|Year : 2018 | Volume
| Issue : 4 | Page : 228-235
EUS-guided vascular interventions
Idan Levy, Kenneth F Binmoeller
Paul May and Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California
|Date of Submission||15-Apr-2018|
|Date of Acceptance||07-Jul-2018|
|Date of Web Publication||16-Aug-2018|
Dr. Kenneth F Binmoeller
Interventional Endoscopy Services, California Pacific Medical Center, 2351 Clay Street, 6th Floor, San Francisco, California
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Levy I, Binmoeller KF. EUS-guided vascular interventions. Endosc Ultrasound 2018;7:228-35
| Introduction|| |
EUS-guided therapeutic interventions are evolving in multiple different directions, affording therapy for various gastrointestinal (GI) conditions. High resolution imaging of mediastinal and abdominal vascular structures from the GI tract create an opportunity for precise vascular access and therapy. This chapter will provide an overview of the current clinical literature regarding EUS-guided vascular interventions, including management of nonvariceal and variceal GI bleeding, EUS-guided portal vein (PV) access and therapeutic implications, and EUS-guided cardiac access and therapy.
| Management of Nonvariceal Gastrointestinal Bleeding|| |
Endoscopic therapies for nonvariceal GI bleeding are well established and entail epinephrine injection,, contact coagulation,, clipping, and band ligation. While successful in most cases, treatment may fail in up to 15% of cases.,
The first report of EUS-guided therapy used a radial scanning echoendoscope to inject epinephrine/polidocanol through a standard sclerotherapy needle to treat a Dieulafoy's lesion. Levy et al. used a curved linear array echoendoscope to treat refractory bleeding in a case series of five patients with hemosuccus pancreaticus, duodenal ulcer, and GI stromal tumors. Patients presented with an average of three bleeding episodes requiring multiple transfusions and had failed multiple endoscopic and radiographic interventions. EUS was able to delineate the bleeding vessel, and alcohol or cyanoacrylate (CYA) was delivered through a 22-gauge fine-needle aspiration (FNA) needle. The absence of postinjection flow indicated hemostasis of the bleeding vessels, which was achieved in all cases without any complications or rebleeding over a mean follow-up of 12 months. Gonzalez et al. described a case series involving five patients with arterial GI bleeding, all refractory to previous endoscopic hemostasis attempts, from Dieulafoy's lesions, pancreatic tumor, pseudoaneurysm secondary to acute pancreatitis, and an arterial anomaly after pancreaticoduodenectomy. EUS-guided CYA or polidocanol injection achieved immediate control of hemorrhage, visualized by Doppler. One patient rebled, necessitating repeat EUS-guided therapy, and the remainder experienced no rebleeding during 9 months of follow-up. EUS-guided CYA injection into the distal arm of the splenic artery achieved successful hemostasis in a patient with life-threatening intracystic hemorrhage of a splenic pseudoaneurysm injured during EUS-guided pseudocyst drainage. Additional case reports describe the treatment of arterial pseudoaneurysms,,, Dieulafoy's lesions,, and a bleeding GI stromal tumor.
In a large series of 17 patients with nonvariceal bleeding, multiple modalities were used to achieve EUS-guided hemostasis, including coil embolization, band ligation, and injection of epinephrine, ethanol, hyaluronate, or CYA. For band ligation, EUS was used to mark the site of the vessel with a subepithelial tattoo. Before EUS, 16 of the 17 patients underwent a median of 2.5 esophagogastroduodenoscopies, 4 had prior unsuccessful radiologic interventions, and 3 had prior surgical interventions. Ten patients with available blood transfusion data received a median of 11 packed red blood cells units. Doppler confirmed either complete cessation or a marked decrease in flow in all patients receiving EUS-guided therapy. The procedure was performed with no adverse events. There was no recurrent bleeding in 15 patients during a median follow-up of 12 months. One patient with a gastric Dieulafoy's lesion needed one additional EUS-guided therapy after 38 months, and another patient with a rectally invasive prostate cancer continued to bleed.
