Emergency tips recanalisation and gastroesophageal varices embolisation with an ethylene vinyl alcohol copolymer agent (Squid) and detachable coils

Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) is currently indicated as first therapeutic option in the main complications of portal hypertension, including bleeding gastroesophageal varices and refractory ascites. In case of bleeding gastroesophageal varices, an adjuvant embolisation within TIPS can be useful to prevent rebleeding. In the present technical note, the management in emergency of a patient with haemorrhagic shock due to bleeding gastroesophageal varices and occluded TIPS is reported. TIPS recanalisation with an adjunctive stent and high-pressure balloon angioplasty and gastroesophageal varices embolisation using detachable coils and a non-adhesive liquid embolic agent were performed during the same emergent procedure. After the procedure, clinical stabilisation of the patient was achieved, with blood transfusions suspension and Blakemore tube removal. At 6 months, regular TIPS patency at colour Doppler and no rebleeding episodes were recorded. To our knowledge, whilst coils are routinely used for varices embolisation, non-adhesive liquid embolic agents have been never mentioned. Liquid embolic agents seem to provide a stable plug strengthening the embolising action of the coils. Further studies involving a cohort of patients with long-term follow-up will be necessary to confirm whether this association can be more effective than coils alone in gastroesophageal varices embolisation.

Non-Adhesive Liquid Embolic Agents in Extra-Cranial District: State of the Art and Review of the Literature

“…The main disadvantages of EVOH include the need to use compatible microcatheters, the cost, and not least the mandatory use of dimethyl sulfoxide DMSO. EVOH indeed needs the previous injection of (DMSO) to allow the conduction inside the microcatheter and to guarantee the fluid formula that the agent is still on the target vessel, this solvent can cause vasospasm, endothelial wall damage, and not least pain [ 21 ] ( Table 1 ).…”

“…The association between NALEA and particles finds its rationale in the aim to close the central microcirculation (nidus) with the microparticles that must be primarily used and then ensure the occlusion of the feeding arteries with NALEA; this technique is well described in AVM embolizations [ 21 ].…”

Safety, Efficacy, and Outcomes of N-Butyl Cyanoacrylate Glue Injection through the Endoscopic or Radiologic Route for Variceal Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis

“…The choice of the best embolic agent, though, is still under debate. Different agents, such as vascular coils, vascular occlude, and liquid embolic agents such as NBCA or ethylene vinyl alcohol-based copolymers (Onyx ® or Squid ® ), can be used [ 3 , 4 , 6 , 70 , 71 , 72 , 76 ]. Lakhoo et al demonstrated that most gastric varices showed persistent patency despite TIPS decompression and variceal embolization using mechanical agents, metallic coils, and/or plugs (61% with varices embolization at a median of 128.5 days after TIPS creation) [ 77 ].…”

Visceral Artery Aneurysms Embolization and Other Interventional Options: State of the Art and New Perspectives

“…In the past, non-adhesive liquid embolic agents have been widely used in intracranial district for cerebral aneurysms [ 61 ], but rarely in abdominal district for VAAs [ 62 ]. Nowadays, ethylene vinyl alcohol copolymer (EVOH) agents, well-known as Onyx (Medtronic, Dublin, Ireland), Squid (Emboflu, Gland, Switzerland) and Phil (Precipitating Hydrophobic Injectable Liquid, MicroVention, Terumo, Austin, USA), are routinely used in many abdominal diseases [ 63 , 64 , 65 , 66 , 67 ] and also in splenic [ 68 ], hepatic [ 69 ], mesenteric [ 70 ] and renal aneurysms [ 71 ]. These liquid embolic agents are EVOH copolymers mixed with micronized tantalum powder and dissolved in dimethyl sulfoxide (DMSO).…”