Nonadhesive massive coiling endoscopic ultrasound-guided embolization in a single session for treatment of gastric varices: learning points of a technical variant

The procedure is performed under orotracheal intubation. The echoendoscope is positioned in the distal esophagus or in the gastric fundus to visualize the gastric varices; if necessary, water may be instilled into the fundus to improve visualization. Detection of the feeding vessel is unnecessary owing to the complexity of the vessel network and is time-consuming.

1. Preparation: a fine-needle aspiration (FNA) needle is prepared by withdrawing the stylet and flushing with saline (> 2 mL) to avoid the risk of injecting air into the vessel. The coil is preloaded into the needle catheter. Once the needle is confirmed by endoscopic ultrasound (EUS) to be inside the gastric varix, no checking of blood return is needed to avoid blood clotting and no contrast filling (varicealography) is necessary to confirm correct insertion into the target vessel.

2. Coil deployment (Nester Coils; Cook Medical, Bloomington, Indiana, USA): deployment is performed under EUS and fluoroscopic guidance. Larger coils (0.035 inch) are used with 19 G needles, and smaller ones (0.018 inch) with 22 G if needed. The coiled diameter is 10–20 mm and the straight length is 7–20 mm. Coils are delivered into the varices through the EUS needle, using the FNA stylet as a pusher. The initial coil must be larger to occupy the varix as much as possible to prevent coil migration [1]. Size selection of subsequent coils is based on the remaining vessel space (must be at least larger than the varix diameter on EUS). No special direction of coil deployment is needed ([Fig. 1], [Video 1]).

3. After several minutes, Doppler is used to confirm absence of flow within the varix; any additional large vessels with persistent Doppler are treated using the same technique. Some Doppler flow may remain; this will reduce with time as a clot is induced by the coil hairs ([Fig. 2]).

Fig. 1 Deployment of the embolization coil. a Large, gastric variceal conglomerate in a patient with recent bleeding. b Endoscopic ultrasound-guided transesophageal deployment of a large cylindrical-shaped coil (Nester coil; Cook Medical, Bloomington, Indiana, USA) through a 19 G needle (Echo-tip; Cook Medical). c Fluoroscopy image of multiple coils delivered into a large gastric varix (coil packing).

Video 1 Nonadhesive massive coiling endoscopic ultrasound-guided embolization in a single session for treatment of gastric varices: learning points of a simple technical variant.

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Fig. 2 Follow-up at 3 months. a Endoscopy showed a markedly smaller variceal complex. b Endoscopic ultrasound showed the variceal conglomerate with absent flow on color Doppler.

There is no standardized approach for EUS-guided coil embolization, and many questions remain about the optimal technique [2] [3] [4] [5]. This technique is feasible, simple, and may reduce the reported risk of reintervention compared with the combined (coil plus adhesive) strategy, avoiding the potential risks of using glue.

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• References

• 1 Rowley MW, Suarez J. Coil migration after EUS-guided coil embolization of gastric varices. Gastrointest Endosc 2021; 93: 764-765
• 2 Thiruvengadam SS, Sedarat A. The role of endoscopic ultrasound (EUS) in the management of gastric varices. Curr Gastroenterol Rep 2021; 23: 1
• 3 Bazarbashi AN, Wang TJ, Thompson CC. et al. Endoscopic ultrasound-guided treatment of gastric varices with coil embolization and absorbable hemostatic gelatin sponge: a novel alternative to cyanoacrylate. Endosc Int Open 2020; 8: 221-227
• 4 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
• 5 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