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DOI: 10.1055/a-2408-6905
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.
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Introduction
Gastric varices, which are less common but more severe than esophageal varices in patients with decompensated cirrhosis due to portal hypertension, are concerning owing to how challenging they are to control and their high rebleeding rates, which reach up to 80%–90% in some studies [1]. Cyanoacrylate glue injection has been the conventional treatment since landmark studies reported three to four decades ago [2] [3]; however, the embolization risk remains uncertain [4]. Endoscopic ultrasonography (EUS), which offers accurate diagnostic evaluation and therapeutics, has become a primary interventional modality [5], surpassing previous methods for safe and effective treatment of gastric varices, despite its limitations.
EUS enhances the ability to accurately locate the varices and minimizes glue usage for variceal obliteration, reducing the embolization risk. Refinements, such as combining coils with glue, appear to enhance obliteration and decrease the embolization risk. Binmoellar et al. conducted a study that suggested a 96% success rate after a single session, without embolic events [5]. To scientifically validate this, a randomized comparative study was designed to assess the efficacy of EUS-guided coil embolization with glue injection (Coil+CYA) versus EUS-guided glue injection alone (CYA) in patients with gastric varices, aiming for obliteration. The study aimed to assess the clinical success of the EUS intervention in the two groups. Secondary objectives involved comparison of variceal recurrence, rebleeding, reinterventions, complications, and overall survival between the two EUS intervention groups.
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Methods
The study was carried out in a single-blinded, prospective, parallel-group randomized format in the gastroenterology department of a major tertiary referral center in north-west India, with approval having been obtained from the institutional ethics committee. The study was conducted from October 2022 to March 2024. Patients were randomly assigned in a 1:1 ratio by block randomization using a computer-generated random sequence. Patients were allocated to either the Coil+CYA or CYA group, as depicted in Fig. 1s, see online-only Supplementary material. Allocation concealment was done using sequentially numbered opaque sealed envelopes, prepared using the computer-generated random sequence. These envelopes were prepared by an individual who was not involved in patient selection, allocation, or observation. The study adhered to the principles outlined in the Declaration of Helsinki, and all patients provided written informed consent in an understandable language.
The sample size for the study was calculated at an alpha error of 0.05 and study power of 80%. The gastric variceal obliteration rate with cyanoacrylate injection alone is expected to be 52% [6] Assuming the obliteration rate with the combined therapy increases by 40%, the sample size was calculated as being a minimum of 46, which was enhanced to 50. The null hypothesis considered for the study was that no difference exists in the efficacy of the combined therapy compared with injection therapy alone.
The study included individuals aged 18 years and older, diagnosed with gastric varices (gastroesophageal varices type 2 [GOV2] and isolated gastric varices type 1 [IGV1]) through endoscopic evaluation, according to the Sarin classification [7], who consented to undergo the endoscopic procedure. Patients presented with either active bleeding from gastric varices, a history of prior bleeding due to gastric varices (secondary prophylaxis), or were eligible for primary prophylaxis of larger and high risk varices, in accordance with the Baveno VII, European Society of Gastrointestinal Endoscopy (ESGE), and UK guidelines for gastric variceal management [8] [9] [10]. Exclusion criteria for this study included: patients concurrently experiencing hepatorenal syndrome and/or multiorgan failure, pregnant or lactating women, individuals with a platelet count <50 000/mL or an international normalized ratio (INR) ≥2, and patients with a history of upper gastrointestinal tract surgery.
The primary objective of the study was to assess the clinical success of EUS intervention in the two groups. Clinical success was determined by the immediate and complete obliteration of the varix, confirmed by demonstration of the absence of flow signal on EUS Doppler examination.
The secondary objectives comprised the technical success rate, rebleeding episodes, gastric variceal reappearance during follow-up, reinterventions needed, time to reintervention, mortality, and overall survival for the two EUS intervention groups. Technical success was defined as the successful execution of the intended procedure. Patients who experienced a repeat episode of bleeding after the initial intervention were categorized as having a rebleeding episode. If a repeat intervention was performed within the same allocation group, it was categorized as a reintervention. EUS was conducted on all patients at the 12-week follow-up to assess for variceal reappearance.
