The Use of Angiography for Determination and Confirmation of the Feeder Vessel as a Modification of the Original EUS-guided Coils and Cyanoacrylate Therapy for Gastric Varices

On the other hand, despite the EUS-injection of coils and CYA have shown very promising results, it is extremely important to have experience performing this technique, as the injection in a wrong vessel could be catastrophic. It has been develop in our unit a modification of Binmoeller´s original technique by performing the injection of coils and CYA by EUS and fluoroscopic guidance. The performance of an angiography guided by EUS and under fluoroscopy evaluation, represents a modification to the original technique that add some benefits: 1) The injection of water-soluble contrast allows identifying the variceal flow and the afferent feeding vessel (left gastric vein) and avoiding splenic vessels embolization. 2) Also, if there is a shunt it can be detected and the injection of CYA can be avoided. 3) In case of active bleeding the angiography allows visualizing which varix is bleeding, and target the correct vessel.

The aim of this study is to show the results and potential benefits by adding an angiography to the original EUS-guided injection of coils in combination with CYA technique, to determinate and confirm the feeder vessel in GV treatment.

MATERIALS AND METHODS

Study design: It will be an interventional, descriptive and prospective study, performed in the Ecuadorian Institute of Digestive Disease (IECED), Omni Hospital Academic Tertiary Center Ecuador. Patients have been included from July 2015 and will continue to be included up to October 2017. The study protocol and consent form has been approved by the institutional review board, and will be conducted according to the declaration of Helsinki. Written informed consent will be obtained from all subjects.

Population selection, inclusion and exclusion criteria: Patients above 18 years old with gastric varices (GV) on the initial standard diagnostic upper endoscopy will be enrolled. GV will be classified according to Sarin and Kumar classification. Only gastro-esophageal varices type II (GOV II) (fundal varices communicating with esophageal varices) and isolated gastric varices type I (IGV I) (fundal varices within a few centimeters of the gastric cardia) will be included. Gastro-esophageal varices type I (GOV I) will be excluded as they can be successfully treated by endoscopic band ligation. Patients with active bleeding and history of previous bleeding due to GV (secondary prophylaxis) will be included as well as patients with high-risk GV suitable for primary prophylaxis according to Baveno VI consensus. The exclusion criteria will be pregnancy, concurrent hepatorenal syndrome and/or multi-organ failure, platelet count less than 50,000/ml or International Normalized Rate (INR) >2, esophageal stricture, splenic or portal vein thrombosis and allergy to iodine.