Endoscopic ultrasound-guided vascular interventions: An expanding paradigm

Table 1 Steps of endoscopic ultrasound-guided management (coil and glue combination) of Gastric varices

EUS-guided management of gastric varices using coil and glue combination
Pre-procedure requirements
All procedures are done under the cover of pre/peri-procedural antibiotics
Patient is usually kept fasting for 4-6 h before the procedure
Adequate resuscitation of the patient, in case of active bleeding is ensured, prior to the procedure
Informed consent prior to the procedure
What is needed prior to the procedure
Linear echoendoscope with at least a 3.7 mm working channel
Needle size: depends on the choice of the endoscopist; for > 10 mm coils, we need 0.035’ coil (19-G needle); can also use 0.018’ coil (22-G needle)
Diameter of the coils: 1.2-1.5 times the largest diameter of varix
Number of coils: depends on size of the varix
Amount of glue: depends on the size of the varix; but usually 2-4 mL is sufficient
Technical aspects
A proper diagnostic EUS is performed
The echoendoscope is usually positioned either in the distal esophagus or the gastric fundus
Saline is filled intra-luminally in the fundus to let the varices “float”. This enables a good acoustic coupling for better visualization of the gastric varices
Adequate examination of the fundus, the intramural varices and the feeder vessels is carried out
The approach can be trans-esophageal or trans-gastric, wherein the trans-esophageal route is given preference
Aim is to obliterate the intramucosal part of the varix
EUS-guided coil and glue embolization is usually performed using a 22-G/19-G (gauge) FNA needle
The size of the coil is determined by the short axis of the diameter of the varix
After puncture of the varix, blood is aspirated to confirm the location. This is followed by flushing of the needle with saline
The coils are then deployed into the varix using the stylet as a pusher. Once the coils are deployed, flushing of the needle is done with normal saline
After coil deployment, 1-2 mL of cyanoacrylate glue is injected followed by rapid flushing with saline
Once, the varix is obliterated, visualized by absence of flow on colour Doppler, the sheath of the needle is advanced beyond the endoscope tip for 2-3 cm before withdrawing the scope. This avoids contact of glue with the endoscope tip
Post procedure
The patients are kept under observation for 12 h
Repeat EUS can be done after 2 d to look for residual varices
Follow-up EUS to be performed at 1- and 3-mo intervals

EUS: Endoscopic ultrasound; FNA: Fine needle aspiration; G: Gauge.