Endoscopic ultrasonography-guided deployment of embolization coils and cyanoacrylate injection in gastric varices versus coiling alone: a randomized trial

 

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Abstract

Background Gastric variceal bleeding is a life-threating condition with challenging management. We aimed to compare the efficacy and safety of endoscopic ultrasonography (EUS)-guided coil embolization and cyanoacrylate injection versus EUS-guided coil embolization alone in the management of gastric varices.

Methods A single-center, parallel-randomized controlled trial involving 60 participants with gastric varices (GOV II and IGV I) who were randomly allocated to EUS-guided coil embolization and cyanoacrylate injection (n = 30) or EUS-guided coil embolization alone (n = 30). The primary end points were the technical and clinical success rates of both procedures. The secondary end points were the reappearance of gastric varices during follow-up, along with rebleeding, the need for reintervention, and complication and survival rates.

Results The technical success rate was 100 % in both groups. Immediate disappearance of varices was observed in 86.7 % of patients treated with coils and cyanoacrylate, versus 13.3 % of patients treated with coils alone (P < 0.001). Median survival time was 16.4 months with coils and cyanoacrylate versus 14.2 months with coils alone (P = 0.90). Rebleeding occurred in 3.3 % of patients treated with combined treatment and 20 % of those treated with coils alone (P = 0.04). With combined treatment, 83.3 % of patients were free from reintervention versus 60 % with coils alone (hazard ratio 0.27; 95 % confidence interval 0.095 – 0.797; P = 0.01).

Conclusions EUS-guided coil embolization with cyanoacrylate injection achieved excellent clinical success, with lower rates of rebleeding and reintervention than coil treatment alone. Multicenter studies are required to define the most appropriate technique for gastric variceal obliteration.

Publication History

Received: 18 June 2019

Accepted: 17 December 2019

Article published online:
03 March 2020

© Georg Thieme Verlag KG
Stuttgart · New York

• References

• 1 Khoury T, Nadella D, Wiles A. et al. A review article on gastric varices with focus on the emerging role of endoscopic ultrasound-guided angiotherapy. Eur J Gastroenterol Hepatol 2018; 30: 1411-1415
  CrossrefPubMedGoogle Scholar
• 2 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
  CrossrefPubMedGoogle Scholar
• 3 Irani S, Kowdley K, Kozarek R. Gastric varices: an updated review of management. J Clin Gastroenterol 2011; 45: 133-148
  CrossrefPubMedGoogle Scholar
• 4 Joo HS, Jang JY, Eun SH. et al. Long-term results of endoscopic histoacryl (N-butyl-2-cyanoacrylate) injection for treatment of gastric varices--a 10-year experience. Korean J Gastroenterol 2007; 49: 320-326
  PubMedGoogle Scholar
• 5 van Beek AP, van Erpecum KJ. Fatal N-butyl-2-cyanoacrylate pulmonary embolism after sclerotherapy for variceal bleeding. Endoscopy 2005; 37: 687
  Article in Thieme ConnectPubMedGoogle Scholar
• 6 Hwang SS, Kim HH, Park SH. et al. N-butyl-2-cyanoacrylate pulmonary embolism after endoscopic injection sclerotherapy for gastric variceal bleeding. J Comput Assist Tomogr 2001; 25: 16-22
  CrossrefPubMedGoogle Scholar
• 7 Soetikno R, Asokkumar R, Chang J. et al. Improving the technique of N- butyl cyanoacrylate (N-BCA) glue injection into gastric varices. Gastrointest Endosc 2016; 83: AB643
  PubMedGoogle Scholar
• 8 Hill H, Chick JFB, Hage A. et al. N-butyl cyanoacrylate embolotherapy: techniques, complications, and management. Diagn Interv Radiol 2018; 24: 98-103
  PubMedGoogle Scholar
• 9 Robles-Medranda C, Valero M, Nebel JA. et al. Endoscopic-ultrasound-guided coil and cyanoacrylate embolization for gastric varices and the roles of endoscopic Doppler and endosonographic varicealography in vascular targeting. Dig Endosc 2018; 31: 283-290
  PubMedGoogle Scholar
• 10 Bick BL, Al-Haddad M, Liangpunsakul S. et al. EUS-guided fine needle injection is superior to direct endoscopic injection of 2-octyl cyanoacrylate for the treatment of gastric variceal bleeding. Surg Endosc 2019; 33: 1837-1845
  CrossrefPubMedGoogle Scholar
• 11 Hikichi T, Obara K, Nakamura S. et al. Potential application of interventional endoscopic ultrasonography for the treatment of esophageal and gastric varices. Dig Endosc 2015; 27 (Suppl. 01) 17-22
  CrossrefPubMedGoogle Scholar
• 12 Romero-Castro R, Pellicer-Bautista F, Giovannini M. et al. Endoscopic ultrasound (EUS)-guided coil embolization therapy in gastric varices. Endoscopy 2010; 42 (Suppl. 02) E35-E36
  Article in Thieme ConnectPubMedGoogle Scholar
• 13 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
  CrossrefPubMedGoogle Scholar
• 14 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
  CrossrefPubMedGoogle Scholar
• 15 Bhat YM, Weilert F, Fredrick RT. et al. EUS-guided treatment of gastric fundal varices with combined injection of coils and cyanoacrylate glue: a large U.S. experience over 6 years (with video). Gastrointest Endosc 2016; 83: 1164-1172
  CrossrefPubMedGoogle Scholar
• 16 de Franchis R. Baveno VI Faculty. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63: 743-752
  CrossrefPubMedGoogle Scholar
• 17 Romero-Castro R, Pellicer-Bautista FJ, Jimenez-Saenz M. et al. EUS-guided injection of cyanoacrylate in perforating feeding veins in gastric varices: results in 5 cases. Gastrointest Endosc 2007; 66: 402-407
  CrossrefPubMedGoogle Scholar

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