To summarize, EUS-guided therapy of nonvariceal bleeding has been shown to be feasible and safe for peptic ulcer disease, Dieulafoy's lesions, bleeding tumors, and pseudoaneurysms. The abilities to directly visualize and target the bleeding vessel with a specific therapy and subsequently confirm hemostasis with real-time Doppler ultrasound are significant advantages of EUS-guided therapy. These advantages have translated into treatment success in patients with recurrent refractory bleeding.
| Management of Esophageal Variceal Bleeding|| |
Band ligation is the preferred technique for primary and secondary treatment of esophageal varices. Recurrent bleeding rates of 15%–65% have been reported , and are thought to be secondary to treatment failure of the perforating veins and collateral vessels feeding the esophageal varices.,
Lahoti et al. were the first to describe the use of EUS-guided endoscopic sclerotherapy for esophageal varices. Sodium morrhuate was injected into the perforating vessels until cessation of flow. A mean of 2.2 sessions was required to completely eradicate the esophageal varices. No rebleeding or complications were recorded over a 15-month follow-up. de Paulo et al. described a cohort of 50 patients with bleeding esophageal varices, randomized to conventional endoscopic sclerotherapy and EUS-guided sclerotherapy. No difference was found in the number of sessions to vessel obliteration or in rebleeding rates between the two groups. Rebleeding was significantly associated with the presence of collateral vessels.
The theoretical advantage of EUS-guided therapy for esophageal varices is the ability to identify and target collateral vessels. Further studies are needed to assess the practical clinical benefit, either in terms of reduction of a number of sessions to achieve vessel obliteration or reduction of rebleeding rates.
| Management of Gastric Variceal Bleeding|| |
Gastric varices (GVs) may be present in up to 20% of patients with portal hypertension, with up to a 65% bleeding rate over 2 years. GVs in connection with esophageal varices (gastroesophageal varices [GOVs]) are located along the lesser curve (GOV1) or at the cardia (GOV2). Isolated GVs (IGVs) are either in the fundus (IGV1) or sporadic, usually around the antrum or pylorus (IGV2). Endoscopic sclerotherapy of GVs is discouraged due to reports of prohibitive rates of adverse events including gastric ulceration, perforation, and rebleeding in 37%–53% of cases., Band ligation is also discouraged due to the larger size of GVs, coupled with a thick overlying mucosa, making suction of the entire varix into the bander difficult. If the contralateral wall of the varix is not captured, postbanding ulceration may lead to catastrophic bleeding. Endoscopic CYA injection for GVs, first described in 1986, has become the treatment of choice for GVs. Hemostasis rates of 58%–100% and rebleeding rates of 0%–40% have been reported. The major and most serious adverse event associated with CYA therapy is systemic embolization, including pulmonary embolism, cardiac embolism, splenic artery embolism, and paradoxical cerebral embolism in patients with foramen ovale. Additional complications include splenic vein thrombosis, renal vein thrombosis, entrapment of the needle in the varix by CYA and damage to the endoscope.
EUS has many conceptual diagnostic and therapeutic advantages in the management of GV. First, the detection rate of GV is increased, as reported by Boustière et al. (six-fold increase in detection rate). GV is located deep in the submucosa and therefore can be mistaken as thickened folds on endoscopy. Second, Doppler ultrasound can confirm posttreatment cessation of blood flow in real time. This advantage has clinical prognostic implications since residual patency of treated varices has been shown to correlate with rebleeding risk. Third, EUS-guided treatment lacks dependency on direct varix visualization, which may be impaired by retained food or blood in the stomach. Fourth, EUS guidance enables accurate delivery of the hemostatic agent into the varix lumen, avoiding paravariceal injection, which can occur in up to 60% of injections. Finally, the main deep “feeder” vessel may be visualized. Targeting the feeder may enable more effective treatment with a lesser quantity of the hemostatic agent. This may reduce embolization risk when using CYA, as suggested by Romero-Castro in a small pilot study  using a mixture of CYA and lipiodol.
As an alternative to glue injection that risks glue embolization, the deployment of stainless steel coils has been reported. The first case was described by Levy et al., treating a refractory ectopic choledochojejunal variceal bleed. Rebleeding occurred, though in the repeat EUS the treated varices were thrombosed. Additional coils were deployed into previously untreated varices. Romero-Castro et al. treated four patients with GVs, with successful obliteration in three patients.
Coils are made of metal alloy and contain radially extending synthetic fibers, which induce clot formation and hemostasis. Coils are 2–15 mm in length and loops are 2–20 mm in diameter. Coil selection is based on the size and diameter of the varix. Coils can be deployed through a 22-gauge needle (0.018” coil) or a 19-gauge needle (0.035” coil). The needle stylet is used to push and deploy the coil into the varix.
