Endoscopic ultrasound-guided vascular interventions: Current insights and emerging techniques

Abstract

Endoscopic ultrasound (EUS) is one of the significant breakthroughs in the field of advanced endoscopy. In the last two decades, EUS has evolved from a diagnostic tool to a real-time therapeutic modality. The luminal gastrointestinal (GI) tract provides a unique opportunity to access multiple vascular structures, especially in the mediastinum and abdomen, thus permitting a variety of EUS-guided vascular interventions. The addition of the doppler and contrast-enhanced capability to EUS has further helped provide real-time visualization of blood flow in vessels through the GI tract. EUS-guided vascular interventions rely on standard endoscopic accessories and interventional tools such as fine-needle aspiration needles and fine-needle biopsy. EUS allows the visualization of various structures in real-time by differentiating tissue densities and vascularity, thus, avoiding radiation exposure. EUS-guided techniques also allow real-time microscopic examination after target biopsy. Furthermore, many necessary interventions can be done during the same procedure after diagnosis. This article provides an overview of EUS-guided vascular interventions such as variceal, non-variceal bleeding interventions, EUSguided portal vein (PV) access with the formation of an intrahepatic portosystemic shunt, and techniques related to diagnosis of GI malignancies. Furthermore, we discuss current insights and future outlook of therapeutic modalities like PV embolization, PV sampling, angiography, drug administration, and portal pressure measurement.

Role of endoscopic ultrasound in vascular interventions: Where are we now?

“…Due to the detrimental high rupture risks of up to 20%, allow for EUS-guided therapy to be an effective option for patients[ 40 ]. Many case-reports and series outlined good outcomes with obliteration of pseudoaneurysm following EUS-guided treatment, as reported by Mann et al [ 27 ], in a recent review of the literature. Recently, one study by Rai et al [ 41 ], aimed to study EUS-guided glue and coil injection in six patients who failed angiographic embolization of splenic artery pseudoaneurysm.…”

“…The study concluded the use of EVL to be limited to collaterals running parallel to the varices whilst sclerotherapy to be used for paraesophageal veins with a larger diameter and a perforation pattern[ 18 ]. Furthermore, the utilization of EUS technology provided effective directed treatment option of pattern types that aided a successful clinical outcome[ 27 ]. Moreover, in one study that utilized a sclerosing agent targeted under EUS guidance, an average of 2 to 3 sessions required to achieve complete obliteration.…”

“…That anatomic proximity of the stomach and duodenum to major vascular structures, make EUS a vital technique in accessing structures such as the portal vein (PV). Existing applications of PV interventions using EUS include sampling, embolization, thrombolysis, and stent placement[ 27 ].…”

“…Following the development of the compact manometer, EUS-guided portal pressure gradient measurement with a needle in the PV and manometer, accurately reflect an indicator of liver disease[ 27 ]. Under EUS, a 22-gauge FNA needle connected to a compact manometer, accurate hepatic venous pressure gradient measurement can be attained[ 46 ].…”

Gender-Specific Coagulation Profiles of Peripheral and Portal Blood May Help to Differentiate Malignant from Benign Pancreatic Tumour—Pilot Study

“…Thus, derived from the same concept and safety profile as islet cell transplantation by interventional radiology using Doppler imaging guidance, in which the portal vein is accessed percutaneously, emerging reports have centered on sampling and investigating portal blood in patients with PDAC. Recently, the utility of EUS-guided vascular access of the portal vein for diagnostic and therapeutic interventions has been evaluated with a satisfactory safety profile [ 23 ].…”