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CC BY-NC-ND 4.0 · Endosc Int Open 2023; 11(02): E202-E210
DOI: 10.1055/a-1984-7070
Original article

EUS-guided cyanoacrylate injection into the perforating vein versus direct endoscopic injection in the treatment of gastric varices

Fady Sabry
1   Mansoura University Faculty of Medicine, Department of Gastroenterology and Hepatology, Mansoura, Egypt
,
Seham Seif
1   Mansoura University Faculty of Medicine, Department of Gastroenterology and Hepatology, Mansoura, Egypt
,
Ayman Eldesoky
1   Mansoura University Faculty of Medicine, Department of Gastroenterology and Hepatology, Mansoura, Egypt
,
Hazem Hakim
1   Mansoura University Faculty of Medicine, Department of Gastroenterology and Hepatology, Mansoura, Egypt
,
Ahmed Youssef Altonbary
1   Mansoura University Faculty of Medicine, Department of Gastroenterology and Hepatology, Mansoura, Egypt
› Author Affiliations TRIAL REGISTRATION: prospective randomized controlled study NCT04222127 at ClinicalTrials.gov (http://www.clinicaltrials.gov/)
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Abstract

Background and study aims Endoscopic injection of gastric varices (GVs) using cyanoacrylate (CYA) is associated with significant adverse events (AEs). We aimed to compare the efficacy and safety of endoscopic ultrasound (EUS)-guided CYA injection into the perforating vein versus direct endoscopic injection (DEI) of CYA in treatment of high-risk GVs.

Patients and methods This was a randomized controlled trial that included 52 patients with high-risk GVs. Group A underwent EUS-guided injection into the perforator vein and Group B underwent DEI of 1 mL CYA. Endoscopic examination and Doppler EUS were repeated after 3 months to confirm eradication. Obliteration by Doppler EUS was considered by absence of Doppler flow within the varix. Repeated injection was performed in the absence of obliteration. Doppler EUS examination was repeated at 3 and 6 months after each injection.

Results Forty-three patients including 27 males and 16 females with mean age 57 years completed the study. Variceal obliteration was achieved during the index session after 3 months in eight of 21 (38.1 %) in group B compared to 17 of 22 (77.2 %) in group A (P = 0.014). There was a significant difference in the amount of CYA needed to achieve obliteration in group B compared to group A (2 vs.1 mL, P = 0.027). There was no statistically significant difference in the overall AE rate between group A and group B (4.5 % vs. 14.3 %, P = 0.345).

Conclusions EUS-guided CYA injection into the perforating veins achieved less amount of CYA, fewer number of sessions to obliteration, and similar overall AE rates in the treatment of high-risk GVs compared to DEI.