A retrospective trial comparing EUS-guided coil deployment to EUS-guided CYA injection found no difference in obliteration rate, number of sessions or rebleeding rate over a 17-month follow-up. Eleven out of 19 patients in the CYA group had adverse events, significantly more than in the coil group (58% vs. 9%, P = 0.01), 9 of whom had asymptomatic pulmonary embolism, found on computed tomography (CT), which was performed routinely for all patients postprocedure. Coil deployment was significantly more expensive than CYA injection; however, the hospital stay was longer in the CYA group.
The deployment of coils followed by immediate CYA injection [Figure 1] can offer three potential advantages over CYA injection alone: (1) the contribution of each method to hemostasis and varix obliteration may be additive; (2) the coil may concentrate the glue at the coil site, thus reducing the CYA volume needed for obliteration; (3) the coil can act as a scaffold to retain CYA within the varix, thus reducing the risk of embolization.
|Figure 1: (a) Type I isolated gastric variceal conglomerate in a patient with a history of bleeding. (b) Sonographic image of the 2.5 cm variceal conglomerate. (c) Deployment of a coil through a 19-gauge needle (arrow pointing to coil). (d) Coil and glue complex (creating acoustic shadow) with nearly no flow confirmed by Doppler. (e) Varix obliterated with coil extruding. (f) No varix seen on sonography with the coil visible in the gastric lumen (arrow)|
Click here to view
We first reported combined coil and glue treatment in 30 patients with recent bleeding from large GVs who were poor candidates for transjugular intrahepatic portosystemic shunt (TIPS). After coil deployment, a mean of 1.4 mL of CYA per patient was injected. Rebleeding occurred in 16.6%, with one rebleed attributed to GVs. Among 24 patients with follow-up, GV remained obliterated in 23 after a single session. There were no complications. We later published a larger series of 152 patients with a mean follow-up of 436 days. Of 100 patients, who had a follow-up EUS, 93% had confirmed varix obliteration. Recurrent bleeding attributed to GVs occurred in 10 out of 125 patients, of whom five had repeat EUS-guided therapy. Forty patients out of the total group had high-risk GVs with no history of bleeding and underwent prophylactic treatment. Obliteration of targeted GVs was achieved in 96% of patients; bleeding occurred in two patients from new varices, both successfully treated endoscopically. These data support consideration of primary prophylaxis of high-risk GV using combined EUS coil deployment and glue injection.
On a technical note, we approach GVs transesophageally with the echoendoscope in an orthograde position. This “retrograde” approach avoids puncture through the mucosa overlying the GV. When anatomically feasible, we include the thick fibromuscular diaphragmatic crus in the needle path. The rationale is that the crus serves as a stabilizing backboard to prevent back-bleeding. The transesophageal approach has the additional advantage of not being hindered by gastric contents, which tend to accumulate in the gastric fundus.
| Management of Ectopic Variceal Bleeding|| |
Bleeding from ectopic varices account for 1%–5% of all variceal bleeding. The most frequent site of bleeding is the duodenum, particularly the duodenal bulb, with mortality rates reaching up to 40%. Other anatomical sites are the small bowel, colon, rectum, and peristoma.
In a 2014 review of the literature, duodenal varices were treated with TIPS in 11 cases, balloon-occluded retrograde transvenous obliteration in 14, ethanolamine sclerotherapy in 1, endoscopic band ligation in 6, and CYA injection in 16. The same group reported on a patient with a refractory bleeding duodenal varix after endoscopic sclerotherapy treated with EUS-guided coil placement followed by glue injection. Additional cases of EUS-guided coil placement ± CYA injection of patients with bleeding duodenal varices have been reported.,
Rectal varices occur in 44%–89% of cirrhotic patients and are a significant cause of lower GI bleeding in patients with portal hypertension ,, although they pose a smaller risk of bleeding than gastroduodenal varices. Massive bleeding is reported with a frequency of 0.5%–3.6%.,, It has been shown that EUS can detect the presence and number of rectal varices better than endoscopy. The intramural rectal varices, perirectal collateral veins, and the communicating veins between them could be clearly observed with an ultrasonic microprobe. Sharma et al. described a series of five patients with lower GI bleeding, two of whom required EUS to identify the inevident rectal varices.
We and others have reported EUS-guided coiling and/or CYA injection for rectal varices.,, EUS-guided CYA injection has also been used for peristomal varices. EUS was postulated to have the advantages of inevident varix visualization, perforating vein identification, precise delivery of treatment directly into the varix, ability to target therapy unhindered by luminal contents, and confirmation of the absence of flow after therapy using Doppler imaging.
| EUS-Guided Portal Venous Access and Therapy|| |
Portal vein access and pressure measurements
PV angiography with pressure measurements can add important information for the management of patients with chronic liver disease and portal hypertension. Transcutaneous portal venography and pressure measurements are not performed in clinical practice due to technical difficulties and a high rate of complications. Currently, portal pressure is measured indirectly as the wedged hepatic portal venous pressure gradient, which is an unreliable surrogate in cases of prehepatic, presinusoidal, and posthepatic portal hypertension.
