Obliteration of gastric varices guided by eco-endoscopy with coils insertion coated with expandable hydrogel polymers

Abstract

Introduction: gastric varices hemorrhage is a severe complication of portal hypertension, with high mortality rates and few management alternatives, especially when there is a contraindication to transjugular intrahepatic portosystemic shunts (TIPS). The usual therapeutic options are the injection of cyanoacrylate, the insertion of coils or both. Hydrocoils are special coils coated with different types of expandable hydrogel polymers conventionally used in neurovascular interventionism. They allow rapid occlusion of vessel, forming a mesh that favors the local formation of thrombus and the development of a neointima on the gel cover. We consider the use of endoscopic ultrasound (EUS) guided hydrocoil insertion in gastric varices, without using cyanoacrylate. Objective: this study aimed to evaluate the safety and effectivity of the application of EUS-guided hydrocoils in patients with gastric varices hemorrhage with TIPS contraindication. Material and methods: this was a retrospective case series of four patients with TIPS contraindication after interventional radiologist evaluation. Linear echoendoscopes, fluoroscopy, 19G needles and hydrocoils (Azur®, Terumo) and Progreat® 3 Fr microcatheters were used. An interventional radiologist expert advised the procedures and endoscopic ultrasound confirmed the varix obliteration. Results: technical and clinical success occurred in all patients involved in this study. There were no adverse effects related to the procedure or endoscopic equipment damage. Conclusions: the application of EUS-guided hydrocoils can be a safe and effective method in the short term for gastric varices bleeding in patients who are not candidates for TIPS. Besides, a complete obliteration of the vascular lumen could occur and thus, dispense with the use of cyanoacrylate. Further studies are needed to corroborate these preliminary results.