Endoscopic ultrasonography: technical aspects
The procedures were carried out in the gastroenterology department, which was fitted out with requisite equipment and accessories for therapeutic interventions. To maintain uniformity, EUS and esophagogastroduodenoscopy were done by a single endoscopist (A.J.). Patients were administered sedation and underwent vital sign monitoring with premedication, overseen by an anesthetist throughout the procedure. All patients underwent preprocedural assessment and postintervention monitoring while remaining within the unit.
The EUS procedure employed a curved linear array transducer in conjunction with a light source. Prior to the procedure, all patients received 2 g of ceftriaxone intravenously. The echoendoscope was positioned in the lower esophagus and gastric cardia to aid better location of the gastric varices and adjacent collaterals. Direct visualization of the collaterals and turbulent blood flow was evaluated using color Doppler ([Fig. 1]). The locations of the feeding vessel and the convergence of collaterals were targeted via the shortest feasible route. A 19-gauge EchoTip Ultra EUS needle was used to puncture the varix under EUS guidance. The position of the needle was subsequently confirmed visually and by the instillation of 3–5 mL of normal saline into the varix. This procedure helps to prevent clot formation at the tip, thereby facilitating easy passage of the pushable coils with a stylet. Adjacent organs were also screened to exclude the presence of other vascular abnormalities, such as a cavernoma or pseudoaneurysm.
In the combined (Coil+CYA) arm, EUS-guided coils (pushable using the stylet) of variable sizes, namely 8×12 mm, 10×14 mm, and 12×17 mm, were deployed inside the varix under direct vision. The ideal size of the coils was determined by estimating the variceal diameter, ensuring that the coil, after release, did not have dimensions greater than the widest point of the varix caliber. This was followed by the injection of n-Butyl-cyanoacrylate until maximum attainable obliteration of blood flow inside the varix had been achieved, with color Doppler being used to confirm this obliteration. Additionally, 1–2 mL of saline was injected after the glue to ensure complete flushing of the needle. Procedural refinements were taken into account while placing the needle tip and directing it to minimize the risks of perforation or coil extrusion, a paradigm dependent solely on the endoscopist's expertise.
In the other intervention arm using glue alone (CYA), EUS-guided glue injection was performed in a similar fashion as described previously, aiming for complete visual obliteration of blood flow inside the varices.
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Follow-up
All patients were invited for follow-up appointments every 2–3 weeks for a comprehensive evaluation of their condition, biochemical tests, and treatment. At 12 weeks following the initial procedure, both groups underwent repeat EUS to assess for persistence of varices or any signs of recurrence, and if necessary were planned for reintervention. Long-term follow-up, extending up to 12 months from enrolment or until the date of death for all patients, was scheduled to assess rebleeding, reintervention, complications, and survival in both groups. If patients experienced variceal rebleeding that required additional intervention during the follow-up period, they underwent a repeat of the same EUS-guided procedure within their respective assigned group.
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Statistical analysis
Categorical variables were described using frequencies and percentages. Quantitative variables were described by their mean (SD) or median and range. The chi-squared test or Fisherʼs exact test were used to analyze categorical variables, as applicable, and the Mann–Whitney U test was used to compare quantitative variables.
A comparison between the two study groups regarding survival time and duration until reintervention was conducted using Kaplan–Meier estimates and log-rank analysis. The relative risk (RR) was estimated by comparing the need for reintervention between the two groups. Statistical significance was determined using a threshold of P<0.05.
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Results
The study included a total of 50 patients, with 24 allocated to the Coil+CYA group and 26 to the CYA group. Baseline data, which included age, sex, etiology of chronic liver disease, and severity scores (Child–Turcotte–Pugh [CTP] and Model for End-Stage Liver Disease-Na [MELD-Na]), revealed no significant disparities between the two groups ([Table 1]). Additionally, blood characteristics, such as hemoglobin levels and platelet count, and the size and location of the gastric varices were similar across the two groups.