Publication History

Received: 30 September 2022

Accepted after revision: 18 November 2022

Accepted Manuscript online:
22 November 2022

Article published online:
23 February 2023

© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Goral V, Yılmaz N. Current approaches to the treatment of gastric varices: glue, coil application, TIPS, and BRTO. Medicina 2019; 55: 335
    CrossrefPubMedGoogle Scholar
  • 2 Lee EW, Shahrouki P, Alanis L. et al. Management options for gastric variceal hemorrhage. JAMA Surg 2019; 154: 540-548
    CrossrefPubMedGoogle Scholar
  • 3 Sarin S, Kumar A. Gastric varices: profile, classification, and management. Am J Gastroenterol 1989; 84: 1244-1249
    PubMedGoogle Scholar
  • 4 Al-Hillawi L, Wong T, Tritto G. et al. Pitfalls in histoacryl glue injection therapy for oesophageal, gastric and ectopic varices: A review. World J Gastrointest Surg 2016; 8: 729-734
    CrossrefPubMedGoogle Scholar
  • 5 Girotra M, Raghavapuram S, Abraham RR. et al. Management of gastric variceal bleeding: Role of endoscopy and endoscopic ultrasound. World J Hepatol 2014; 6: 130-136
    CrossrefPubMedGoogle Scholar
  • 6 Belletrutti PJ, Romagnuolo J, Hilsden RJ. et al. Endoscopic management of gastric varices: efficacy and outcomes of gluing with N-butyl-2-cyanoacrylate in a North American patient population. Can J Gastroenterol 2008; 22: 931-936
    CrossrefPubMedGoogle Scholar
  • 7 Ma L, Tseng Y, Luo T. et al. Risk stratification for secondary prophylaxis of gastric varices due to portal hypertension. Dig Liver Dis 2019; 51: 1678-1684
    CrossrefPubMedGoogle Scholar
  • 8 Lôbo MRA, 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
    CrossrefPubMedGoogle Scholar
  • 9 Michael PG, Antoniades G, Staicu A. et al. Pulmonary glue embolism: an unusual complication following endoscopic sclerotherapy for gastric varices. Sultan Qaboos Univ Med J 2018; 18: e231-e235
    CrossrefPubMedGoogle Scholar
  • 10 Hall PS, Teshima C, May GR. et al. Endoscopic ultrasound-guided vascular therapy: the present and the future. Clin Endosc 2017; 50: 138-142
    CrossrefPubMedGoogle Scholar
  • 11 Thiruvengadam SS, Sedarat A. The role of endoscopic ultrasound (EUS) in the management of gastric varices. Curr Gastroenterol Rep 2021; 23: 1-10
    CrossrefPubMedGoogle Scholar
  • 12 Wang AJ, Li BM, Zheng XL. et al. Utility of endoscopic ultrasound in the diagnosis and management of esophagogastric varices. Endosc Ultrasound 2016; 5: 218-224
    CrossrefPubMedGoogle Scholar
  • 13 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
  • 14 Martínez-González J, López-Durán S, Vazquez-Sequeiros E. et al. Management of fundic varices: endoscopic aspects. Rev Esp Enferm Dig 2015; 107: 501-508
    PubMedGoogle Scholar
  • 15 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
  • 16 Philips CA, Ahamed R, Rajesh S. et al. Beyond the scope and the glue: update on evaluation and management of gastric varices. BMC Gastroenterol 2020; 20: 1-14
    CrossrefPubMedGoogle Scholar
  • 17 De Franchis R, Bosch J, Garcia-Tsao G. et al. Baveno VII - Renewing consensus in portal hypertension. J Hepatol 2022; 76: 959-974
    Google Scholar
  • 18 Ibrahim M, Mostafa I, Devière J. New developments in managing variceal bleeding. Gastroenterology 2018; 154: 1964-1969
    CrossrefPubMedGoogle Scholar
  • 19 Guo YW, Miao HB, Wen ZF. et al. Procedure-related complications in gastric variceal obturation with tissue glue. World J Gastroenterol 2017; 23: 7746-7755
    CrossrefPubMedGoogle Scholar
  • 20 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
  • 21 Wang X, Yu S, Chen X. et al. Endoscopic ultrasound-guided injec­tion of coils and cyanoacrylate glue for the treatment of gastric fundal varices with abnormal shunts: a series of case reports. J Int Med Res 2019; 47: 1802-1809
    CrossrefPubMedGoogle Scholar
  • 22 McCarty TR, Bazarbashi AN, Hathorn KE. et al. Combination therapy versus monotherapy for EUS-guided management of gastric varices: A systematic review and meta-analysis. Endosc Ultrasound 2020; 9: 6-15
    CrossrefPubMedGoogle Scholar
  • 23 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
  • 24 Abdel-Aty M, Fouad M, Sallam MM. et al. Incidence of HCV induced-esophageal varices in Egypt: valuable knowledge using data mining analysis. Medicine 2017; 96: e5647
    CrossrefPubMedGoogle Scholar
  • 25 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 26 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
    CrossrefPubMedGoogle Scholar
  • 27 Wang YM, Cheng LF, Li N. et al. Study of glue extrusion after endoscopic N-butyl-2-cyanoacrylate injection on gastric variceal bleeding. World J Gastroenterol 2009; 15: 4945-4951
    CrossrefPubMedGoogle Scholar
  • 28 Chan RS, Vijayananthan A, Kumar G. et al. Imaging findings of extensive splenic infarction after cyanoacrylate injection for gastric varices: a case report. Med J Malaysia 2012; 67: 424-425
    PubMedGoogle Scholar
  • 29 Tan YM, Goh KL, Kamarulzaman A. et al. Multiple systemic embolisms with septicemia after gastric variceal obliteration with cyanoacrylate. Gastrointest Endosc 2002; 55: 276-278
    CrossrefPubMedGoogle Scholar