Coil plus glue therapy beneficial for gastric varices

Cyanoacrylate (CYA) injection delivers better results when augmented with endoscopic ultrasonography (EUS)-guided coil embolization for gastric variceal obliteration in a single-centre study.

CYA glue injection has been the standard treatment for gastric varices for nearly 4 decades; however, the risk of embolization remains uncertain. [Endoscopy 1987;19:221-224; Am J Gastroenterol 2003;98:1982-1988; Clin Gastroenterol Hepatol 2010;8:760-766]

“EUS enhances the ability to [locate varices accurately] and minimizes glue usage for variceal obliteration, reducing embolization risk. Refinements, such as combining coils with glue, appear to enhance obliteration and decrease embolization risk,” said the researchers. “Coils provide a scaffold with interwoven synthetic fibres for the CYA glue, enhancing adherence and clotting, while reducing embolization risk.”

To validate this hypothesis, the investigators compared the efficacy of EUS-guided coil + CYA against CYA alone in cirrhosis patients with gastric varices. Fifty patients (mean age 41 years, 72 percent men) were randomized 1:1 to either arm. The cirrhosis was primarily due to alcohol (~50 percent), followed by nonalcoholic steatohepatitis (20 percent). Technical success rates were 100 percent for both arms. [Endoscopy 2025;57:107-115]

During the initial intervention, all 24 patients (100 percent) in the combination arm had complete cessation of blood flow. With CYA alone, 24 of the 26 patients (92.3 percent) achieved this endpoint. A comparison between arms yielded a p-value of 0.49.

Median glue volume needed to achieve complete obliteration was lower in the combination vs CYA alone arm (1.5 vs 3.5 mL; p<0.001).

Rebleeding episodes were also numerically lower with combination therapy than CYA alone, both at 0–12 (n=1 vs 4) and 12–24 weeks (n=1 vs 5), but the comparisons fell short of statistical significance (p=0.35 and p=0.08, respectively).

At 12 weeks post-procedure, coil + CYA led to fewer varix reappearances on EUS (12.5 percent vs 19.2 percent; p=0.70) and significantly fewer reinterventions (20.8 percent vs 53.8 percent; p=0.01) than CYA alone.

The mean time to reintervention was significantly longer with the combination treatment vs the comparator (44.3 vs 24.6 weeks; p=0.01). According to the investigators, reinterventions were attempted for rebleeding episodes during follow-up or variceal reappearances seen via EUS at 12 weeks.

The mean survival time differed significantly between the intervention and comparator arm (48.3 vs 42 weeks; p=0.04), and the mortality rate was lower with the former vs the latter (29.2 percent vs 34.6 percent; p=0.77). The deaths were attributed to bleeding (n=2 and 3, respectively), hepatic encephalopathy (n=4 in each arm), and other causes (n=1 and 2).

Overall, no major adverse events were reported. Three patients in the combo arm experienced early complications (two cases of abdominal pain and one case of fever), whereas in the CYA arm, there were five (two abdominal pain, three fever).

Gastric variceal bleeding a serious issue

“Gastric variceal bleeding [is] a significant concern for all cirrhotic patients … [and] is life-threatening, with significant rebleeding risk despite standard CYA glue injection therapy,” said the researchers.

The findings support EUS for addressing gastric variceal bleeding. “The implementation of EUS-guided techniques for variceal obliteration is safe and contributes to an effective therapeutic toolkit, ultimately improving survival rates,” said the researchers.

Despite the small sample size, the results align with evidence reflecting the efficacy of combined coil and glue usage in a single session. [Gastrointest Endosc 2011;74:1019-1025; Arq Gastroenterol 2019;56:99-105] “The findings unequivocally endorse the combined use of coils with CYA glue to achieve effective and comprehensive gastric variceal obliteration compared with either approach alone,” they said.

“However, before these findings can be generalized, it is imperative to evaluate resource availability and cost-effectiveness of the combined procedure relative to glue therapy alone,” the researchers noted.