The PV can be easily identified by EUS, permitting access, contrast injection, and pressure measurement using a standard FNA needle. These were first performed in the porcine model using a 22-gauge needle by the tranduodenal extrahepatic route. In 15% PV pressure measurements were not attainable, most probably due to the small needle caliber and difficulty holding a stable needle position within the PV for continuous monitoring. Complications such as intraperitoneal bleeding in 1 pig out of 19 and subserosal hematoma formation in all pigs were described. A different group demonstrated a good-quality portal angiography, enabling continuous portal pressure measurements over 1 h, with consistent results and minimal variability, achieved by the transhepatic route with a modified catheter. Animal respiratory motions and movements of the endoscope operator did not influence the stability of the catheter within the PV. The transhepatic route is thought to prevent postprocedure hemorrhage due to a tamponade effect of the hepatic parenchyma on the needle and catheter track.
Huang et al. published the first study to measure the portal pressure gradient (PPG), the pressure gradient between the PV and the inferior vena cava (IVC)/hepatic vein (HV) in humans. They used a 25-gauge needle passed either through the transduodenal extrahepatic or the transgastric intrahepatic routes. A 100% procedural success with no complications was reported. Patients with cirrhosis had significantly higher PPG. In further analysis, PPG had excellent correlation with the presence of varices, portal hypertensive gastropathy, and thrombocytopenia. Tsujino et al. combined EUS-guided liver biopsy and PPG measurements. Adequate samples were obtained in 73% and recovery time was significantly shorter for the EUS procedure compared with percutaneous liver biopsy, with no reported complications. These studies establish the feasibility, efficacy, and accuracy of EUS-guided portal pressure measurement, aiding in diagnosis and management of portal hypertension. It also provides an accurate measurement of presinusoidal portal hypertension, as HV pressure gradient is not reliable in this setting.
EUS-guided FNA of portal vein thrombus
PV thrombosis (PVT) is a common complication of hepatocellular carcinoma (HCC). Venous thromboembolism is also a frequent complication of pancreaticobiliary tumors, occurring in 20%–36%.,, A malignant thrombus cannot be accurately distinguished from a bland thrombus by imaging studies, such as sonography, the usual modality used to detect a vascular thrombus. Transabdominal US-guided sampling of a PV thrombus may lead to false-positive results if traversing through liver tumor tissue and potentially can cause serious biliary or other vascular injuries. Furthermore, HCC can be diffusely infiltrating without an obvious mass. EUS-guided FNA of PVT may overcome these limitations by enabling direct access to the PV. A few studies have reported EUS-guided FNA of PVT to be safe and provide sufficient tissue for the diagnostic staging of HCC.,,, The transduodenal approach to the extrahepatic PV is best suited for direct access to the PV without passing through liver tissue. EUS-guided FNA of PVT has also been described in patients with tumors other than HCC. In addition to reports of EUS-guided FNA of PV thrombus, EUS-guided FNA of IVC thrombus to diagnose adrenocortical adenocarcinoma  and a pulmonary artery thrombus to diagnose a synchronous lung adenocarcinoma in a patient with pancreatic cancer  have been described.
EUS-guided FNA of remote malignant thrombi was reported in a large cohort study. Cytology was positive or suspicious for malignancy in 12 out of 17 patients. Three patients were upstaged and two patients converted from a resectable to nonresectable disease. This study highlights the ability of EUS to detect and diagnose occult tumor thrombi, which impacts cancer staging.
EUS-guided portal venous blood sampling
An additional role for EUS-guided diagnosis can be the collection of circulating tumor cells (CTCs) from portal venous blood. This is of particular interest in pancreaticobiliary tumors, CTCs of which are theoretically sequestered in portal circulation and filtered in the liver, thus possibly explaining their inconsistent detection in peripheral blood. This has been demonstrated in a study by Catenacci et al., in which CTCs were found in significantly more patients in the PV than in peripheral blood. Furthermore, a significantly higher number of CTCs were found in portal blood than in peripheral blood, sufficient enough to perform genomic and proteomic profile of the CTCs.
