Management of gastric varices with EUS-guided coil ablation

Abstract

Background and Aims: Gastric varices are associated with a greater risk of bleeding and mortality than esophageal varices. Standard treatments, including endoscopic cyanoacrylate injection and balloon retrograde transvenous obliteration, pose risks of arterial embolization in patients with a patent foramen ovale. This case highlights the use of EUS-guided coil embolization as an alternative approach. Methods: An 80-year-old man with cirrhosis, gastroesophageal varices, atrial fibrillation, type 2 diabetes mellitus, and coronary artery disease presented with hemodynamically significant upper gastrointestinal bleeding. Endoscopy revealed gastroesophageal varices with active stigmata of bleeding. A transthoracic echocardiogram with a bubble study confirmed a patent foramen ovale, increasing the risk of embolization with endoscopic cyanoacrylate or balloon retrograde transvenous obliteration. Given contraindications to a transjugular intravenous portosystemic shunt, EUS-guided coil embolization was performed. Results: Ten EUS-guided Nester coils were deployed until Doppler flow cessation was observed. Postprocedure endoscopy confirmed hemostasis, and hemoglobin levels stabilized. Follow-up endoscopy showed no active bleeding and shrinkage of gastric varices. The patient remained stable and was discharged 5 days postprocedure. Conclusions: EUS-guided coil embolization is a safe and effective alternative for managing gastric varices in patients with high arterial embolization risk.