Endoscopic ultrasound (EUS)-guided therapy of gastric varices, first reported as the use of a cyanoacrylate (CYA) injection [1 ], now includes the deployment of coils without CYA [2 ] and the combined method, involving deployment of one to two coils followed by an injection of CYA [3 ]. Regardless of the method used, EUS-guided therapy of gastric varices is increasingly performed because of its safety profile and accuracy. EUS-guided angiography can be used to assess fluidodynamics, the anatomy of gastric varices, and gastrorenal shunt (GRS) patency.
We present some of our findings after EUS-guided angiography, injecting hydrosoluble or liposoluble contrast through 19-gauge needles in the perforating feeding vein, during EUS-guided therapy of gastric varices with coil deployment only ([Fig. 1 ]). [Video 1 ] shows four examples of our findings. Case A shows high blood flow clearing the contrast immediately. Case B shows the contrast flowing through five coils towards the GRS and the inferior vena cava (IVC). Case C shows the liposoluble contrast (Lipiodol) seeming to be retained after deploying sixteen coils but some droplets passing to the GRS and the IVC. Case D shows the passage of contrast through five coils towards the GRS and IVC.
Fig. 1 Angiographic images showing: a hydrosoluble contrast media passing through five coils and displaying a huge gastrorenal shunt (GRS; arrows); b the fluidodynamic behavior of the hydrosoluble contrast media flowing through the five coils towards the GRS and the inferior vena cava (arrows).
Video 1 Anatomic and hemodynamic findings during endoscopic ultrasound-guided angiography of gastric varices.
In all of these cases, gastric variceal obliteration was achieved. These findings could explain the results of two studies that used CYA mixed with Lipiodol and performed a chest computed tomography scan after the EUS-guided procedure [4 ]
[5 ]. One study found a 47 % rate of asymptomatic pulmonary glue embolism after EUS-guided injection of CYA [4 ]. The other study, which compared endoscopic injection of CYA with the EUS-guided combined technique (coil + CYA), found asymptomatic pulmonary glue embolism in 50 % and 25 % of patients, respectively [5 ].
The rationale for the use of CYA after deploying coils is that the glue is trapped by the coils. However, some studies [4 ]
[5 ] and the cases shown in [Video 1 ] raise a note of caution on the use of CYA. EUS-guided angiography evaluates fluidodynamic behavior of hydrosoluble/liposoluble contrasts, providing an insight into the behavior of any substance injected in such large, high flow blood vessels, even when multiple coils have previously been deployed, and would be helpful if EUS-guided therapy is considered. Therefore, we prefer to deploy as many coils as needed to obtain a thick mesh and leave them time to obstruct the blood flow, so avoiding any potential adverse events associated with the use of CYA.
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