Limitations of Cyanoacrylate Injection in the Treatment of Gastric Fundal Varices

We read with great interest a recent case report by Cheng et al. [1] describing intraperitoneal leakage of sclerosant after endoscopic injection sclerotherapy with cyanoacrylate for bleeding gastric fundal varices. The authors suggest that the leakage was caused by rupture of the varices due to abrupt elevation of intravariceal pressure.

We have the following comments. Firstly, did the treated varices disappear? If not, rupture would be likely, since residual blood flow via the feeding vein would cause the intravariceal pressure to rise. Although the authors used computed tomography to assess the obliteration of the varices, endoscopic ultrasonography [2] appears to be necessary to assess variceal eradication properly.

Secondly, what was the morphology of the varices that were treated? If the varices were diffuse fundal ones as defined in the classification published by Iwase et al. [3], complete obliteration with cyanoacrylate would be difficult due to structural complexity and rapid blood flow [4].

Thirdly, the size of the fundal varices treated is not clear. If the diameter is over 12 mm, it has been proposed that the ratio of cyanoacrylate to contrast medium should be increased to more than 62.5 % [5]. When the volume injected and the dilution of cyanoacrylate are increased, polymerization is delayed and the risk of systemic complications related to embolization also increases. We previously reported the leakage of cyanoacrylate into a draining vein (gastrorenal shunt) after undiluted cyanoacrylate was injected into fundal varices with a maximum diameter of 13 mm [2]. Was the cyanoacrylate dilution ratio chosen by Cheng et al. appropriate for safe treatment of the varices? We suspect that the collateral was a gastrorenal shunt; the presence of such a shunt can be detected by computed tomography, especially multi-detector-row computed tomographic angiography [6]. If the authors had carried out fluoroscopy during the procedure, they might have detected leakage of cyanoacrylate into the draining vein. For elective treatment of fundal varices, balloon-occluded retrograde transvenous obliteration [7] is preferable to cyanoacrylate when the main route of drainage is a gastrorenal or gastrophrenic shunt.

References

• 1 Cheng H C, Cheng P N, Tsai Y M. et al . Sclerosant extravasation as a complication of sclerosing endotherapy for bleeding gastric varices.  Endoscopy. 2004;  36 239-241
• 2 Izumiya T, Matsumoto A, Nomura T. et al . Balloon-occluded retrograde transvenous obliteration as adjunctive treatment for gastric fundal varices.  Gastrointest Endosc. 2004;  59 156-158
• 3 Iwase H, Maeda O, Shimada M. et al . Endoscopic ablation with cyanoacrylate glue for isolated gastric variceal bleeding.  Gastrointest Endosc. 2001;  53 585-592
• 4 Sato T, Yamazaki K, Toyota J. et al . Color Doppler findings of gastric varices compared with findings on computed tomography.  J Gastroenterol. 2002;  37 604-610
• 5 Irisawa A, Obara k, Sato A. et al . Adherence of cyanoacrylate which leaked from gastric varices to the left renal vein during endoscopic injection sclerotherapy: a histopathologic study.  Endoscopy. 2000;  32 804-806
• 6 Willmann J K, Weishanpt D, Böhm T. et al . Detection of submucosal gastric fundal varices with multi-detector row CT angiography.  Gut. 2003;  52 886-892
• 7 Kanagawa H, Mima S, Kouyama H. et al . Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration.  J Gastroenterol Hepatol. 1996;  11 51-58