EUS-guided portal vein embolization
Selective PV embolization has been performed in animals before liver lobectomy to induce affected lobe atrophy and hypertrophy of the functional liver remnant.,
EUS-guided liver-directed chemotherapy and radiotherapy
With limited treatment options, patients with diffuse liver metastasis resort to palliative systemic chemotherapy. However, hepatic tissue drug levels may be suboptimal, limited by concurrent systemic toxicities, driving the need for targeted liver therapy. Transarterial microbead injection into the hepatic artery affords higher hepatic drug levels with lower systemic levels, but risks ischemic biliary strictures, as the bile duct blood supply relies on the hepatic artery. EUS-guided PV injection of chemotherapy has been described in animal models., Drug-eluting microbeads or nanoparticles were successfully injected with resultant significantly higher liver levels and lower systemic levels, in comparison to the levels achieved by systemic injection. These trials are encouraging as a new modality for hepatic metastases treatment while decreasing the systemic toxicity and biliary tract sclerosis rate associated with hepatic artery infusion therapy.
CT-guided implantation of iodine-125 seeds into PV tumor thrombi has been reported by Zhang et al. Out of 10 patients with PV tumor thrombosis secondary to HCC, five patients responded completely, five patients had a partial response, and 1 patient had a stable disease course. An EUS-guided approach would have theoretical advantages of more direct access with a decreased risk of vessel injury and malignant cell seeding.
EUS-guided creation of intrahepatic portosystemic shunt
TIPS is a well-recognized and frequently used treatment of portal hypertension and its complications, mainly for the prevention of acute or recurrent variceal bleeding and refractory ascites.,, Buscaglia et al. described the first EUS-guided creation of an intrahepatic portosystemic shunt in a live porcine model. Under EUS guidance, the HV and the PV were sequentially punctured, contrast was injected to confirm needle location within the PV, after which a guidewire was advanced through the needle to the PV, the needle was then removed and the stent was inserted over the wire with its distal end in the PV and its proximal end in the HV. There were no complications, including a 2-week survival period in two pigs.
Binmoeller et al. used a similar technique to deploy a fully covered lumen-apposing metal stent (LAMS) in a porcine model. Necropsy confirmed successful stent placement between the PV and the HV with no tissue injury or hematomas. Schulman et al. successfully deployed a LAMS for the creation of TIPS in five pigs. Placement of LAMS addressed the concern of stent migration. Technical success was 100%, with no bleeding on necropsy, but with two pigs developing partial in-stent thrombosis. Long-term data, with refinements of devices and tools, are required before these procedures can be implemented in humans.
EUS-guided cardiac intervention
The heart's proximity to the esophagus makes it accessible to EUS, as routinely used in cardiology. Fritscher-Ravens et al. performed porcine EUS-guided puncture of the heart, in which a 22- or a 19-gauge needle was introduced into the left atrium, left ventricle, coronary arteries, and aortic valve. While under cardiac monitoring, the authors injected contrast agents, performed radiofrequency ablation of the aortic valve and inserted pacing wires. No arrhythmias during the procedure were recorded; no cardiac abnormalities before euthanasia and no bleeding or hematomas in necropsy were noted. Subsequently, the same group performed pericardial fluid aspiration in two patients and FNA of a 5 cm left atrial mass in a third patient with no adverse events. Larghi et al. described EUS-guided drainage of a pericardial cyst  with no complications. Romero-Castro et al. described EUS-guided FNA of a pericardial tumor. No arrhythmias were noted. A s[table 6]-mm hyperechoic lesion at the puncture site, consistent with a hematoma, was noted after FNA. EUS-guided cardiac puncture of a right atrial tumor was recently described with no adverse event during the following 72 h.
| Conclusion|| |
The GI tract provides an excellent window to access vascular structures in the abdomen and mediastinum. Interventional EUS continues to evolve, offering new exciting diagnostic and therapeutic options. We can deliver sclerosants, CYA and coils into bleeding vessels, measure PV pressures, biopsy intravascular thrombus, collect circulating cells, and potentially access the heart and pericardium, all through a standard FNA needle. Data are still limited to either small numbers of patients or animal experimental studies. Clinical effectiveness and safety data are awaited from larger prospective controlled trials.
Conflict of Interest
There are no conflicts of interest.
| References|| |
Lin HJ, Hsieh YH, Tseng GY, et al.
A prospective, randomized trial of large- versus small-volume endoscopic injection of epinephrine for peptic ulcer bleeding. Gastrointest Endosc
Song SY, Chung JB, Moon YM, et al
. Comparison of the hemostatic effect of endoscopic injection with fibrin glue and hypertonic saline-epinephrine for peptic ulcer bleeding: A prospective randomized trial. Endoscopy
Kanai M, Hamada A, Endo Y, et al.
