title: EUS-guided treatment of gastric fundal varices with combined injection of coils and cyanoacrylate glue: a large U.S. experience over 6 years (with video).
abstract: OBJECTIVE
  Conventional endoscopic treatment of gastric fundal varices (GFV) with cyanoacrylate (CYA) glue may be complicated by embolization and rebleeding. We evaluated the long-term outcomes of EUS-guided injection of coils and CYA glue for therapy of GFV.
  
  
  METHODS
  A retrospective chart review of patients treated for GFV was performed. The main outcomes measured were hemostasis, obliteration on surveillance EUS, post-treatment bleeding rate, and adverse events.
  
  
  RESULTS
  From March 2009 to 2015, 152 patients with GFV were treated. Seven (5%) had active hemorrhage, 105 (69%) had recent bleeding, and 40 (26%) were treated for primary prophylaxis. Treatment was technically successful in 151 patients (>99%). Mean number of coils was 1.4 (range, 1-4 coils), and mean volume of CYA was 2 mL (range, 0.5-6). Follow-up was available for 125 patients with treated GFV (mean, 436 days; range, 30-2043). Among 100 patients with follow-up EUS examinations, complete obliteration (on Doppler study) of GFV was confirmed in 93 (93%). Post-treatment bleeding from obliterated GFV occurred in 3 of 93 patients (3%). Twenty-five patients who had clinical and/or EGD follow-up had 3 post-treatment bleeding episodes after a median follow-up of 324 days (range, 41-486). Among the 40 patients treated for primary prophylaxis, 28 underwent follow-up EUS and 27 (96%) had confirmed obliteration. Mild postprocedure abdominal pain occurred in 4 of 125 patients (3%), and clinical signs of pulmonary embolization were seen in 1 patient (1%). Another 4 of 125 patients (3%) presented with minor delayed upper GI bleeding from coil/glue extrusion.
  
  
  CONCLUSIONS
  EUS-guided combined coil and CYA glue injection of high-risk GFV appears to be highly effective for hemostasis in active bleeding and primary and secondary bleeding prophylaxis. Once obliteration was achieved, post-treatment bleeding from GFV occurred in only 3% during long-term follow-up. Combination therapy appears safe and may reduce the risk of CYA embolization.
authors.affiliation: Paul May and Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California, USA.
authors.forename: Yasser M
authors.initials: YM
authors.lastname: Bhat
authors.affiliation: Paul May and Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California, USA.
authors.forename: Frank
authors.initials: F
authors.lastname: Weilert
authors.affiliation: Paul May and Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California, USA.
authors.forename: R Todd
authors.initials: RT
authors.lastname: Fredrick
authors.affiliation: Paul May and Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California, USA.
authors.forename: Steven D
authors.initials: SD
authors.lastname: Kane
authors.affiliation: Paul May and Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California, USA.
authors.forename: Janak N
authors.initials: JN
authors.lastname: Shah
authors.affiliation: Paul May and Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California, USA.
authors.forename: Chris M
authors.initials: CM
authors.lastname: Hamerski
authors.affiliation: Paul May and Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California, USA.
authors.forename: Kenneth F
authors.initials: KF
authors.lastname: Binmoeller
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003131:Combined Modality Therapy; D003487:Cyanoacrylates / Q000627:therapeutic use*; D004621:Embolization, Therapeutic / Q000379:methods*; D019160:Endosonography; D004932:Esophageal and Gastric Varices / Q000628:therapy*; D005260:Female; D005748:Gastric Fundus; D006471:Gastrointestinal Hemorrhage / Q000517:prevention & control* / Q000628:therapy; D005773:Gastroscopy / Q000379:methods*; D016558:Hemostasis, Endoscopic; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D025321:Surgery, Computer-Assisted; D013523:Surgical Equipment; D014014:Tissue Adhesives / Q000627:therapeutic use*; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D003487:Cyanoacrylates; D014014:Tissue Adhesives