The next technique that we're going to show will be EUS-guided coil placement. This is becoming increasingly popular for treatment of gastric varices, and while our model doesn't have gastric varices in it, we do have some variceal-like structures that we can apply our coils. Now, Ajay is going to first demonstrate to you how these are prepared. So this is where we run down to our IR suite and have our nurses. Now they know where to steal these, I mean, get these coils from. So these are the two different kinds of coils. One are called the nester coils, one are called the tornado coils. We mainly rely on nester coils. They come in two different sizes. One is the size of the coil, which is 0.18 or 0.35. We use mostly the 0.35-sized coils, which can only be used through a 19-gauge needle. These 0.18 coils can be used through both a 22- and a 19-gauge needle. Then they come in different diameters, which you would anywhere from 4 to 2 centimeters, and the decision you make about which coil to use is based on your EUS findings regarding the size of the varice that you see, the largest size of the varice. Then the third thing is the length of the coil. They come in 7, 14, and I think 20 centimeters long. For most of my cases, I use a 14-centimeter long coil. So we're going to do a demonstration, one outside, to see how the packaging comes and how to do it. These coils are a little expensive, so it's good to know before you do a real case how to do it. So these come in this packaging with a sheet, which is kind of stylet to push it in, a safety valve, a safety wire, which you take off, and then we'll have our 19-gauge needle to use it. I think the needle is on. Let's grab our needle. Oh, there it is. So usually what you would do is you would puncture the needle, which would already be in the varice, and then you would deploy the coil, but we'll go through the loading part of the coil outside right now. So your stylet should be out. Ajay, are you going to put saline down the... Yes, so we will do in the patient where the needle is in the varice, we have flushed it with saline, done our aspiration. Here we are just doing the coil part, and we'll do it in the patient again, how the whole sequence works. So then you use your pusher to kind of load the coil into the needle. So now your coil is in the needle channel, and then you take this whole contraction off, and then you take the stylet back, and start pushing the coil into the varice. Then this would all be visible under EUS guidance, but we're trying to see if we can deploy one coil here. I have never used a 4-millimeter coil, so this is one of the smallest coil sizes that are available. Usually always it's right, or anywhere between 1 to 2 centimeters size coil, but you can see the coil coming out. Let's see if I can... And then if you can... And then you have to push your stylet all the way in, and it falls off. Sometimes it doesn't fall off, but most of the times it falls off. All right, and we try to do the same thing in a live patient, or a demo patient. So one issue I've had, Ajay, is sometimes the coil is hard to get out. And so you can also use a syringe with a little bit of saline in it, and flush it out the rest of the way. In fact, IR has some pretty cool syringes that are really stiff plastic that can shoot it. So if you're having trouble sometimes at the end with the stylet, where sometimes it gets hung up, you can try and flush it with saline. So again, we'll pretend I found a large varice here that I'm happy to coil. And we'll first start by... I'm going to puncture the cyst, or puncture our varice. Ajay, do you try and look for the feeder vessel, if you can, to minimize the number of coils you got to put in? This is the biggest feeder vessel we have. This is the big one. Usually, I try to find the feeder vessel, but not go extramural, beyond the muscularis. But that's always a good practice to try to find. But a lot of times, it's not possible. Again, all of these patients are intubated. We do a lot of water insufflation to find the feeder vessel. I do spend a lot of time looking for the vessels and see if I can find the feeder vessel. So once you're in the varice, first thing you do is you aspirate back to make sure you get some blood. And then you flush it with sterile normal saline and see the flow in there. Following this, we'll be loading our coil in there. Now, the size of the varice will determine the size of the coil. And sometimes, you need more than one coil. A lot of times, you need more than one coil. The largest size I have used is up to 2 centimeters. So for demonstration purposes, this is a demonstration of the technique, but we would not have chosen this size coil for this size varice. So Ajay, I don't know if you said this, but as far as the size of the coil, we generally go measure the diameter and go about a third bigger with the coil. Is that right? We don't want coils migrating. And if you pick this size, it would probably be gone in an instant. Yeah, I would rather go to the biggest size possible. If the varice is 12 or 14 millimeters, I would go with a 14 millimeter because I am okay with a little bit of coil extruding and me having to have difficulty deploying it rather than, I mean, the risk of coil going anywhere else, which is pretty negligible though. But you will see those case reports of coils in lungs and such. And then next we'll advance our stylet to push the coil out of the tip of the needle. And then, Ashley, do you always follow these with a glue or gel foam? What is your approach for these? I do kind of like to do that. I think there's some data suggesting that it may be better to do both, but certainly when you put the coils in, when you watch under Doppler, I mean, the Nestor coils have these little fuzzies all along it that promote coagulation. You see the flow just stop. I mean, you see like coagulation in action. It's really, really cool. And