We will go to Dr. Mervyn Dew from Brigham and Women's Hospital who will show us an EUS guided coil embolization with an absorbable gelatin sponge for gastric viruses. So we have a hopefully a good case of gastrointestinal coiling for you guys today. So this is a patient, a woman with a history of a decompensated cirrhosis secondary to alcohol use disorder. Her MELD sodium score is 10. She does have a history of very, very small esophageal viruses that I'll show you right here. Really not much to speak of here. But if you go down here into the... Marvin, we don't have your endo view, we just have the PowerPoint right now. Oh, okay. Now we got it. We have a four-part view. We've got your endo, your fluoro, and your endo. All right, great. So here's a retroflex view with our upper scope and you can appreciate here, very large cardiofundal varix. She does have a history of profound anemia and we do feel that the gastric viruses have been intermittently bleeding. So she has been referred for an EUS coiling procedure. BRTO of note, I'm just going to come out with the scope and we'll switch over to the EUS. BRTO was considered, however, the patient does have large volume ascites. And so BRTO, balloon-assisted retrograde transvenous obliteration that interventional radiology performs, has a very high rate of causing ascites or making ascites worse within a year after BRTO. BRTO, just to remind the audience, is an endovascular procedure performed by interventional radiology where a gastrorenal shunt or a splenorenal shunt is identified connecting the cable system to the portal venous system. And that shunt is a prerequisite, anatomic prerequisite for a BRTO procedure. A balloon is placed at the base of the shunt and then above the shunt, usually sclerosin is injected, thereby knocking out the shunt in the varices, gastric varices at the top of the shunt. So that is a very effective endovascular procedure, but it does come with a certain risk of complication. Worsening of ascites is one, and also worsening of esophageal varices is actually seen in up to 50% of patients. So for these reasons, because she has small esophageal varices, sorry, I couldn't quite hear that. That's okay. That was Spain broadcasting. It's okay. That wasn't for you. Okay. All right. So because of those reasons, she was referred for endoscopy. And so let me just review the serine classification system. So the serine classification includes IGV1s and GOV2s. I would say this is a GOV2 because if we're saying that she has small esophageal varices, these extend into the cardiac fundus. These would be GOV2s. IGV1s are basically the same phenomenon with esophageal varices. And so these cardiofundal varices—let me switch over to EUS here. So the cardiofundal varices represent up to 15% of gastric varices, and these are the biggest ones. They're located in an off-grid location for us endoscopically, and these are the ones that bleed and are historically refractory to endoscopic banding therapy. And so the historical gold standard treatment for these cardiofundal varices has been a glue injection, cyanacrylate. But with the advent of EUS, I would say over the past 10 years, we're now able to really target these lesions even in the setting of acute bleeding. And so we're actually able to increase our precision intravascular therapy as well as expand what we're able to inject. So today we'll be injecting coils upon which we'll be injecting a secondary adjunct agent historically that has been cyanacrylate. But at our institution, we've been gaining confidence in something called gel foam, which is an absorbable gelatin sponge. It's quite ubiquitous in hospitals and interventional radiology suites. So I'm giving you a view of the cardiofundal varice here. I think because of the amount of ascites that she has, it's quite easy to appreciate what is intramural versus extramural. But sometimes if you don't have this level of ascites, it's actually very helpful to inject fluid into the stomach lumen. And we're going to do that now just to really delineate what is intramural versus extramural. If you don't do that step, sometimes it's very disorienting with the... Marvin, if I could ask you a question. Yeah. Hey, Jason. Hey, Marvin. So we're really intrigued about this gel foam technique and hopefully we can see that today. What do you think are the benefits of gel foam over cyanacrylate glue? So cyanacrylate, again, historical standard, originally reported with Nipzohendra has gained quite widespread acceptance, but we've had our troubles with it. It is very unforgiving to use. I think that's a good amount of water right there. All right. Thanks. And so you'll have the glue sort of erode through the gastric varix and that can lead to ulcerations. We've had embolic complications with the glue. I'll go ahead and use a 19-gauge needle. Just an empty one, please. Do you think we could have a little bigger view of the EOS image? Yeah. Right now we have a full part view. It'd be great if we had the EOS in the in room. Let's go. Yeah. Yeah, that's great. Okay, great. So let me just tell you a little bit about the, just flesh out the complications with the glue. In addition to the embolic complications and the ulceration, we've had scope damage also. We've also had to glue through the needle such that with needle withdrawal, it's quite traumatic. So with gel foam, gel foam does have a history of precedent intravascular use by our colleagues in interventional radiology. And it's, again, very economical. It's very easy to make a slurry out of it. It's essentially a porcine-derived gelatin that can be made into a slurry. And so we use that as our secondary adjunct agent. Let me tell you a little bit about our room setup. The patient is, obviously, under general anesthesia, intubated, supine position, sometimes with a leftward tip. And that helps with the water settling in a dependent fashion