Endoscopic ultrasound-guided intervention for gastric varices: sticky stuff might not (yet) be enough

Abstract

Bleeding gastroesophageal varices remain a devastating and life-threatening clinical condition that requires immediate and urgent intervention, with the ultimate goal being hemostasis. While esophageal varices (80 %-85 %) form the bulk of all variceal bleedings in patients with cirrhotic portal hypertension (PHT), gastric varices should not be ignored as a trivial remainder. The second, albeit less frequent, scenario in which gastric varices are found relates to prehepatic conditions (so-called left-sided PHT), such as noncirrhotic thrombosis of the portal/ splenic vein [1]. Gastric varices are classically divided into gastroesophageal varices (GOV) or isolated gastric varices (IGV), according to Sarin [1, 2]. This editorial focuses specifically on fundal type varices (GOV2 and IGV1), as they follow a different natural history course and represent the true endoscopic stalemate compared with GOV1 gastric varices, which are esophageal varices extending into the gastric lesser curvature and are treated similarly to esophageal varices, by endoscopic band ligation. Bleeding gastric varices, irrespective of their etiology, tend to bleed less frequently than esophageal varices; however, when they do bleed, the clinical situation is vastly more disheartening [1-3]. The reasons for this apparent discrepancy relate to greater difficulties in achieving hemostasis and, thus, greater propensity to rebleed, which in turn both lead to increased bleeding-related mortality. Multiple factors are considered essential in this situation, including the large submucosal component typical of gastric varices, the vascular anatomy feeding and draining the gastric varix, and most importantbut amenablethe lack of widespread treatment options and expertise available for this condition. Referring to Robles-Medranda C et al. p. 268-275 and Mohan BP et al. p. 259-267

Role of endoscopy in hepatology

“…Forty years later, this technique is still widely applied and considered the (best available) golden standard with hemostasis rates between 58 and 100%, rebleeding rates between 0 and 40% at the price of an emboligenic risk of 4% reported in initial cohorts [116 , 117] . These technical drawbacks have remained unchanged over time and relate in essence to the mutual reinforcing combination of an untargeted (some would call it "blind") nature of the conventional endoscopic approach on the one hand and the underappreciated complexity of the vascular anatomy of the culprit gastric varix [118] . Indeed, gastric varices consist of a large submucosal component with different feeding and draining vessels characterized in detail in different afferent and efferent venous in-and outflow types described by Kiyosue et al [119] .…”

“…An EUS-guided approach overcomes all these issues as EUS not only allows precise targeting of the vessels responsible for feeding the gastric varix but also directly monitors, via Doppler, the effect of therapy on variceal flow in real time, as well as the theoretical risk of embolization [118 , 123] . In addition to EUS-guidance, the combined application of vascular platinum coils (preferably with synthetic strands), which serve as a scaffold, with glue upgraded our game against gastric varices [118] . Binmoeller et al [123] were the first to report on this combined EUS-guided approach initially as a rescue strategy and later as a worthy, and even superior, alternative.…”

Advances in Endohepatology

“…This results in an initial hemostasis rate of 90% with a durable obliteration in 60% of patients but at the cost of a rebleeding rate of 15%-20% and an emboligenic risk of 4%. Therefore, our considered "gold standard" is better rephrased as the "best The American Journal of GASTROENTEROLOGY available" (54). The untargeted nature of this conventional approach together with the far much more complex vascular anatomy of gastric varices (compared with their esophageal counterparts) explain the suboptimal approach of conventional endoscopic injection of tissue adhesives (52,54).…”

“…Therefore, our considered "gold standard" is better rephrased as the "best The American Journal of GASTROENTEROLOGY available" (54). The untargeted nature of this conventional approach together with the far much more complex vascular anatomy of gastric varices (compared with their esophageal counterparts) explain the suboptimal approach of conventional endoscopic injection of tissue adhesives (52,54). Indeed, gastric varices usually consist of a large submucosal component with different feeding and draining vessels characterized in detail in different afferent and efferent venous inflow and outflow types by Kiyosue et al ( 55).…”

“…In addition, one should not lose track from the fact that endoscopic hemostasis for gastric varices bleeding is not the end but merely the beginning if one considers the background of the PHT syndrome associated with cirrhosis. In addition, the option of EUS coil and glue should be balanced against other potential nonendoscopic alternatives such as TIPS, balloon-occluded transvenous obliteration or coil-assisted retrograde transvenous obliteration, or shunt surgery and even liver transplantation (54). The most recent ESGE guideline (60) concluded that EUS-guided management of bleeding gastric varices combining injection of coils and cyanoacrylate may be used in centers with expertise and familiarity with this technique.…”