Endoscopic Ultrasound-Guided Coil Injection Therapy in the Management of Gastric Varices: The First U.S. Multicenter Experience

Background and aims Despite the significant morbidity associated with gastric variceal bleeding, there is a paucity of high-quality data regarding optimal management. Endoscopic ultrasound-guided coil therapy (EUS-COIL) has recently emerged as a promising endoscopic modality for the treatment of gastric varices (GV), particularly compared to traditional direct endoscopic glue injection. While data exists on the feasibility and safety of EUS-guided coil therapy in the management of GV, these have been limited to select centers with particular expertise. The aim of this study was to report the first U.S. multicenter experience of EUS-COIL for the management of gastric varices. Methods Retrospective analysis of patients with bleeding GV or GV at risk of bleeding who underwent EUS-guided coil injection therapy at 10 US tertiary care centers between 2018 and 2022 were included. Baseline patient and procedure-related information were obtained. EUS-guided coil therapy entailed the injection of 0.018 or 0.035” hemostatic coils using a 22G or 19G fine needle aspiration needle. Primary outcomes were technical success (defined as successful deployment of coil into varix under EUS guidance with diminution of Doppler flow), clinical success (defined as cessation of bleeding if present and/or absence of bleeding at 30 days post intervention), and intraprocedural and post procedural adverse events. Results A total of 106 patients were included (mean age 60.4 ± 12.8, 41.5% female). The most common etiology of GV was cirrhosis (71.7%), with alcohol being the most common cause (43.4%). 71.7% presented with acute GV bleeding requiring intensive care unit stay and/or blood transfusion. The most common GV encountered were isolated gastric varices type 1 (60.4%). A mean of 3.8 ±/-3 coils were injected with a total mean length of 44.7 +/- 46.1 cm. Adjunctive glue or absorbable gelatin sponge was injected in 82% of patients. Technical success and clinical success were 100% and 88.7% respectively. Intraprocedural complications (pulmonary embolism and GV bleeding from FNA needle access) were seen in 2 patients (1.8%) while post procedure complications were seen in 5 (4.7%), of which 3 were mild. Recurrent bleeding was observed in 15 patients (14.1%) at mean 32 days. Eighty percent of patients with recurrent bleeding were successfully re-treated with repeat EUS-COIL therapy. No significant differences were observed in outcomes between high volume (>15 cases) and low volume (<7 cases) centers. Conclusions This U.S. multicenter experience on EUS-guided coil injection therapy for GV confirms high technical and clinical success with low adverse events. No significant differences were seen between high and low volume centers. Repeat EUS-guided coil injection therapy appears to be an effective rescue option for patients with rebleeding GV. Further prospective studies should compare this modality to other interventions commonly used for GV. Despite the significant morbidity associated with gastric variceal bleeding, there is a paucity of high-quality data regarding optimal management. Endoscopic ultrasound-guided coil therapy (EUS-COIL) has recently emerged as a promising endoscopic modality for the treatment of gastric varices (GV), particularly compared to traditional direct endoscopic glue injection. While data exists on the feasibility and safety of EUS-guided coil therapy in the management of GV, these have been limited to select centers with particular expertise. The aim of this study was to report the first U.S. multicenter experience of EUS-COIL for the management of gastric varices. Retrospective analysis of patients with bleeding GV or GV at risk of bleeding who underwent EUS-guided coil injection therapy at 10 US tertiary care centers between 2018 and 2022 were included. Baseline patient and procedure-related information were obtained. EUS-guided coil therapy entailed the injection of 0.018 or 0.035” hemostatic coils using a 22G or 19G fine needle aspiration needle. Primary outcomes were technical success (defined as successful deployment of coil into varix under EUS guidance with diminution of Doppler flow), clinical success (defined as cessation of bleeding if present and/or absence of bleeding at 30 days post intervention), and intraprocedural and post procedural adverse events. A total of 106 patients were included (mean age 60.4 ± 12.8, 41.5% female). The most common etiology of GV was cirrhosis (71.7%), with alcohol being the most common cause (43.4%). 71.7% presented with acute GV bleeding requiring intensive care unit stay and/or blood transfusion. The most common GV encountered were isolated gastric varices type 1 (60.4%). A mean of 3.8 ±/-3 coils were injected with a total mean length of 44.7 +/- 46.1 cm. Adjunctive glue or absorbable gelatin sponge was injected in 82% of patients. Technical success and clinical success were 100% and 88.7% respectively. Intraprocedural complications (pulmonary embolism and GV bleeding from FNA needle access) were seen in 2 patients (1.8%) while post procedure complications were seen in 5 (4.7%), of which 3 were mild. Recurrent bleeding was observed in 15 patients (14.1%) at mean 32 days. Eighty percent of patients with recurrent bleeding were successfully re-treated with repeat EUS-COIL therapy. No significant differences were observed in outcomes between high volume (>15 cases) and low volume (<7 cases) centers. This U.S. multicenter experience on EUS-guided coil injection therapy for GV confirms high technical and clinical success with low adverse events. No significant differences were seen between high and low volume centers. Repeat EUS-guided coil injection therapy appears to be an effective rescue option for patients with rebleeding GV. Further prospective studies should compare this modality to other interventions commonly used for GV.