This ASG video tip is sponsored by Braintree, maker of the newly approved Soufflave and Soutab. Hi, I'm Krishna Guram, I'm an assistant professor of medicine at Icahn School of Medicine at Mount Sinai, director of Endoscopy at Elmhurst Hospital in Queens, New York. Today, we're going to talk about gastric versus coil and glue technique. I have nothing to disclose. Now, to get a complete picture of the variceal gluing and coiling, there was an excellent ASG video tip that was done a few years ago by Marvin Roy. The link is below. I would recommend you guys to review that before this. This is just an adjunct to that. But to really understand gastric varices, a good understanding of the anatomy should be present. The gastric variceal is different than the esophageal varices because there are multiple efferent vessels that feed it, and there's different efferent vessels that drain it. When you look at the esophageal varices, it's usually supplied with the left gastric vein. The gastric varice, on the other hand, can be supplied with the left gastric vein, the posterior gastric vein, and the short gastric vein, all which can be in a different anatomical variation that can feed it. The efferent can be only from the gastrorenal or splenorenal shunt. Therefore, a simple banding that you can do in esophageal varices does not really control the bleeding in gastric varices. It can be a temporizing method, but not a final solution. That's why a combination of tips, borto, or coil and glue can be used. If you look at the serine classification and correlate it with the blood supply, it makes much more sense. In GOV1, the left gastric vein feeds the esophageal varices, and these esophageal varices extend to the lesser curvature. This is the one situation where the treatment by itself can be esophageal banding or GOV1 banding. For GOV2, it's a combination of left gastric vein, posterior gastric vein, and short gastric vein. Now, isolated gastric varices 1 are very similar to GOV2, as they're supplied by the short gastric vein and posterior gastric vein. And in isolated gastric varices 2, it's more supplied by the gastroepipoietic vein. We had a 41-year-old male with alcoholic cirrhosis who was brought in by EMS because of hematemesis and melanoma, which later turned out to have bright red blood prorectin. He has been having about 15 beers per day and has been binging for the last six months. His initial blood pressure was in the 70s and heart rate in the 130s, and a hemoglobin of 2.3, which did improve with fluid resuscitation and five units of packed RBC administration. His INR was 1.6 with a total bileo 1.8, and his AST was 70 with an elevated BN of 27. An endoscopy was subsequently performed, and in the fundus, a small red punctate area was present. With gentle water irrigation, there was massive bleeding that occurred. To get control of this acute bleeding, we put a bander, and in a retroflexed position in the stomach, we were able to band the gastric varix. We were able to achieve hemostasis, and the patient was hemodynamically stable. We knew that this was just a temporizing method. We had a discussion about tips versus Berto and coil and glue, and due to severe alcohol abuse and lack of follow-up, we felt that the coil and glue would be the best option. We usually use a 19-gauge needle, but a 22-gauge needle can be also used. We draw multiple syringes with defi water and try to avoid any ionizable material like normal saline. We usually use glass syringes, and like medallion, as lipoidol can cause breakdown of plastic. Because of the same reason, we also use glass or metal beakers. And finally, we use a Trufil system, which has the n-butylsanoacrylate, tantalum powder, and the lipoidol solution. We first take the n-butylsanoacrylate, and we put this into the beaker. This is about 1 mL in solution. Then we take 3 mL of lipoidol solution to have a 1 is to 3 ratio. You can have 1 is to 2 or 1 is to 1, depending on how early you want it to clot. Once this is mixed completely, we start using tantalum powder, as this has increased radio opacity and can be visualized in fluoroscopy. We tend to use fluoroscopy with our EUS for better visualization and for safety. Once the combination is mixed, we take multiple syringes with 0.5 mL of solution and have multiple vials with our D5 water in different syringes for flushing. Using a linear echoendoscope, we try to target the area of where the varices are present, and we do Doppler to understand their location and to find the feeding vessel. We also measure the size of the varice so as to put the corresponding coil in. As a routine, we use a 19-gauge needle to puncture the varice and aspirate blood. Then we flush it with D5 water. For confirmation, we also like to use Dopplers and find a venous hum. We inject contrast and do a CNA to identify the actual varices. It's important to remember to use full contrast instead of a 50-50 mixture of water to have a good visualization. We usually use the tornado embolization coils for 0.35 for bigger and 0.18 for the smaller varices, but the goal is to pack as much as possible. Once in the duct, we deploy the coil, which is very hyperechoic, as you can see in this imaging. Once the coil has been deployed, we use the 0.5 mL aliquots of the sinoacrylate mixture and flush it down, followed by D5 water flushes. We continue this process until no further flow on Doppler is seen on EUS. As you can see here, there is no further flow present that is seen on Doppler. On fluoroscopy, you can see the coils deployed and the sinoacrylate mixture, which perfuses through different areas of the varices and obliterates those areas. It's very important to understand the anatomy of the gastric varices. Measure the size of the varices to understand the length and size of the coil that needs to be utilized. Try to find a feeding vessel when possible to have better response, but anything is fine. Fluoroscopy is not essential, but it is helpful in deploying coils and glue. When using lipoidol, it is important to have glass or metal objects, as plastic material can melt. D5 water can be utilized for flushes. Also, the mixture of lipoidol to sinoacrylate can be modulated as needed to prevent early polymerization with a 1 is to 1 or 1 is to 3 ratio.

Krishna Guram

assistant professor of medicine

gastric varices

coil and glue technique

esophageal varices