Within the Coil+CYA group, there were five active bleeders (20.8%), whereas in the CYA group, there were six (23.1%). Secondary prophylactic intervention, for patients with a history of prior bleeding, was administered to 12 individuals (50.0%) in the Coil+CYA group and 16 (61.5%) in the CYA group. Seven patients (29.2%) in the Coil+CYA group and four (15.4%) in the CYA group underwent EUS intervention as primary prophylaxis owing to larger variceal size and increased risk of bleeding.
The Coil+CYA group required fewer sessions to achieve complete gastric variceal obliteration compared with the CYA group (P = 0.01). The median volume of cyanoacrylate glue used in the Coil+CYA group was 1.5 mL (95%CI 1.3–1.7 mL), while in CYA group it was 3.5 mL (95%CI 2.6–3.3 mL). The Coil+CYA group needed a lower volume of cyanoacrylate glue for complete obliteration compared with the CYA group (P<0.001) ([Table 2]). In the Coil+CYA group, the number of coils inserted per patient ranged from one to four. The intended procedure was successfully completed in 100% of patients in both groups. During the initial intervention, complete cessation of blood flow was observed via EUS in 24 patients (100%) in the Coil+CYA group and 24 (92.3%) in the CYA group (P = 0.49).
Rebleeding incidents were assessed within the specified time intervals (0–12 weeks and 12–24 weeks post-procedure) in both groups, as a part of the secondary outcomes ([Table 3]). During the initial 12-week period, in the Coil+CYA group, one patient (4.2%) exhibited a rebleeding episode compared with four patients (15.4%) in the CYA group (P = 0.35). During the subsequent period (weeks 12–24), one patient (5.0%) from the Coil+CYA group experienced rebleeding, whereas five individuals (29.4%) did so in the CYA group (P = 0.08). EUS conducted at 12 weeks post-procedure demonstrated variceal reappearance in three patients (12.5%) within the Coil+CYA group and five patients (19.2%) within the CYA group (P = 0.70) ([Fig. 2]).
Significantly fewer reinterventions were performed in the Coil+CYA group (20.8%) compared with the CYA group (53.8%; P = 0.03). The RR of reintervention in the Coil+CYA group compared with the CYA group was calculated as being 0.387. This indicates that the risk of reintervention in the Coil+CYA group was 38.7% of the risk in the CYA group, which corresponds to a relative risk reduction (1 − RR) of 0.613.
Kaplan–Meier analysis was conducted to compare the cumulative incidence of reintervention between the two groups ([Fig. 3]). The cumulative incidence of reintervention was significantly lower in Coil+CYA group compared with the CYA group. The log-rank test suggested a significant difference in the cumulative incidence of reintervention between the groups (P = 0.01). The mean time to reintervention in the CYA group was 24.6 weeks (95%CI 18.4–30.9 weeks); in the Coil+CYA group, it was 44.3 weeks (95%CI 37.5–51.1 weeks). Reinterventions were attempted either for rebleeding episodes during the follow-up period or for variceal reappearance observed with EUS at 12 weeks.
The mean survival differed significantly between the Coil+CYA group (48.3 weeks, 95%CI 44.6–51.9 weeks) and the CYA group (42.0 weeks, 95%CI 39.1–44.9 weeks; P = 0.04), as shown in the Kaplan–Meier curve ([Fig. 4]). Overall, the mortality rates were 29.2% (n = 7) in the Coil+CYA group and 34.6% (n = 9) in the CYA group (P = 0.77). The causes of death in both groups are detailed in [Table 3], with two of the patients who died (28.6%) in the Coil+CYA group and three (33.3%) in the CYA group succumbing to bleeding events. Hepatic encephalopathy and hepatocellular carcinoma accounted for the remaining fatalities.
