Gastric fistula formation is a known complication of bariatric surgery. Many gastric fistulae can be managed endoscopically, however, it can be difficult to successfully treat chronic fistulae. Cardiac septal occluders continue to emerge as a new tool that may be able to close fistulae in fewer sessions. However, a drawback of these devices is their diameter, and therefore, inability to deploy in tight fistulae. On the other hand, vascular plugs come in smaller diameters, and therefore, may be able to deploy in smaller fistulae. We present two cases where vascular plugs were successfully used to close gastrogastric and gastrobronchial fistulae. Case 1. A 37-year-old woman underwent a laparoscopic sleeve gastrectomy, which is complicated by gastric leak and gastrobronchial fistula formation. Attempted management involved percutaneous drainage by interventional radiology, endoscopic diversion, pneumatic dilation of the gastric sleeve stenosis, and fistula closure via through the scope helical tach system. However, she continued to aspirate liquids and have aspiration pneumonia. Additional strategies that were considered included over-the-scope clips, over-the-scope suturing, and endoscopic vacuum therapy. However, given the challenging position and nature of the fistula, these options were not considered feasible. Therefore, vascular plug occlusion therapy was offered. A 6-millimeter vascular plug was chosen that had a maximum catheter length of 100 centimeters. It should be noted that because the delivered catheter is 100 centimeters in length, the plug cannot be deployed through an endoscopic working channel. Therefore, a separate modified catheter must be used for delivery. The plug diameter should be 50% greater than target lumen diameter. We will now provide the next demonstration of how to set up and deploy a vascular plug. The equipment entails a sheathed vascular plug, which is attached to a delivery wire, a plastic loader, and hoop dispenser. The pin vice is a separate piece that attaches onto the delivery wire and with counterclockwise movement deploys the device. By advancing the wire, the plug is deployed. The vascular plug is made of a nitinol mesh, screw attachment, and radiopaque marker bands that help confirm its placement radiographically. The plug can be recaptured by pulling back on the wire. The vascular plug is meant to only be initially housed inside the sheath provided in the packaging. The plug must be transferred onto a catheter that is then later used to guide deployment into the target defect. We use a 3.7 millimeter biliary dilation catheter that comes with a radiopaque marker and a tapered end. The tapered end must be cut to allow for plug deployment. The back end of the delivery catheter will be modified twice. First, the lower lock is cut to eventually allow for long exchange. At this point, the delivery catheter should be longer than the endoscope working channel. This allows us to endoscopically engage the target with the catheter via the working channel. Once the catheter is in place and long exchange is performed, the catheter is cut down once again to accommodate the 100 centimeter delivery wire and vascular plug. To load the plug, the sheath is loaded directly into the proximal end of the dilation catheter. The vascular plug and delivery wire are advanced. Once in position, the delivery wire is advanced to open the plug or retracted to recapture it. We will now switch to an endoscopic view. As the delivery wire is advanced, the vascular plug is unsheathed and opens. As the wire is retracted, the vascular plug is recaptured, which allows for repositioning. Once fully deployed in the desired position, the pin vice is attached to the wire. The pin vice allows the endoscopist to turn the wire counterclockwise, therefore spinning the vascular plug and releasing it in the desired position. If the plug is anchored in the fistula, it will unscrew and release. We now return to our case of a gastrobronchial fistula. The fistula is appreciated in a tangential position on an operandoscopic exam. A modified catheter engages the fistula. A 0.018-inch guide wire is then passed through the gastrobronchial fistula and looped in the bronchus. The catheter then deep cannulates the fistula over the wire. Exchange is performed with the catheter left in place. The catheter is modified to accommodate the 100-centimeter delivery wire. A nasal scope is advanced alongside the catheter. This is done to directly see the vascular plug deployment. The vascular plug is advanced down to the catheter tip. Through direct endoscopic visualization, the vascular plug is advanced into the fistula and therefore opens as it is unsheathed. The proximal end of the vascular plug can be seen endoscopically, and the plug's position is confirmed fluoroscopically. The pin vice is attached to the delivery wire and then rotated counterclockwise. Because the plug is in the appropriate place in the fistula, counterclockwise motion unscrews and deploys the plug. The plug's position is confirmed endoscopically and fluoroscopically. The patient did well postoperatively and reported symptomatic improvement. She notes an ability to tolerate almost all foods and liquids. The patient was seen by thoracic surgery for management of her diseased lung. However, given her improvement, they did not believe a gastrectomy or other surgical intervention of the stomach was required. Case 2. A 46-year-old woman who underwent Roux-en-Y gastric bypass revision three years ago presents with significant reflux. An upper GI series was performed and demonstrated presence of a gastrogastric fistula. Fistula closure was attempted with endoscopic suturing and APC ablation. The patient had some initial relief, but the fistula failed to close and symptoms persisted. The decision was made to use a vascular plug to occlude the fistula. On upper endoscopy, bypass anatomy is appreciated and a fistula is seen in the blind pouch. The fistula opening is treated with APC in an effort to promote deeper epithelialization. A 10-7-5 biliary dilation catheter cannulates the tract. Contrast is injected and proves that the fistula communicates with the excluded stomach. Lung exchange is performed, leaving the catheter in place. A standard upper endoscope is advanced down to visualize the biliary catheter tip. The plug is then loaded into the catheter and advanced down. The plug's advancement is monitored fluoroscopically as it comes to the end of the delivery catheter and eventually opens within the fistula. The vascular plug is fully deployed into the fistula and the endoscopist is able to advance and retract the vascular plug to obtain the optimal position. To deploy, the pin vise is attached to the wire and then turned counterclockwise. Contrast is then pushed through the upper endoscope to confirm that the fistula has been fully occluded. No contrast is appreciated in the fistula tract nor in the excluded stomach. The patient did well postoperatively and has had no further reflux symptoms. The cases in this video demonstrate it is technically feasible to deploy vascular plugs using modified versions of available endoscopic tools. Further study is required to fully understand the potential and limitations of vascular plugs in gastrointestinal tract disorders.

vascular plugs

gastric fistulae

bariatric surgery

gastrogastric fistulae

gastrobronchial fistulae