EUS guided feeder vessel embolization of gastric varices

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Authors: Ashish Agarwal, Chhagan Lal Birda, Ankit Agarwal

Case Report

A 42-year-old female patient with cirrhosis secondary to hepatitis C presented to the gastroenterology clinic of our hospital. Routine Upper GI endoscopy (UGIE) was done for variceal screening, which showed a large globular isolated fundal varix at the lesser curvature (IGV-1, F3). There were no esophageal varices. There was no jaundice or ascites and the MELD score was 16. After discussion with interventional radiology, she was planned for EUS-guided embolization of feeder vessel of the fundal varix using coils and cyanoacrylate glue.

Conduct

For this procedure, the MicroNester embolization coil (Cook Medical) of diameter 12 mm was used.

The steps of the procedure are as follows:

1. Identification of the feeder vessel: A gastric varix will have an inflow (feeder) and an outflow tract (gastrorenal shunt). The feeder will connect the varix with the splenoportal axis, while the outflow will connect the varix with the renal vein. Thus, it is important to trace the entire tortuous route of the feeder and document its origin from the splenoportal axis to avoid mispuncture of an outflow tract.

2. Puncture the feeder varix with a 19 G FNA needle and confirm intravariceal position by aspiration of blood.

3. If the varix is also visible on the screen, pushing agitated saline at this stage may confirm the flow of agitated saline towards the varix.

4. Place a coil inside the varix. The size of the coil chosen should be 10-12 mm in diameter. The number of coils needed is generally one to two.

5. Push 2 ml of glue after the placement of the coil.

6. Remove the needle and confirm absence of flow in the varix on Doppler examination.

7. Observe for 6-12 hours.

In the current case, the patient was discharged 6 hours post-procedure.

Follow up

Repeat EUS after 4 weeks (Video 2) shows obliteration of the varix with no flow on Doppler study.

Commentaries

EUS-guided vascular intervention has significantly expanded the scope of both diagnostic and therapeutic approaches for vascular pathologies. Despite its increasing clinical application, there remains a paucity of data regarding the standardization of procedural techniques.

EUS-guided fundal varix embolization has emerged as a safe and effective modality and has transformed the management of gastric varices. Although endoscopic cyanoacrylate glue injection under direct visualization is feasible, it is associated with a substantial risk of adverse events. These include systemic embolization to the lungs, brain, or spleen, leading to serious complications, as well as local complications such as perforation, venous thrombosis, sepsis, and tissue necrosis. Procedural challenges, including needle adherence and glue clogging of the endoscope channel, necessitate meticulous technique, and appropriate personal protective equipment, particularly eye protection.

Identifying the feeding vessel can be technically challenging, and sometimes multiple feeder vessels may be present. Furthermore, differentiation between inflow and outflow tracts on EUS imaging is often difficult. While the technical approach is similar and does not confer a clear advantage over direct EUS-guided variceal embolization, targeting the feeder vessel does decrease the number of coils required to achieve effective embolization and reduces the need for reintervention.

How to cite this article

Agarwal A, Birda CL, Agarwal A. EUS guided feeder vessel embolization of gastric varices. Endoscopia Terapeutica, 2026 Vol I. Disponível em: https://endoscopiaterapeutica.net/pt/casosclinicos/eus-guided-feeder-vessel-embolization-of-gastric-varices/