GIE Senior Associate Editor David L. Diehl, MD, highlights this article from the September issue: “EUS-guided thrombin injection and coil implantation for gastric varices: feasibility, safety, and outcomes” by Joanne O’Rourke, MBChB, et al.

One of the pillars of endohepatology is EUS-guided treatment of gastric varices. Although endoscopic glue injection with cyanoacrylate (CYA) has been a standard approach for many years, there is a real risk of glue embolization to the lung or brain. Combining coils and CYA injection is superior to CYA alone with fewer adverse events (AEs).

One of the drawbacks of CYA injection is the risk of scope damage if the glue comes into contact with the internal channel or outside the endoscope. Even worse is if the injection needle gets glued into place because it was not withdrawn from the varix soon enough. Working with CYA can be tricky, and there is a learning curve.

Some groups have looked to agents other than CYA for gastric varix treatment. Thrombin for injection is widely used for intravascular embolization procedures. There is a large body of data on the use of thrombin injection for the endoscopic treatment of gastric varices, including a prospective randomized trial of thrombin versus CYA published in 2020.¹ The data show that thrombin is as good as CYA for hemostasis efficacy with fewer AEs.

O’Rourke et al reviewed cases of combination EUS-guided coil and thrombin treatment for gastric varices at their tertiary liver unit over a 5-year period. Of 20 patients, 80% had fundic isolated gastric varies, and 20% had gastroesophageal varices type 2. Procedural indications were primary prophylaxis in 37%, secondary prophylaxis in 58%, and active bleeding in 11%. Complete obliteration was achieved in 85% with rebleeding in 2 cases. There were only 2 AEs (minor bleeding).

This case series suggests that the combination of thrombin and coils is a suitable alternative therapy for gastric varices. Use of thrombin can avoid some of the procedural pitfalls associated with the use of CYA.

Figure 1 Large isolated gastric varix type 1 treated by EUS-guided coil and thrombin embolization. A large gastric variceal complex measures 5 cm high in the gastric cardia. EUS-guided 19 Access was obtained, and three 20-mm × 14-cm Nester coils followed by two 12 mm × 14 cm and one 10 mm × 14 cm were placed. This was followed by injecting a total of 2500 IU of thrombin. Obliteration of blood flow was clearly seen on EUS Doppler US at the end of the procedure with clot formation. A, A retroflexed standard endoscopic view of the varix (1). B, A T1 magnetic resonance image displaying the large complex gastric fundal varix (2), however notably, further establishes the variceal complex’s single nature. C, Endosonographic view of the largest vessel measured 19.5 mm (3) within the variceal complex. D, An EUS 19 Access needle (4) placed within the varix. E, Tip of the embolization coil (5) exiting the needle. F, Multiple coils now placed (6). G, Echogenic thrombus (7) demonstrated within the entire variceal complex. H, Fluoroscopic imaging showing deployed coils (8), although it should be noted that fluoroscopic imaging in our series is only obtained once.

Read the full article online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

1. Lo GH, Lin CW, Tai CM, et al. A prospective, randomized trial of thrombin versus cyanoacrylate injection in the control of acute gastric variceal hemorrhage. Endoscopy 2020;52:548-55. ↩︎