in the fundus and cardia. And you can see the cardia nicely there. We do a dose of antibiotics. My choice is ciprofloxacin. We'll have two units of packed red cells, cross-matched and ready in the room. And fluoro, I get questions about fluoroscopy. Fluoro is not necessary, but I think it's a helpful adjunct modality to have. So, to actually see where it's... One of the pearls about this procedure is that once you, as the endotonographer, puts the needle into the target, your job is to stay very, very still. And most of the work is actually done by your staff, your assistants. And so they have to be very, very knowledgeable about the coils that you're injecting and also flu or gel foam or whatever your choice is for adjunct agent. So, instead of my left hand down, when I find myself swinging and have my patient, and we can switch over to... So, a little bit awkward, but it exposes the scope of what we do, really the lion's share of the work. So, the first thing that I'm going to do is measure the sort of maximal axial diameter. So, here we have nine millimeters. And so, the standard teaching is you're using coils. I'm going to ask you to hold this, Steve. We'll give you one of those coils. Marvin, this is Ken. Do you target near the penetrating vessel or... That's a great question. So, I don't... I personally... I'll go either way. If the perforating vessel is obvious to me, sometimes, and it's easy, sometimes, I'll actually target that. But I think these gastrobaricies are, especially the large ones, can be very, very large and complex. And so, they can have multiple afferent and multiple efferent vessels. And it's not very obvious which ones you're necessarily targeting with that maneuver. So, my personal preference is just to go for intravaricial injection. So, these are the Nestor coils that we use. And I just want to make the audience aware of three important numbers. This is a question that I get a lot. So, the coil diameter, the wire diameter is 0.035 inch. So, this is what goes down a 19-gauge needle. The other variety is 0.018 inch, and that goes down a 22-gauge needle. Next, you have the constrained length of these coils. Here, it's 20 centimeters. That's quite long, but actually, it's not as much hemostatic material as you might think. And then, the coils, in this particular case, wants to make like a cylindrical, slinky-type shape in free space. And so, the diameter of that would be 18 millimeters. So, we're going to choose something that's 30 percent larger than your largest axial diameter. So, I think an 18-millimeter would be fine. Marvin, this is Natalie. Thank you for that. So, I'm assuming you mean the diameter of the coil is 30 percent larger. As far as the length, do you always go for 20? Do you feel like that's the best length, or will you vary the length, too, depending on the varic size? I think there are different philosophies, but my personal philosophy is to inject as much hemostatic material as possible. And so, to that end, what I'll do is I'll usually choose an 18 to 20-millimeter diameter cylindrical coil in 20 centimeters in length, as you said, 0.035 inch thickness. All right. Yeah. So, can you also zero in on this? We want to show you the loading technique. So, this stylet becomes the pusher for these coils. And so, these coils are made of platinum. It's a platinum central core, but it's very, very soft, very malleable. Okay. So, there's a bunch of pieces to this Nester coil that ultimately become extraneous. So, we're going to discard that. We're going to discard the plastic tube that keeps it straight. And then there's a plastic lure lock, and we're going to slide that down. All right. Attach that, and then we're going to make sure that that's flush. And then we're going to use a stylet to sort of dip into. You guys catching that? Okay, good. That should be nice and smooth. And so you want to put—you almost want to overestimate. Be extra cautious and just—yeah, make sure that— Okay, that feels good. Then we'll take out the stylet. And then undo this, please. Okay, and then we'll repeat the stylet insertion. So this is now essentially ready to go. I'll leave a little tail hanging out like that because I want my needle bevel to be sharp. And we are using the new therapeutic EOS scope from Flugee. So this insulin channel is a little bit— Can we get the large EOS image back? Okay, there's the sheet. All right, we're going to pull back that. Hold on, we're just getting the in route right now. There you go. You're good. You guys have my EOS? Yep. Okay. I'm going to repeat my survey here. Just really line up my shot there. Might go for that needle. Dr. Marvin, sorry if I missed it. What was the size of the coil that you decided on for this case? This is a .035, 18 millimeter diameter, 20 centimeters constrained length. So basically our longest and largest nester. And there was our initial insertion. I'm going to be a little bit greedy here. Try to go a little bit— Is it okay to shish kebab vessels like that? I've not had any issues, not found wood so far. This is a 19 gauge. I've actually gone through and through one. But I ended up extruding the coil in through space, in the stomach lumen, and then pulling back and then deploying the rest, almost like plugging the hole that I just made, and that seemed to work well. All right. So let me just do a quick— Can you turn down the sensitivity on that Doppler? It's very, very— Sorry, guys. This first coil deployment is very important, make sure it is intravascular. The argument can be made to actually go in with a needle that's empty and then draw back blood and make sure or inject contrast. That's also a way of doing it, but I like to have my preloaded. So that's my personal preference. I think that looks pretty decent, so we're going to start to extrude here. Can somebody help me with the floor over here? Is that my back? Yeah, it looks good, Marvin. Go