it's very cool how you can see under EOS how these show up so brightly. So you can see the coil coming out over into the lumen. Most of the times you would pick a coil and a varix where the coil kind of almost completely obliterates the lumen. So now the coil is deployed and we'll take the stylet out. Now we follow up usually with, we usually use Dermabond, which is again an off-label use of that. And it's kind of messy because your nurses hate you for using it. You can ruin the scope. Everything is so sticky. So what we are doing here is what Dr. Four uses more often is the gel foam. So you cut these gel foam pieces into a small syringe, use sterile normal saline and use a three-way cloth swab to kind of mix it and make it into a slurry. And then you can follow your coil deployment with injection of gel foam slurry. Again, before we do that, we will again get a little bit of blood flow back, then flush it with sterile normal saline to make sure the needle track is clean and the gel foam goes easily. How much gel foam do you inject, Ashley? You can just do a few cc's. You know, the concept is, is that you have the coils in there already as scaffolding. And you really, I mean, if you look at what IR does, they really pack those coils in. So I think you shouldn't be shy. If you had a big space like that, I mean, you could probably put five coils easily. If you had the big ones, five coils easily into the space. And then the gel foam is just a little added bonus. We also sometimes add contrast to the gel foam just within that slurry. And then you can watch on fluoro and see it sort of stay within the varix. Also look for flow, right, if there's no more flow. And the beauty of the gel foam is it's not off-label use. Whereas cyanoacrylate, it's off-label for injecting into vessels, which, I mean, people do, but it's just, you know, patients have to be aware it's off-label. But also the gel foam, the slurry is something that will sort of stick around for about three days. And then the body can kind of recantalize. So if it does embolize, it's kind of less of a tragic thing. So we kind of like it. And it also doesn't polymerize quickly. It can sit on your back table all ready to go. So you don't have to feel like you're rushing around or you have to worry about ruining your US scope. While we're talking gel foam, I just want to show the package in case any of the attendees are thinking about adopting it in their practice. This is what Ashley's talking about, is what she uses. And it was really simple to prepare compared to some of the cyanoacrylate agents. I've used cyanoacrylate in the past when we can get it. And depending on the number of carbons in your cyanoacrylate, the smaller number of carbons, the faster it polymerizes. So some are required to, you have to cut with lipidol, which slows down the polymerization. Dermabond, I think, is an eight carbon molecule so that it polymerizes a little bit more slowly. That's good because there's less risk that it will get stuck to your scope. But it's less good because it can have a higher rate of embolization. And so I like this idea of using the gel foam as a supplement to the coils. There are a number of makers, sorry, who make that. So it's absorbable gel sponge or something. Absorbable sponge. So you can get it from a number of producers. And they do make pre-made syringes, but I'm sure they're more expensive. So it's just easy. IR has this. You can just go down or the OR and just get a little sheet and cut it up into little bits. I think the biggest question comes is with patient selection, which patients go to IR and which patients will come to us for EUS guided glue and coil embolization. Dr. Maranki, do you have any tips for this? Our approach is not very standardized. Our approach is not very standardized either. Yeah, no. There's sort of a varying adoption across our institution and among the endoscopists regarding their willingness to pursue it versus not, as well as availability. It's not always depending on the endoscopy schedule. Sometimes patients will not be good candidates for coming to endoscopy. I think ours as well. We definitely have an algorithm, though. We actually did develop. And it's patients who are candidates for TIPS, that's probably what they should get. And if there's a contraindication. But also you have to make sure there's no shunt on a CT scan. So if they have a shunt, they should go for BRTO. So patients who have no shunt who are not TIPS candidates, we will generally consider coil and glue, unless IR gets to them first. Did you mention echocardiogram too? That's part of an algorithm for determining even if a patient's a candidate for gel foam. No, we don't do that. No, we don't. That's not in our algorithm, actually. And then I guess while we're on the topic of varices, this is a little not related to what we're doing today. But we've had conversations at lunch today about the role of endoscopic stenting in the management of variceal bleeding that is refractory to banding. Do you have any experience with that, Dr. Foe? Negative. Yeah, it's apparently a part of the Bivino consensus guidelines that, you know, it's an alternative to Blakemore tube in the setting of refractory esophageal strictures, excuse me, esophageal varices that have been, you know, unable to be banded or refractory to banding or bleeding despite banding. In my experience, we've had really good success with the gastric balloon in a Blakemore tube, but it is something that's been considered and been used at our institution for refractory bleeds with fairly decent results. It's probably an N of 3 now at this point. But I'm not totally convinced of its success just because there's no stricture, there's a high rate of migration. And I think it's going to have an evolving role in endohepatology.

EUS-guided coil placement

gastric varices treatment

nester coils

gel foam supplement

endoscopic stenting