Efficacy of argon plasma coagulation in nonvariceal upper gastrointestinal bleeding. Endoscopy
Chau CH, Siu WT, Law BK, et al.
Randomized controlled trial comparing epinephrine injection plus heat probe coagulation versus epinephrine injection plus argon plasma coagulation for bleeding peptic ulcers. Gastrointest Endosc
Chou YC, Hsu PI, Lai KH, et al.
A prospective, randomized trial of endoscopic hemoclip placement and distilled water injection for treatment of high-risk bleeding ulcers. Gastrointest Endosc
Mumtaz R, Shaukat M, Ramirez FC. Outcomes of endoscopic treatment of gastroduodenal Dieulafoy's lesion with rubber band ligation and thermal/injection therapy. J Clin Gastroenterol
Targownik LE, Nabalamba A. Trends in management and outcomes of acute nonvariceal upper gastrointestinal bleeding: 1993-2003. Clin Gastroenterol Hepatol
Barkun AN, Bardou M, Kuipers EJ, et al.
International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med
Fockens P, Meenan J, van Dullemen HM, et al
. Dieulafoy's disease: Endosonographic detection and endosonography-guided treatment. Gastrointest Endosc
Levy MJ, Wong Kee Song LM, Farnell MB, et al.
Endoscopic ultrasound (EUS)-guided angiotherapy of refractory gastrointestinal bleeding. Am J Gastroenterol
Gonzalez JM, Giacino C, Pioche M, et al.
Endoscopic ultrasound-guided vascular therapy: Is it safe and effective? Endoscopy
Gonzalez JM, Ezzedine S, Vitton V, et al
. Endoscopic ultrasound treatment of vascular complications in acute pancreatitis. Endoscopy
Chaves DM, Costa FF, Matuguma S, et al.
Splenic artery pseudoaneurysm treated with thrombin injection guided by endoscopic ultrasound. Endoscopy
2012;44 Suppl 2:E99-100.
Lameris R, du Plessis J, Nieuwoudt M, et al
. A visceral pseudoaneurysm: Management by EUS-guided thrombin injection. Gastrointest Endosc
Roach H, Roberts SA, Salter R, et al
. Endoscopic ultrasound-guided thrombin injection for the treatment of pancreatic pseudoaneurysm. Endoscopy
Folvik G, Nesje LB, Berstad A, et al
. Endosonography-guided endoscopic band ligation of Dieulafoy's malformation: A case report. Endoscopy
Ribeiro A, Vazquez-Sequeiros E, Wiersema MJ. Doppler EUS-guided treatment of gastric Dieulafoy's lesion. Gastrointest Endosc
Kumbhari V, Gondal B, Okolo Iii PI, et al.
Endoscopic ultrasound-guided angiotherapy of a large bleeding gastrointestinal stromal tumor. Endoscopy
2013;45 Suppl 2:E326-7.
Law R, Fujii-Lau L, Wong Kee Song LM, et al.
Efficacy of endoscopic ultrasound-guided hemostatic interventions for resistant nonvariceal bleeding. Clin Gastroenterol Hepatol
Helmy A, Hayes PC. Review article: Current endoscopic therapeutic options in the management of variceal bleeding. Aliment Pharmacol Ther
Hou MC, Lin HC, Lee FY, et al
. Recurrence of esophageal varices following endoscopic treatment and its impact on rebleeding: Comparison of sclerotherapy and ligation. J Hepatol
Krige JE, Bornman PC, Goldberg PA, et al
. Variceal rebleeding and recurrence after endoscopic injection sclerotherapy: A prospective evaluation in 204 patients. Arch Surg
Irisawa A, Obara K, Bhutani MS, et al.
Role of para-esophageal collateral veins in patients with portal hypertension based on the results of endoscopic ultrasonography and liver scintigraphy analysis. J Gastroenterol Hepatol
Irisawa A, Saito A, Obara K, et al.
