostasis, rate of rebleeding, procedure-related complications, and mortality.

RESULTS

GV were identified in 170 patients, 87 of whom were treated with 261 injections of undiluted NBC. Among 46 patients with active bleeding of GV, initial hemostasis was achieved in 84.8%. Rebleeding was seen in 23.4% patients over a mean follow-up of 16 months. No case of clinical distal embolization was seen. Large GV size, fundal location, and large esophageal variceal size were predictive of GV bleed. The mortality was 8.8% for all patients with GV; 10.3% for patients with GV treated with NBC, and 7.2% for those with GV not treated with NBC. Child-Pugh status was the only predictor of mortality.

LIMITATION

Only 1 intervention group.

CONCLUSION

Undiluted NBC is safe and effective in the management of gastric variceal bleeding.

Evaluation of therapeutic effects and serious complications following endoscopic obliterative therapy with Histoacryl

Background and aims:

Our aim was to evaluate the utility of endoscopic obliterative therapy with Histoacryl for gastric varices and to investigate the incidence of serious complications.

Methods:

Endoscopic obliterative therapy with Histoacryl was performed on 129 gastric variceal patients. Sixty-five patients had cardiofornical varices, and 64 had fundal varices. Forty-five of 129 patients were emergency cases and the other 84 patients were prophylactic cases. Endoscopic therapy was performed under fluoroscopy using 70% Histoacryl (Histoacryl diluted with 5% Lipiodol).

Results:

Endoscopic hemostasis of gastric varices was successful in 45/45 (100%) emergency cases. The recurrence rate of gastric varices was 17/120 (14.2%) among patients whose variceal eradication was achieved. Additional treatment was successfully performed in all recurrent cases. The incidence of serious complications was 4/129 (3.1%), including two cases of splenic infarction, one case of pulmonary embolism, and one case of an inflammatory tumor of pancreatic tail. The two patients with splenic infarction improved with conservative medical treatment. The patient with pulmonary embolism showed no respiratory symptoms, and died of liver failure. The patient with the pancreatic tumor, which was diagnosed as an inflammatory tumor, was treated surgically.

Conclusions:

Endoscopic obliterative therapy with Histoacryl is a useful and relatively safe method for treatment of bleeding gastric varices. Nonetheless, careful attention must be paid to avoid potentially serious complications.

A standardized injection technique and regimen ensures success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices (with videos)

BACKGROUND

N-butyl-2-cyanoacrylate has been successfully used for the treatment of bleeding from gastric fundal varices (FV). However, significant rebleeding rates and serious complications including embolism have been reported.

OBJECTIVE

Our purpose was to analyze the safety and efficacy of N-butyl-2-cyanoacrylate for FV bleeding by using a standardized injection technique and regimen.

DESIGN

Retrospective.

SETTING

Two tertiary referral centers.

PATIENTS

A total of 131 patients (91 men/40 women) with FV underwent obliteration with N-butyl-2-cyanoacrylate by a standardized technique and regimen.

INTERVENTIONS

(1) Dilution of 0.5 mL of N-butyl-2-cyanoacrylate with 0.8 mL of Lipiodol, (2) limiting the volume of mixture to 1.0 mL per injection to minimize the risk of embolism, (3) repeating intravariceal injections of 1.0 mL each until hemostasis was achieved, (4) obliteration of all tributaries of the FV, (5) repeat endoscopy 4 days after the initial treatment to confirm complete obliteration of all visible varices and repeat N-butyl-2-cyanoacrylate injection if necessary to accomplish complete obliteration.

MAIN OUTCOME MEASUREMENTS

Immediate hemostasis rate, early rebleeding rate, bleeding-related mortality rate, procedure-related complications, long-term cumulative rebleeding-free rate, and cumulative survival rate.

RESULTS

Initial hemostasis and variceal obliteration were achieved in all patients. The mean number of sessions was 1 (range 1-3). The mean total volume of glue mixture used was 4.0 mL (range 1-13 mL). There was no occurrence of early FV rebleeding, procedure-related complications, or bleeding-related death. The cumulative rebleeding-free rate at 1, 3, and 5 years was 94.5%, 89.3%, and 82.9%, respectively.

CONCLUSION

Obliteration of bleeding FV with N-butyl-2-cyanoacrylate is safe and effective with use of a standardized injection technique and regimen.

Cyanoacrylate in the treatment of gastric varices complicated by multiple pulmonary emboli

Bleeding gastric varices are increasingly being obliterated with the aid of endoscopic injection of n-butyl-cyanoacrylate (histoacryl) diluted with lipiodol. This glue acts as a tissue adhesive that polymerizes on contact with blood in a gastric varix. Severe glue pulmonary embolism is a rare complication of injection therapy. This case involves a 52-year-old man with fundal gastric varices, who developed multiple pulmonary emboli following glue injection with profound hypoxia requiring hospital admission for 13 days, but with eventual recovery of normal lung function.