Endoscopic ultrasound-guided injection of N-butyl-2-cyanoacrylate into portal venous collateral vessels that were feeding bleeding duodenal varices

Endoscopic injection of sclerosants (N-butyl-2-cyanoacrylate, fibrin glue) is a well-established treatment for bleeding gastroesophageal and ectopic varices, with injection into the varices usually performed under direct endoscopic view [1]. Alternatively, injection can be performed under endoscopic ultrasound (EUS) guidance [2] [3] [4]. We describe a case of duodenal varices with recurrent bleeding that were not accessible to direct endoscopic injection because of postoperatively altered anatomy ([Fig. 1] and [Fig. 2]).

Fig. 1 Endosonographic view of calcifying pancreatitis.

Fig. 2 Endoscopic views showing: a the major papilla and duodenojejunostomy with hyperplastic tissue; b the region of the major duodenal papilla and duodenojejunostomy with variceal bleeding.

A 25-year-old woman with a congenital malformation complex (VACTERL association) underwent resection of the pancreatic tail with duodenojejunostomy and splenectomy at the age of 10 years because of obstructive jaundice due to severe chronic calcifying pancreatitis. After that and due to cardiopathy with stasis (corrected Fallot tetralogy), the patient developed portal venous collateral vessels and duodenal varices.

Because direct sclerosant injection was not possible, we examined the duodenum and stomach using EUS. Even gentle compression of the duodenal wall by the EUS device, which is necessary for a proper examination, made it impossible to perform EUS-guided injection therapy of the submucosal duodenal varices; however, we found portal venous collaterals feeding the duodenal varices. We therefore successfully treated the duodenal varices by EUS-guided injection of N-butyl-2-cyanoacrylate into the feeding portal venous collaterals ([Fig. 3]). In two sessions, with the patient under general anesthesia, we applied a total of four portions of the mixture, which consisted of 0.5 mL N-butyl-2-cyanoacrylate and 0.7 mL Lipiodol. In doing this, it is vital to ensure that the injection is strictly intravascular. Before puncturing each collateral, we used a 22 G needle to inject distilled water first into the vessel. Once we were sure of the intravascular position, we injected N-butyl-2-cyanoacrylate ([Video 1]). It was even possible to puncture and treat vessels with a diameter of 3 mm. No complications occurred in our patient and, to date, no new bleeding has been observed.

Fig. 3 Fluoroscopic view of the region showing portal venous collaterals treated by cyanoacrylate glue (arrows) and calcifying pancreatitis.

Video 1 Demonstration of endoscopic ultrasound-guided injection of cyanoacrylate glue into portal venous collaterals that were feeding duodenal varices.

We conclude that EUS-guided obliteration of portal venous collaterals that are feeding varices is an effective treatment for recurrent bleeding from varices that are not suitable for direct endoscopic treatment.

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• References

• 1 Ibrahim M, Mustafa I, Deviere J. New developments in managing variceal bleeding. Gastroenterology 2018; 154: 1964-1969
• 2 Gonzalez JM, Giacino C, Pioche M. et al. Endoscopic ultrasound-guided vascular therapy: is it safe and effective?. Endoscopy 2012; 44: 539-542
• 3 Kimura G, Hashimoto Y, Ikeda M. Successful obliteration of bleeding duodenal varices by EUS-guided injection of N-butyl-2-cyanoacrylate. VideoGIE 2017; 2: 317-319
• 4 Dedania B, Kukreja K, Davee T. et al. Endoscopic ultrasound-guided sclerosant injection and coil embolization of bleeding gastric varices. Endoscopy 2018; 50: 283-285