Is EUS (Endoscopic Ultrasonography) + Coiling and glue suitable for primary prophylaxis of large fundal varices in an elderly patient with liver cirrhosis and portal hypertension?

EUS-Guided Coiling and Glue for Primary Prophylaxis of Large Fundal Varices in Elderly Patients

EUS-guided coil and cyanoacrylate injection can be used for primary prophylaxis of large fundal varices in elderly patients, with excellent safety and efficacy demonstrated in a dedicated study showing only 2.5% bleeding rates and 4.9% adverse events over 3 years of follow-up. 1

Evidence Supporting Primary Prophylaxis with EUS-Guided Therapy

The most compelling evidence comes from a single-center observational study specifically examining EUS-guided coil and cyanoacrylate injection (EUS-CCI) for primary prophylaxis in 80 patients with high-risk gastric varices (>10 mm or cherry red spot). 1 This study demonstrated:

• Technical success rate of 100% with EUS confirmation of variceal obliteration in 96.7% of cases 1
• Post-treatment bleeding occurred in only 2.5% of patients over a mean follow-up of 3.0 ± 2.4 years 1
• Adverse event rate of only 4.9%, with no deaths related to gastric variceal bleeding and no need for emergent TIPS during follow-up 1
• 67.7% achieved obliteration with a single treatment session, using a mean of 1.5 coils and 2 mL of glue 1

Why EUS-Guided Combination Therapy is Preferred

The combination of coils plus glue is superior to monotherapy. Meta-analyses demonstrate that EUS-guided combination therapy (coil + glue) achieves:

• Hemostasis rates of 96-98% with adverse event rates of only 10% 2
• Significantly fewer recurrences (5%) compared to glue alone or coils alone 2
• Superior gastric variceal obliteration (84%) compared to direct endoscopic injection (63%, P = .02) 2

The combination approach reduces the risk of glue embolization while providing mechanical stabilization with coils, making it particularly appropriate for elderly patients who may be at higher risk for complications. 2

Specific Considerations for Elderly Patients

Age itself should not be a contraindication to EUS-guided therapy for primary prophylaxis, as the procedure demonstrates:

• Very low adverse event rates (0-7%) across multiple studies 2
• High technical success rates (approximately 99%) even in complex cases 2, 3
• Avoidance of more invasive alternatives like TIPS or BRTO, which may carry higher procedural risks in elderly patients 2, 3

The procedure is performed under general anesthesia with prophylactic antibiotics, which provides optimal conditions for precise needle placement and minimizes patient movement. 2

Clinical Algorithm for Decision-Making

For elderly patients with large fundal varices (GOV2 or IGV1 >10 mm), proceed with EUS-CCI if:

1. The varices are high-risk (>10 mm in size or have cherry red spots) 1
2. The patient has not previously bled from these varices 1
3. Your center has appropriate EUS expertise, as this is a technically demanding procedure requiring specific training 2
4. The patient can tolerate general anesthesia, which is preferred for EUS-guided procedures 2

Treatment technique involves:

• Using a 19-gauge or 22-gauge FNA needle via transgastric or transesophageal approach 2
• Targeting the intramural varix or perforator vein with Doppler guidance 2
• Placing 1-3 coils sequentially until Doppler flow is significantly reduced 2, 1
• Injecting cyanoacrylate (mean 2 mL) after coil placement 1

Important Caveats and Pitfalls

Do not confuse fundal varices (GOV2, IGV1) with lesser curve varices (GOV1). GOV1 varices extending along the lesser curvature should be managed like esophageal varices with beta-blockers or endoscopic variceal ligation, as they frequently disappear when esophageal varices are eradicated. 4

Ensure appropriate training and backup support. EUS-guided injection therapy requires specific training, and experienced interventional radiologists should be available in case of complications. 2 The technique is heterogeneous regarding vessel targeting, coil size/number, and injectate type, so institutional protocols should be established. 2

Consider post-procedure PPI therapy. While the evidence is primarily for post-endoscopic variceal obliteration, PPI use has shown decreased rebleeding risk (OR 0.554,95% CI 0.352-0.873). 3

Alternative Approaches if EUS Expertise Unavailable

If EUS-guided therapy is not available at your center, traditional endoscopic cyanoacrylate injection remains an option for fundal varices, though it has higher adverse event rates (21% vs 10% for EUS-guided combination therapy) and lower obliteration rates. 2, 3

Beta-blockers alone are insufficient for primary prophylaxis of isolated fundal varices, as the evidence for pharmacological prophylaxis applies primarily to esophageal varices and GOV1. 4, 5, 6