Endoscopic ultrasound guided occlusion of shunt efferent for gastric variceal bleeding or ECARTO Endoscopic ultrasound is emerging as one of the preferred modalities for management of gastric variceal bleeding. Typically the gastric varix or its feeder or the afferent pathway is targeted on endoscopic ultrasound. However, gastric varices and its feeders are often multiple and difficult to embolize completely on EUS. Outflow of the gastric varices, however, is a single vascular channel usually. The efferent or the outflow tract can be an attractive target for embolizing with EUS akin to obliteration of shunt efferent by interventional radiologists. We present a case of gastric variceal bleeding in a patient with multiple feeders or afferents to gastric varices managed with EUS guided coil-assisted retrograde transgastric occlusion of the gastro renal shunt efferent or ECARTO resulting in complete obliteration of gastric variceal complex. A 41 year old gentleman with chronic liver disease of child B status was referred to our unit after failed endoscopic glue injection for fundal varices elsewhere. After hemodynamic resuscitation his CT images were reviewed for definitive management. CT imaging revealed features of chronic liver disease. Fundal varices were partially obliterated, however, residual fundal varices were noted with a large patent gastro renal shunt. The portal vein was patent. One feeder to the gastric varix was noted from the left gastric vein. There was a single outflow of the shunt into the left renal vein. Another feeder to the varix was noted from the posterior gastric vein. In view of two feeders from the left and posterior gastric vein and the single outflow tract, a decision was made to target the outflow or the efferent rather than the feeder or the varix. We decided to use a combination of coils and n-butyl cyanoacrylate glue to provide scaffolding and prevent systemic embolization of glue. Lipoidol was used along with glue to prevent polymerization of glue within the EUSFNA needle while avoiding systemic embolization. Additionally, Lipoidol would provide visibility on fluoroscopy. Endoscopy showed a large gastric variceal complex with evidence of previous glue injection. The following technique was adopted to identify the shunt efferent on EUS. With the scope position at the level of the GE junction, the left renal hilum was visualized and the left renal vein identified within it. The shunt efferent or the outflow tract of the fundal variceal complex was identified joining into the left renal vein. On clockwise counterclockwise movement of the scope, the efferent could be traced back to the fundal variceal complex. The segment of the efferent limb just distal to the fundal varix was selected for the lowest risk of migration of glue. Under EUS guidance, a 19-gauge FNA needle was introduced into the shunt efferent and three pushable fibered coils of 12mm diameter each were inserted. The coil diameter was decided based on the efferent diameter on EUS and CT. The coils were oversized by 20% to prevent non-target embolization. Following the insertion of coils, a decrease in shunt flow was noted on Doppler. Subsequently, two aliquots of 0.5 ml glue mixed with liperidol in 1 is to 1 ratio were injected using combined fluoroscopic and EUS guidance. Complete obliteration of the gastric variceal complex was noted after glue injection. CT scan done the following day showed localization of the coils and glue within the shunt efferent. On axial images, complete obliteration of the gastric varices and the gastro renal shunt was noted. The patient did not have any further episodes of upper GI bleed. CT imaging at six months showed obliterated gastric variceal complex. Endoscopy was also repeated which showed similar findings with no fundal varices. Small esophageal varices were however noted. In conclusion, endoscopic ultrasound guided coil assisted retrograde transgastric occlusion of shunt efferent or ECARTO is a feasible, safe and effective alternative to IR guided therapy for bleeding gastric varices. This is especially for patients who have multiple feeders or efferent pathways to their gastric variceal complex, who have a single efferent or an outflow tract which can be targeted on EUS for coiling.

ECARTO

gastric variceal bleeding

endoscopic ultrasound

coil-assisted occlusion

chronic liver disease