Endoscopic ultrasonography-guided coil embolization and cyanoacrylate injection versus cyanoacrylate injection alone for gastric varices: a randomized comparative study

Abstract

Background Bleeding from gastric varices is life-threatening, with significant rebleeding risk despite standard cyanoacrylate glue injection therapy. Our aim was to evaluate the efficacy and safety of endoscopic ultrasonography (EUS)-guided coil embolization with cyanoacrylate injection (Coil+CYA) compared with EUS-guided cyanoacrylate injection alone (CYA) for the treatment of gastric varices.

Methods The study was conducted at a tertiary referral center in India, using a single-blinded, prospective, and parallel-group randomized design. A total of 50 patients were randomly assigned (1 : 1) to Coil+CYA or CYA. The primary outcome was clinical success (i.e. variceal obliteration). Secondary outcomes involved technical success, gastric variceal recurrence during follow-up, rebleeding episodes, reintervention, and survival.

Results Post-intervention, gastric variceal obliteration assessed by EUS was higher in the Coil+CYA group (100% vs. 92.3%; P = 0.49), with both groups achieving 100% technical success. Rebleeding episodes during 0–12 and 12–24 weeks were comparable in the two groups. At 12 weeks, on EUS, variceal reappearance was less common in the Coil+CYA group (12.5% vs. 19.2%; P = 0.70). Significantly fewer reinterventions were needed in the Coil+CYA group (20.8% vs. 53.8%; P = 0.03). The time to reintervention was significantly longer in the Coil+CYA group (P = 0.01), and the survival time was also longer (P = 0.04).

Conclusions EUS-guided coil embolization with cyanoacrylate injection achieved superior clinical success, reducing the need for reintervention and resulting in improved survival compared with cyanoacrylate injection alone.

Publication History

Received: 29 December 2023

Accepted after revision: 18 July 2024

Article published online:
18 September 2024

• References

• 1 Martins FP, Macedo EP, Paulo GA. et al. Endoscopic follow-up of cyanoacrylate obliteration of gastric varices. Arq Gastroenterol 2009; 46: 81-84
• 2 Soehendra N, Grimm H, Nam VC. et al. N-butyl-2-cyanoacrylate: a supplement to endoscopic sclerotherapy. Endoscopy 1987; 19: 221-224
• 3 Greenwald BD, Caldwell SH, Hespenheide EE. et al. N-2-butyl-cyanoacrylate for bleeding gastric varices: a United States pilot study and cost analysis. Am J Gastroenterol 2003; 98: 1982-1988
• 4 Cheng LF, Wang ZQ, Li CZ. et al. Low incidence of complications from endoscopic gastric variceal obturation with butyl cyanoacrylate. Clin Gastroenterol Hepatol 2010; 8: 760-766
• 5 Binmoeller KF, Weilert F, Shah JN. et al. EUS-guided transesophageal treatment of gastric fundal varices with combined coiling and cyanoacrylate glue injection (with videos). Gastrointest Endosc 2011; 74: 1019-1025
• 6 Romero-Castro R, Ellrichmann M, Ortiz-Moyano C. et al. EUS-guided coil versus cyanoacrylate therapy for the treatment of gastric varices: a multicenter study (with videos). Gastrointest Endosc 2013; 78: 711-721
• 7 Sarin SK, Lahoti D, Saxena SP. et al. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology 1992; 16: 1343-1349
• 8 De Franchis R, Bosch J, Garcia-Tsao G. et al. Baveno VII – Renewing consensus in portal hypertension. J Hepatol 2022; 76: 959-974
• 9 Gralnek IM, Camus Duboc M, Garcia-Pagan JC. et al. Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022; 54: 1094-1120
• 10 Tripathi D, Stanley AJ, Hayes PC. et al. U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut 2015; 64: 1680-1704
• 11 Boregowda U, Umapathy C, Halim N. et al. Update on the management of gastrointestinal varices. World J Gastrointest Pharmacol Ther 2019; 10: 1-21
• 12 Kim T, Shijo H, Kokawa H. et al. Risk factors for hemorrhage from gastric fundal varices. Hepatology 1997; 25: 307-312
• 13 North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices: A prospective multicenter study. NEJM 1988; 319: 983-989
• 14 Wani ZA, Bhat RA, Bhadoria AS. et al. Gastric varices: classification, endoscopic and ultrasonographic management. J Res Med Sci 2015; 20: 1200-1207
• 15 Wiechowska-Kozlowska A, Milkiewicz P. Endoscopic ultrasonography in the assessment of portal hypertension. Gastroenterol Klin 2014; 14: 148-155
• 16 Kozieł S, Pawlak K, Błaszczyk Ł. et al. Endoscopic ultrasound-guided treatment of gastric varices using coils and cyanoacrylate glue injections: results after 1 year of experience. J Clin Med 2019; 8: 1786
• 17 Mishra SR, Sharma BC, Kumar A. et al. Primary prophylaxis of gastric variceal bleeding comparing cyanoacrylate injection and beta-blockers: A randomized controlled trial. J Hepatol 2011; 54: 1161-1167
• 18 Levy MJ, Song LMWK, Kendrick ML. et al. EUS-guided coil embolization for refractory ectopic variceal bleeding (with videos). Gastrointest Endosc 2008; 67: 572-574
• 19 de Almeida Lôbo MR, Chaves DM, de Moura DTH. et al. Safety and efficacy of EUS-guided coil plus cyanoacrylate versus conventional cyanoacrylate technique in the treatment of gastric varices: A randomized controlled trial. Arq Gastroenterol 2019; 56: 99-105
• 20 Robles-Medranda C, Oleas R, Valero M. et al. Endoscopic ultrasonography-guided deployment of embolization coils and cyanoacrylate injection in gastric varices versus coiling alone: a randomized trial. Endoscopy 2020; 52: 268-275