Endoscopic recurrence of esophageal varices is associated with the specific EUS abnormalities: Severe periesophageal collateral veins and large perforating veins. Gastrointest Endosc
Lahoti S, Catalano MF, Alcocer E, et al
. Obliteration of esophageal varices using EUS-guided sclerotherapy with color Doppler. Gastrointest Endosc
de Paulo GA, Ardengh JC, Nakao FS, et al
. Treatment of esophageal varices: A randomized controlled trial comparing endoscopic sclerotherapy and EUS-guided sclerotherapy of esophageal collateral veins. Gastrointest Endosc
Sarin SK, Lahoti D, Saxena SP, et al
. Prevalence, classification and natural history of gastric varices: A long-term follow-up study in 568 portal hypertension patients. Hepatology
Trudeau W, Prindiville T. Endoscopic injection sclerosis in bleeding gastric varices. Gastrointest Endosc
Ríos Castellanos E, Seron P, Gisbert JP, et al
. Endoscopic injection of cyanoacrylate glue versus other endoscopic procedures for acute bleeding gastric varices in people with portal hypertension. Cochrane Database Syst Rev
Soehendra N, Nam VC, Grimm H, et al
. Endoscopic obliteration of large esophagogastric varices with bucrylate. Endoscopy
Garcia-Tsao G, Sanyal AJ, Grace ND, et al.
Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology
de Franchis R, Primignani M. Endoscopic treatments for portal hypertension. Semin Liver Dis
Seewald S, Ang TL, Imazu H, et al.
A standardized injection technique and regimen ensures success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices (with videos). Gastrointest Endosc
Boustière C, Dumas O, Jouffre C, et al.
Endoscopic ultrasonography classification of gastric varices in patients with cirrhosis. Comparison with endoscopic findings. J Hepatol
Iwase H, Suga S, Morise K, et al.
Color Doppler endoscopic ultrasonography for the evaluation of gastric varices and endoscopic obliteration with cyanoacrylate glue. Gastrointest Endosc
Sarin SK, Kumar A. Sclerosants for variceal sclerotherapy: A critical appraisal. Am J Gastroenterol
Romero-Castro R, Pellicer-Bautista FJ, Jimenez-Saenz M, et al.
EUS-guided injection of cyanoacrylate in perforating feeding veins in gastric varices: Results in 5 cases. Gastrointest Endosc
Levy MJ, Wong Kee Song LM, Kendrick ML, et al
. EUS-guided coil embolization for refractory ectopic variceal bleeding (with videos). Gastrointest Endosc
Romero-Castro R, Pellicer-Bautista F, Giovannini M, et al.
Endoscopic ultrasound (EUS)-guided coil embolization therapy in gastric varices. Endoscopy
2010;42 Suppl 2:E35-6.
Romero-Castro R, Ellrichmann M, Ortiz-Moyano C, et al.
EUS-guided coil versus cyanoacrylate therapy for the treatment of gastric varices: A multicenter study (with videos). Gastrointest Endosc
Binmoeller KF, Weilert F, Shah JN, et al
. EUS-guided transesophageal treatment of gastric fundal varices with combined coiling and cyanoacrylate glue injection (with videos). Gastrointest Endosc
Bhat YM, Weilert F, Fredrick RT, et al.
EUS-guided treatment of gastric fundal varices with combined injection of coils and cyanoacrylate glue: A large U.S. experience over 6 years (with video). Gastrointest Endosc
Rana SS, Bhasin DK, Rao C, et al
. Endoscopic ultrasound-guided treatment of bleeding duodenal varix. Indian J Gastroenterol
Kakizaki S, Toyoda M, Ichikawa T, et al.
Clinical characteristics and treatment for patients presenting with bleeding duodenal varices. Dig Endosc
Kinzel J, Pichetshote N, Dredar S, et al
. Bleeding from a duodenal varix: A unique case of variceal hemostasis achieved using EUS-guided placement of an embolization coil and cyanoacrylate. J Clin Gastroenterol
Fujii-Lau LL, Law R, Wong Kee Song LM, et al.
Endoscopic ultrasound (EUS)-guided coil injection therapy of esophagogastric and ectopic varices. Surg Endosc
Mukkada RJ, Chooracken MJ, Antony R, et al
. EUS-guided coiling for bleeding duodenal collateral vessel. Gastrointest Endosc
Hosking SW, Smart HL, Johnson AG, et al
. Anorectal varices, haemorrhoids, and portal hypertension. Lancet
Chawla Y, Dilawari JB. Anorectal varices – Their frequency in cirrhotic and non-cirrhotic portal hypertension. Gut
Goenka MK, Kochhar R, Nagi B, et al
. Rectosigmoid varices and other mucosal changes in patients with portal hypertension. Am J Gastroenterol
McCormack TT, Bailey HR, Simms JM, et al
. Rectal varices are not piles. Br J Surg
Johansen K, Bardin J, Orloff MJ. Massive bleeding from hemorrhoidal varices in portal hypertension. JAMA
Wilson SE, Stone RT, Christie JP, et al
. Massive lower gastrointestinal bleeding from intestinal varices. Arch Surg
Dhiman RK, Choudhuri G, Saraswat VA, et al.