Complications
After the completion of the intended procedure, adverse events, including pain, fever, bleeding, hemodynamic instability, and perforation, were monitored. In the Coil+CYA group, only three patients (12.5%) experienced early complications: two had abdominal pain that was managed conservatively and one had a fever that persisted for 3 days before subsiding with antipyretics. Similarly, in the CYA group, five patients (19.2%) experienced fever (n = 3) or abdominal pain (n = 2). No patients experienced a major adverse event.
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Discussion
Gastric varices develop in 20% of individuals with intrahepatic portal hypertension associated with liver cirrhosis [11]; however, certain extrahepatic conditions like splenic vein thrombosis, pancreatitis, pancreatic malignancy, and myeloproliferative neoplasms, among others, can also contribute to their formation. Individuals with these extrahepatic conditions tend to experience lesser long-term morbidity owing to their improved liver physiology [12]. In this study, 8.3% (n = 2) of the combined group and 11.5% (n = 3) of the CYA group developed gastric varices due to the pancreatitis spectrum, while the rest were cirrhosis related. Sarin et al. reviewed 568 portal hypertension patients, categorizing gastric varices by location, incidence, bleeding risks, and mortality [7]. Our study followed the Sarin classification. While GOV1 is common [13], we included GOV2 and IGV1 patients, as GOV1 often responds to standard band ligation.
Mortality from gastric variceal bleeding can reach up to 20% [14]. The bleeding risk associated with gastric varices can be predicted by assessing factors such as their location (IGV1 > GOV2), size (>5 mm), hepatic venous pressure gradient (>12 mmHg), CTP grade B or C, and endoscopic evidence of recent bleed stigmata (red spot, ulcer, visible bleed) [13]. In this study, the CTP grades in the combined therapy group were A (n = 2), B (n = 5), and C (n = 15); in the CYA group, they were A (n = 2), B (n = 3), and C (n = 18). Transjugular intrahepatic portosystemic shunt or balloon-occluded retrograde transvenous obliteration are relatively contraindicated in end-stage liver disease with higher CTP and MELD-Na scores. The limitations of conventional glue therapy restricts its widespread usage. Further analysis, particularly through head-to-head comparisons using EUS approaches as attempted in this study, is warranted owing to the lack of conclusive data in this regard.
EUS surpasses conventional endoscopy for gastric variceal management in locating superficial varices and identifying deep collaterals, including perforators, within the mucosa, submucosa, or perivisceral area [15]. Both groups demonstrated comparable technical success and excellent variceal obliteration in this study, serving as indicators of the efficacy of the modality, endoscopist expertise, and facility resources, consistent with prior research by Binmoeller et al. and Koziel et al. [5] [16].
The established use of cyanoacrylate glue for gastric variceal prophylaxis and management is supported by Mishra et al., who suggested its superiority over nonselective beta-blockers for prophylaxis [17]. ESGE and Baveno VII recommend endoscopic therapy with tissue adhesives (e.g. n-Butyl-cyanoacrylate) for acute bleeding from IGV1 and GOV2 varices [8] [9]. UK guidelines also endorse cyanoacrylate injection for the prevention of rebleeding and primary prophylaxis [10]. Levy et al. studied coil usage for ectopic varices, and this was followed by the study of Binmoeller et al. on combined coil and adhesive usage for better and longer lasting obliteration [5] [18]. Coils provide a scaffold with interwoven synthetic fibers for the cyanoacrylate glue, enhancing adherence and clotting, while reducing the embolization risk. In our study, the median glue volume used was significantly lower in the combined group, and fewer sessions were needed for complete flow obliteration compared with the CYA group. Previous studies by Lobo et al. and Binmoeller et al. have emphasized the efficacy of combined coil and glue usage in a single session [5] [19]. Koziel et al. also proposed less favorable long-term outcomes with coils alone [16], although this was not an aspect analyzed in our study.
