BEWARE OF THE GLUE

Background:

Endoscopic injection of cyanoacrylate (CYA) was a stepforward in the therapy of gastric varices (GV). However has been associate to adverse events, mainly, GE (glue embolism). To minimize the risk of GE, EUS-guided injection in the perforating feeding vein of GV of CYA was reported (1), followed by the deployment of coils in GV without injection of CYA (2). Another approach is to deploy into the gastric varix itself one or two coils followed by injection of CYA (3, 4). One multicenter study reported a rate of pulmonary GE of 30% after an average injection of CYA mixed with lipiodol by EUS-guidance (5).

Aims & Methods:

In the following videos we present, after injecting pure contrast through 19G needles into the GV, some aspects of the hemodynamic in this setting.

Results:

First-video: high-blood flow velocity and how the contrast is rapidly cleared out. Second-video: how the contrast flows through 5 coils through the gastrorenal shunt and up to the superior cava vein. Third-video: clearance of contrast in spite of 4 coils deployed. Fourth-video: how the flow is obstructed and the contrast remains in the gastric varix except for several small drops that run through the coils. Fifth-video: shows a completely procedure. Two coils are deployed and though them the contrast is fragmented into small drops and flows towards the gastrorenal shunt and superior cava vein. After deployment more coils, a mesh is obtained and thromboses of GV is achieved.

Conclusions:

EUS-guided therapy of GV seems promising because of its accuracy and safety profile. Although it is postulated that injection of CYA without lipiodol is safe there is no way to carry out asymptomatic GE if lipiodol and CT scans are not used.

1. GIE 2007;66 (2):402 – 7.

2. Endoscopy. 2010;42 Suppl 2: E35 – 6.

3. GIE 2011;74 (5):1019 – 25.

4. GIE 2016;83 (6):1164 – 72.

5. GIE 2013;78 (5):711 – 21.