EUS-guided transesophageal coiling and cyanoacrylate glue obliteration of gastric fundal varices
Comments: Using a curved linear array echoendoscope, the gastric fundus can be imaged with the transducer positioned in the distal esophagus. Transesophageal access offers an alternative route to treat gastric fundal varices under EUS-guidance without entering the stomach.
This anatomical cartoon illustrates transesohageal access to the gastric fundus from the distal esophagus.
On radial EUS imaging the fundus is seen from the distal esophagus on the patient's left side. The esophageal and stomach walls are shown. Sandwiched between the two is the diaphragmatic crus muscle, seen as a thick hypoechoic band.
On linear EUS imaging the transducer is withdrawn from the stomach into the distal esophagus. We see the fundus from the esophagus. The esophageal and gastric walls are shown, and interposed between the two is the diaphragmatic crus. The transesophageal access path to the fundus is shown.
There are several advantages to a transesophageal approach to gastric fundal varices. The endoscope is orthograde in the esophagus, thus retroflexion in the stomach is not required to access varices. Treatment is not hindered by gastric contents, such as blood and food. There is no disruption of the thinned gastric mucosa overlying the varix, and therefore no risk of bleeding complicating puncture. The deeper feeder vessels are easily accessed.
The rationale for coil placement before glue injection is that it provides a scaffold to retain glue at the site of intravariceal injection. This reduces the risk of embolization. The coil contributes to varix obliteration
A coil is deployed in a container of blood, followed by 1 cc of glue. The glue adheres to the synthetic fibers on the coil. Coil and adherent glue are removed in one piece from the container. The glue is firmly adherent to the coil.
The aim of the study was to evaluate the technical feasibility and outcomes of EUS–guided transesophageal injection of gastric varices with coils and cyanoacrylate glue.
A front-view forward array echoendoscope with color Doppler was used
The varix was punctured with a 19G FNA needle under EUS guidance using a transesophageal approach . A single embolization coil , 12-20 mm in diameter was deployed into the varix followed by 1.0 mL: of 2-Octyl-cyanoacrylate.
The tip of the front view, forward array echoendoscope is shown here, with overlapping optical and ultrasound imaging planes
The coil is delivered through a standard 19 G FNA needle with the pushing stylet.
Gastroscopy is performed with the front view echoendoscope. The fundal varices are seen on transesophageal imaging. The gastric wall is deep to the varices. The varix is targeted with the 19 G needle and a coil is deployed, seen well by its echogenicity. 1 ml of glue is injected. The glue creates intense acoustic shadowing a it fills the varix lumen.
Instrumental palpation shows the varix to be “hard”.
In this second case we see a conglomerate of fundal varices with a white nipple sign. The varix deep to the crus muscle is targeted with the 19 G needle. A coil is deployed and unravels in the varix lumen. This is followed by 1 ml of glue, creating acoustic shadowing.
In this third case there is active bleeding from a flat fundal varix . The varix is targeted under EUS-guidance using a transesophageal approach. One coil is deployed followed by 1 ml of glue. The bleeding stops immediately and glue is seen extruding from the rupture site of the fundal varix.
Over a period of weeks the coil and glue are treated like a foreign body and spontaneously extrude into the gastric lumen. At two months the varices are barely visible and replaced by scar.
The results in 8 patients with bleeding fundal varices are shown.
In conclusion, EUS-guided transesophageal access to fundal varices is feasible and appears safe. Transesophageal delivery of coils and glue is feasible and appears safe. The transesophageal approach has several practical advantages over conventional access to fundal varices in retroflexion Coil deployment prior to glue oblieration may eliminate the risk of glue embolization.
| Contributed by: |
Kenneth F. Binmoeller, MD California Pacific Medical Center |
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Citation: Binmoeller, KF (May 03 2010). EUS-guided transesophageal coiling and cyanoacrylate glue obliteration of gastric fundal varices. The DAVE Project. Retrieved Sep, 8, 2010, from http://daveproject.org/viewfilms.cfm?film_id=896 Times viewed since Feb 2006: 1945 |
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