Endoscopic ultrasound-guided variceal therapy: tips, tricks, and pitfalls

EUS-guided variceal therapy (EUS-VT) is effective in eradicating cardiofundal varices. EUS-VT carries a higher success rate compared with direct endoscopic injection with fewer adverse events and fewer sessions. Herein, we aim to highlight important technical points to achieve successful EUS-VT outcomes.

In this video, we demonstrate room set-up, equipment preparation, variceal measurement, and proper coil and needle selection, along with coil loading, adjunct hemostatic delivery, and water-assisted visualization. Key pitfalls, including needle-coil mismatch, migration, and management of eroded coils, are also illustrated.

The first patient had large bleeding gastric varices and underwent EUS-VT with three 0.035-inch × 20-mm × 20-cm coils, using a sewing technique to prevent migration and provide stability of subsequent coil placement, followed by injection of 5 mL of absorbable gelatin sponge (Gelfoam; Pfizer Inc, New York, NY, USA). The second patient was referred with eroded coils from prior EUS-VT (where four 0.035-inch × 20-mm × 20-cm coils were placed and 7 mL of Gelfoam was applied); the coils were endoscopically removed using a forward-viewing gastroscope with a distal attachment cap and endoscopic scissors.

EUS-VT has demonstrated higher variceal obliteration rates and fewer required sessions compared with conventional direct endoscopic injection in published series; however, successful outcomes depend critically on the procedural technique and team expertise.