ahead and get the floor and start extruding, please. Stephen, can you help with that? Yeah, go ahead. Can you go up a little bit? Hold on just a second. Can you move the patient so that we can see floor stethically what's going on? No, hold on just for a second. Yeah, go ahead. No. No. Okay, go ahead. Can you guys see the floor? Yeah. All right, go ahead. Si. So I think this is a very large... Quiero la de la derecha. So that's the first coil, guys. You can see that? Yep. And this will start changing. You can see less Doppler flow with just a couple of minutes. So you'll see that the last portion of the coil really packed in quite nicely. And so I think that first part may be out in the shunt, and then you can see that the last part quite nicely. So we're going to build on this, and I'm going to start moving my needle backwards. I'm not sure we're seeing live flora, we seem to have a playback loop of prior... How about that? Can you see that? It looks like live now, I think, yeah. So that first part of the loop, I think, is out in the shunt. Very large vessel, and then you can see that the terminus of the coil packing quite nicely. So we're just going to repeat this process, guys. We will come back to you when you're ready for the gelatin sponge in a few minutes. Thank you. Okay, so in the interim, we've placed four coils. And if you can see the fluoroscopic view. And so when I put the Doppler on, most of the spherics has been... The Doppler flow is literally the last part here. And we're going to inject gel foam, otherwise known as absorbable gelatin sponge. This stuff is a purified collagen matrix that can be formed into a slurry. We like to use this brand, it's called Surgiflow. And it's sort of already... There's a certain amount of the gel foam, and there's an easy... For mixing with fluid. So we like to use a mixture of saline and contrast. And so for a 19-gauge needle, here is to get the right viscosity. So for a 19-gauge needle, we will use 8 to 10 cc's of fluid. For a 6.2-gauge needle, we'd use up to 12 to 15 cc's of fluid for the right viscosity. All right, so we're going to remove the stylet here. So you've got syringe to syringe transfer without a stopcock. Say that again. You were able to mix it with the two syringes connected. I didn't see a stopcock in between. There is no stopcock for this kit. It's a male and female connector. And so you can just do a direct connection and mixing between the two syringes. Alternatively, you can go to your local OR or IR and raid their gel foam supply. And this is an example of their gel foam. It comes in a gauze pad form. It also comes in powder formulation. And then you can take it and go ahead and connect it. You need to cut it up into small pieces, right? Okay. So we can go ahead and inject under, yep, in live floral, please. So we're going to inject right now. Go ahead. One in. Marvin, what's your rationale in terms of volume? As much as possible, honestly. But it's usually one of the CCs that will get in there and it goes away. Actually, okay. Can you thin it out a little bit? Can you thin it out a little bit? Yep. Okay. We are having some technical difficulties with the formulation. I think it's been out a little bit too long. It wasn't really created fresh. So we're going to mix another tray here. Marvin, if we're able to see you guys mixing it, that'd be great. I think one of the, one of the big advantages of, of this approach is the kind of the ease with preparation. I think, you know, we've all struggled with, with preparation of glue. Yes, I totally agree. Now, honestly, this is the easiest part of the procedure, but we're, of course Murphy's law we're having. Do you have a lower law? Marvin. Would you ever just do gel foam alone? Or do you think it should be done with coil every time? Go ahead. Okay. Okay. Yeah, let's do that. Let's do a syringe first. Yeah, sorry. We're still having a little bit of difficulty. Natalie, your question about monotherapy with gel foam. I do use gel foam by itself for very, very small vessels. For example, there's a type of gastric varix that we tend to see with the needle. The needle might be clotted right now. So, you know, the other thing you can do is put down the stylet sort of dislodge it and then you can see. So the type of gastric varices you see in a setting of like splenic vein inclusion or portal vein inclusion tends to be like this diffuse, small phenotype. And that can be very challenging for coil therapy. If we do coil therapy in that situation, it'll be a 22 gauge needle. And then we'll inject gel foam through that. And sometimes that's enough to really sufficiently treat the area. Marvin, with this particular case, was this a single puncture of the varices complex? That's right. That's right. Yeah. Yeah, that's right. What you're seeing right now is a single puncture, but sometimes with the very, very large. Okay. Thank you. There we go. But sometimes with the large varices, I have done more than one puncture. Yeah, go ahead. Okay. All right. So we're injecting the gel foam now. Keep going. How much do you think you've injected? Okay, stop. All right. Yeah, let me just do it. I think I'm going to withdraw my needle. I think it's not complete resolution of the Doppler flow, but I think that's sufficiently treated that I'm going to – I feel confident removing my needle at this point. No, it's okay. If you came back, that flow would be gone, or you think there may be some residual based on what you see before you pull your needle out? I think as quickly as an hour from now, if we were to look at this area, I think this flow would be gone. Okay. What I've been doing is having these patients come back at one month and almost always completely obliterated. Okay. Well, thank you so much.

EUS guided coil embolization

gastric varices

decompensated cirrhosis

small esophageal varices

absorbable gelatin sponge

gel foam injection