Hi, I'm Marvin Yu with the ASGE video tip for EUS-guided coiling of gastric varices. These are my relevant disclosures. To highlight this technique, I'd like to present a case of a 51-year-old woman with a history of alcoholic cirrhosis who presented with large volume hematemesis. On the left is an endoscopic image of her gastric varices taken four months prior. On the right is endoscopic footage of her gastric variceal hemorrhage. The amount of blood clot in the stomach prevents an adequate endoscopic view of the bleeding source. However, I'll show momentarily that EUS is able to delineate the entire variceal anatomy. The Serin classification system is the classification system most often used for gastric varices. The varices in this case is IGV-1, or isolated gastric varices type 1. There are no esophageal varices and the gastric varices are located in the cardiofungal region. The other common bleeding type is GOV-2, or gastroesophageal varices type 2. These are similar, but with concomitant esophageal varices. These two types, IGV-1 and GOV-2, are most amenable to EUS-guided therapies. Here is a treatment algorithm for bleeding gastric varices. Keep in mind that according to current AASLD guidelines, the treatment of choice for bleeding IGV-1 and GOV-2 gastric varices is TIPS. However, initial endoscopic management is possible, particularly at the time of diagnosis and where expertise is available. For IGV-1 and GOV-2, thrombogenic agents can be injected. Moreover, EUS provides a platform for controlled delivery. Now, before starting the procedure, remember the following. You need a minimum of two large-bore IVs, and I usually have packed red blood cells cross-matched in the room. General anesthesia with endotracheal inhibition is key, and fluoroscopy can be helpful, particularly if you are early in your coiling experience. During the procedure, position the patient supine or supine with a slight leftward tilt. Aim for the scope to be in the distal esophagus to assess the gastric varices in transesophageal fashion. This is ergonomically favorable. You can fill the stomach with 100 to 250 cc's of water to optimize the EUS view of the gastric varices. This will help to delineate intramural versus extramural vessels. Finally, rotate towards your right shoulder away from the patient to visualize the cardiofundal region. This position allows your assistant to better assist with the needle, and coil delivery is necessary. Assess the variceal region. You may be able to identify a feeder vessel, which can be preferentially targeted. Exclude the extramural collaterals. Measure the largest radial diameter of the gastric varice. This is important for choosing the correct needle size and the correct coil size. Personally, I use a 19-gauge needle for vessel diameter greater than 5 millimeters and a 22-gauge needle for vessel diameter less than 5 millimeters. For choosing the correct coil, let's review basic coil features. Here are commonly used hemostatic coils. These are constructed of a platinum core covered in synthetic fibers. The packing of the coil within a vessel plus the synthetic fibers promote clot formation. They can be used singly or in multiples. They are stored and loaded or advanced in a linear configuration, but are predisposed to assume various shapes in free space, such as the cylinder shown here. There are three important numbers to note. The wire diameter, either 0.035 inch or 0.018 inch, the diameter of the cylinder that is ultimately produced, and the length of the wire. Now, 0.035 inch wires fit through a 19-gauge F&A needle, while 0.018 inch wires fit through a 22-gauge needle. Now, here is how the coils are loaded in an F&A needle. The stylet is used to initially load the coil into the back of the F&A needle. The introducer is then removed, and then the stylet is reinserted to act as a pusher. Now leave some of the stylet hanging out of the F&A handle until you are ready to deploy the coil. This is what the coils look like when they are being extruded from the needle tip. There are different approaches to coil injection. Some endoscopists routinely inject one or two coils, followed by an adjunct like cyanacrylate glue. In this strategy, it is important to choose a coil diameter at least 30% greater than the diameter of the target vessel to prevent the coil from washing away. Personally, I choose the largest coils, advance the 19-gauge needle into the distal-most compartment of the gas varix, and inject the coil until it achieves a dense pack. Then withdraw the needle into the next compartment to inject more of the coil, and so forth. In some large varices, I inject up to five or more coils. Fluoroscopy is not absolutely necessary, but can be helpful to visualize packing of the coil. In contrast, it can be injected to assess for runoff. A doppler is also critically important to assess for degree of hemostasis. At the conclusion, you can inject an adjunct again, such as glue, thrombin, or gel foam. Now back to our patient. Here are endoscopic images before the bleed, during the bleed, and one year after. As you can see, her cardiofundal varices have been obliterated. In conclusion, EUS guidance allows for targeted treatment of gas varices with coils and other adjuncts. An EUS approach is best suited for IgV1 and GoV2 gas varices. Finally, where available, EUS coiling could be the initial step in a step-up strategy.

EUS-guided coiling

gastric varices

alcoholic cirrhosis

thrombogenic agents

coil sizes