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Endoscopic ultrasound guided coil and glue placement is advocated as a better method for gastric variceal obturation. The coils are placed before glue injection and work as scaffold to retain glue, thus decreasing risk of glue embolization. We present a case of EUS guided coil and glue embolization for a large gastric varix, the patient had symptomatic pulmonary embolization despite use of coils.   

A 53-year-old male, who was a diagnosed case of Non-alcoholic steatohepatitis, related decompensated cirrhosis was referred to our institute with history of hematemesis, 4 days back. Esophagogastroduodenoscopy done outside revealed a large fundal varix; no intervention was done due to fear of bleed after endoscopic glue as it was a large varix. After informed consent, patient was planned for endoscopic ultrasound (EUS) guided combined injection of coil and cyanoacrylate (CYA) glue. A gastroscopy (Figure 1A) and EUS revealed a large fundal varix, which measured 2 cm at short axis (Figure 1B) and 6 cm at long axis. A total of 2 coils (20 mm diameter, 14 cm length, 0.035’’ thickness, Nester® embolization coil) were placed in distal followed by proximal part of varix through 19 G EUS-FNA needle (Figure 1C). The coil placement was followed by injection of 1 ml of CYA and 1 ml Lipiodol combination. The Doppler after some time of procedure showed markedly decrease flow at site of injection, however, a part of varix proximal to first site of injection remained patent. One more coil and 1 ml glue + 1 ml lipiodol was further injected in remaining patent part of varix after observation for some time post first. The whole procedure was done under fluoroscopic guidance and no embolization of glue was noted during procedure (Figure 1D), the Doppler application showed obliterated varix (Figure 1E). The patient complained of low-grade fever on second day post procedure. A chest roentgenogram was done, and cultures were sent. The chest X-ray revealed starry sky appearance due to glue embolization (Figure 1F). Glue embolization could be seen, as mixture of glue and lipiodol (which is radio opaque) was used. Patient’s work up for other causes of fever was negative and he improved with conservative management. Patient underwent a successful liver transplantation later. A chest X-ray done during pre-transplant work up, 1 month after procedure showed same findings, interestingly obturated gastric varix with coils and glue in situ was also visible (Figure 2). So, it was some part of glue that got detached and caused pulmonary emboli. 

Thromboembolization of endoscopic glue injection has been shown by various studies and it may be devastating in some patients.¹ EUS guided coil placement is associated with decrease risk of embolization as compared to glue injection. In fact, glue embolization was common but remained asymptomatic.² Combined EUS guided delivery of coil followed by CYA serves as a cost effective (fewer coils are needed) and safe (less amount of glue is needed, and coils act as a scaffold to retain the glue, thereby decreasing the chances of glue embolization) approach. This combined therapy had few adverse events only as noted in a retrospective analysis of 152 patients by Bhat et al.³ The current case highlights important aspects of EUS guided intervention for gastric varices. Adverse events are bound to happen in some patients and proper patient counselling is mandatory. Despite EUS guidance and use of coil to retain glue, some of the patients may have glue embolization as happened in index case. N-butyl-CYA has short polymerization time, thus it is common to mix lipiodol to increase polymerization time so that long EUS needle can be taken out after glue injection. Also, lipiodol makes injection of glue visible on fluoroscopy. N-octyl-CYA, which is not available here, has a longer polymerization time and thus mixing with lipiodol is not needed as shown by Bhat et al.³ As happened in present case, large gastric varices need extra precautions to prevent complications. Transjugular intrahepatic portosystemic shunt (TIPSS) placement was not done in current case as he was a candidate for liver transplantation, however, TIPSS should have a better role than EUS guided intervention in such (and selected) cases as TIPSS also solves issues of esophageal varices and ascites. We believe that safety data of EUS guided glue should be analyzed for small and large varices separately, then only we come to know about exact risk of embolization in large varices. It should be noted that we injected glue twice that might have increased risk of embolization. It was necessary as a large varix could not be obliterated by first injection and patient had history of variceal bleed, also coils were placed before each glue injection. This report raises some important but unanswered questions. Should we use EUS guided intervention (and not TIPSS) for such large varices? What is role of multiple times injection to achieve complete obturation versus single time injection and observation in follow up? It is also important to know that patients with pulmonary embolization may present as fever.⁴ 

Acknowledgements: none.

Funding and conflict of interest: None for any author.