EUS-guided injection of cyanoacrylate in perforating feeding veins in gastric varices: results in 5 cases.

BACKGROUND: Bleeding from gastric varices can be challenging because of its high mortality and recurrent bleeding rates. Endoscopic therapy with tissue adhesives can control acute hemorrhage, but recurrent bleeding could appear if obliteration is not achieved, and endoscopic vision could be troublesome in the case of massive hemorrhage. The glue injected could be responsible for embolic phenomena and local complications. EUS has proved useful in minimizing the risk of recurrent bleeding from gastric varices, accurately showing if they are obturated or not. The presence of perforating veins detected by EUS has been reported as a risk factor for recurrent bleeding from esophageal varices. OBJECTIVE: To assess the efficacy of EUS-guided cyanoacrylate injection in gastric varices at the entrance of the perforating veins to obtain variceal obturation. DESIGN: Open-basis case series study. SETTING: Tertiary care, academic medical center, Seville, Spain. PATIENTS: Five consecutive patients with gastric varices were enrolled from May 2005 through May 2006. INTERVENTIONS: We injected cyanoacrylate-lipiodol in gastric varices with 22-gauge needles by EUS guidance. MAIN OUTCOME MEASUREMENTS: To analyze the obliteration of gastric varices, the recurrent bleeding rate, and safety of EUS-guided cyanoacrylate-lipiodol injection. RESULTS: EUS-guided injection of the perforating veins by using cyanoacrylate-lipiodol was successful in eradicating gastric varices in the 5 patients treated, without recurrent bleeding or other complications during the study follow-up. LIMITATION: This is a single-center nonrandomized study. CONCLUSIONS: EUS-guided injection of cyanoacrylate at the level of the perforating veins in the treatment of gastric varices seems to be a safe, efficient, and accurate approach. Further controlled studies are warranted.

Recombinant-activated factor VII as hemostatic therapy in eight cases of severe hemorrhage from esophageal varices.

BACKGROUND AND AIMS: There are several treatment options for gastroesophageal variceal hemorrhage. In severe cases, bleeding persists and is associated with a dismal outcome. The coagulation disorders might be correlated with risk of bleeding in patients with portal hypertension. The administration of activated recombinant factor VII corrects prothrombin time transiently in nonbleeding patients with cirrhosis as well as in bleeding ones. The aim of this study was to assess the hemostatic efficacy of activated recombinant factor VII in bleeding esophageal varices. METHODS: Between May 2001 and September 2002, 112 patients with cirrhosis and an episode of acute esophageal variceal bleeding were admitted. On an open basis with a single intravenous dose of 4.8 mg of recombinant factor VII, we treated 8 patients experiencing severe and active hemorrhage from esophageal varices unresponsive to pharmacologic therapy, endoscopic therapy, or balloon tamponade. RESULTS: Eight (7%) of 112 patients met entry criteria. Hemostasis was achieved in all the cases after recombinant activated factor VII therapy. Rebleeding and mortality rates were 25% and 50% (2 and 4 patients), respectively. CONCLUSIONS: In our experience, recombinant activated factor VII achieves hemostasis in bleeding esophageal varices unresponsive to standard treatment.