In our study, three patients (12.5%) in the Coil+CYA group and five (19.2%) in the CYA group experienced minor adverse events, such as fever and abdominal pain, consistent with findings from the previous literature. No symptomatic embolism occurred in our study, contrasting with the study of Lobo et al., where 25% of patients in the glue group exhibited embolic manifestations [19]. Another study with a similar design also reported no instances of embolism, affirming the efficacy of coils in reducing embolic events when used in conjunction with glue and thereby ensuring successful obliteration [16].
Rebleeding episodes, indicative of long-term efficacy, were assessed in two periods: the initial 3 months (0–12 weeks) and the subsequent 3 months (12–24 weeks). The CYA group exhibited a higher number of rebleeding episodes in both periods. EUS conducted at 12 weeks on patients who had not experienced prior rebleeding indicated similar rates of variceal reappearance: three patients (12.5%) in the Coil+CYA group and five (19.2%) in the CYA group. A total of five patients (20.8%) in the Coil+CYA group and 14 (53.8%) in the CYA group required reintervention during the follow-up period, showing a significant difference. Reintervention was performed while ensuring allocation to the same group as the initial procedure.
Following the initial procedure, the median time observed until the first reintervention was significantly longer in the combined therapy group compared with the injection alone group. In a comparable study examining the use of coils alone for gastric varices, a greater need for reintervention was observed in the coil alone group compared with the combined therapy group [20].
These findings unequivocally endorse the combined use of coils with cyanoacrylate glue to achieve effective and comprehensive gastric variceal obliteration compared with either approach alone, and notably glue therapy alone as demonstrated in the present study. However, before these findings can be generalized, it is imperative to evaluate resource availability and cost-effectiveness of the combined procedure relative to glue therapy alone.
Despite the inherent risk of EUS scope dysfunction associated with glue usage, an EUS-guided approach was chosen for the glue arm of this study to mitigate any confounding factors stemming from the superior efficacy of the EUS scope in locating the varices compared with a conventional upper gastrointestinal endoscope with an injector. In the context of a comparative study, efforts were made to enhance uniformity by using the EUS scope in both study arms.
Mortality throughout the follow-up period, while not a predetermined outcome, was similar across the two groups, which is attributable to the systemic impact of the underlying disease. Moreover, the duration of follow-up, serving as an auxiliary measure of median survival time, displayed superiority for the Coil+CYA group.
The principal limitation of this study stemmed from its small sample size, rendering it underpowered and difficult to generalize the analysis. Another important consideration was the necessity for an EUS scope and accessories, and an equally skilled endoscopist for the successful execution of this intervention. This highlights the crucial requirement for a resource-rich setting during the procedure. Throughout the follow-up period, additional attention was given to drug and dietary compliance through periodic visits; however, this aspect is influenced by multiple factors, including a patient’s lifestyle, education, and economic status, which ultimately affects the outcome of the disease spectrum.
In conclusion, gastric variceal bleeding, a significant concern for all cirrhotic patients, can be addressed with advancements such as EUS. The implementation of EUS-guided techniques for variceal obliteration is safe and contributes to an effective therapeutic toolkit, ultimately improving survival rates. Within the therapeutic options, cyanoacrylate glue can be administered directly or volume reduction can be achieved by combining it with coils, with comparable efficacy; however, the combined approach (Coil+CYA) stands out for its ability to minimize embolic complications, enhance efficacy, reduce reinterventions, and consequently delay the need for reintervention in the long term. This is well-supported by the current study, although it is of small size. Further large-scale multicenter trials with blinded designs are warranted to validate the management algorithm for broader applicability.
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Conflict of Interest
The authors declare that they have no conflict of interest.
Acknowledgement
The authors would like to acknowledge Dr. Manoj Verma for his guidance with the statistical analysis.
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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
Correspondence
Publication History
Received: 29 December 2023
Accepted after revision: 18 July 2024
Article published online:
18 September 2024
© 2024. Thieme. All rights reserved.
Georg Thieme Verlag KG
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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