Endoscopic ultrasonographic evaluation of the rectum in cirrhotic portal hypertension. Gastrointest Endosc
Sato T, Yamazaki K, Toyota J, et al.
The value of the ultrasonic microprobe in the detection and treatment of rectal varices: A case report. Hepatol Res
Sharma M, Rai P, Bansal R. EUS-assisted evaluation of rectal varices before banding. Gastroenterol Res Pract
Weilert F, Shah JN, Marson FP, et al
. EUS-guided coil and glue for bleeding rectal varix. Gastrointest Endosc
Connor EK, Duran-Castro OL, Attam R. Therapy for recurrent bleeding from rectal varices by EUS-guided sclerosis. Gastrointest Endosc
Storm AC, Kumbhari V, Saxena P, et al.
EUS-guided angiotherapy. Gastrointest Endosc
Tsynman DN, DeCross AJ, Maliakkal B, et al.
Novel use of EUS to successfully treat bleeding parastomal varices with N-butyl-2-cyanoacrylate. Gastrointest Endosc
Armonis A, Patch D, Burroughs A. Hepatic venous pressure measurement: An old test as a new prognostic marker in cirrhosis? Hepatology
Lai L, Poneros J, Santilli J, et al
. EUS-guided portal vein catheterization and pressure measurement in an animal model: A pilot study of feasibility. Gastrointest Endosc
Giday SA, Clarke JO, Buscaglia JM, et al.
EUS-guided portal vein catheterization: A promising novel approach for portal angiography and portal vein pressure measurements. Gastrointest Endosc
Huang JY, Samarasena JB, Tsujino T, et al.
EUS-guided portal pressure gradient measurement with a simple novel device: A human pilot study. Gastrointest Endosc
Tsujino T, Huang JY, Samarasena JB, et al.
Safety and feasibility of combination EUS-guided portal pressure gradient measurement and liver biopsy: The realization of endo-hepatology. Gastrointest Endosc
Ansari D, Ansari D, Andersson R, et al
. Pancreatic cancer and thromboembolic disease, 150 years after trousseau. Hepatobiliary Surg Nutr
Epstein AS, Soff GA, Capanu M, et al.
Analysis of incidence and clinical outcomes in patients with thromboembolic events and invasive exocrine pancreatic cancer. Cancer
Larsen AC, Brøndum Frøkjaer J, Wishwanath Iyer V, et al.
Venous thrombosis in pancreaticobiliary tract cancer: Outcome and prognostic factors. J Thromb Haemost
Lai L, Brugge WR. Endoscopic ultrasound is a sensitive and specific test to diagnose portal venous system thrombosis (PVST). Am J Gastroenterol
Lai R, Stephens V, Bardales R. Diagnosis and staging of hepatocellular carcinoma by EUS-FNA of a portal vein thrombus. Gastrointest Endosc
Michael H, Lenza C, Gupta M, et al
. Endoscopic ultrasound -guided fine-needle aspiration of a portal vein thrombus to aid in the diagnosis and staging of hepatocellular carcinoma. Gastroenterol Hepatol (N Y)
Moreno M, Gimeno-García AZ, Corriente MM, et al.
EUS-FNA of a portal vein thrombosis in a patient with a hidden hepatocellular carcinoma: Confirmation technique after contrast-enhanced ultrasound. Endoscopy
2014;46 Suppl 1:E590-1.
Kayar Y, Turkdogan KA, Baysal B, et al.
EUS-guided FNA of a portal vein thrombus in hepatocellular carcinoma. Pan Afr Med J
Rustagi T, Gleeson FC, Chari ST, et al.
Remote malignant intravascular thrombi: EUS-guided FNA diagnosis and impact on cancer staging. Gastrointest Endosc
Sisman G, Erzin YZ, Senturk H. Diagnosis of adrenocortical carcinoma via endosonography-assisted fine-needle aspiration of inferior vena cava thrombosis:First case in the literature. Dig Endosc
Gincul R, Gomez V, Kerr SE, et al
. Endoscopic ultrasound-guided fine-needle aspiration of a pulmonary artery malignant thrombus. Endoscopy
2015;47 Suppl 1:E547-9.
Allard WJ, Matera J, Miller MC, et al.
Tumor cells circulate in the peripheral blood of all major carcinomas but not in healthy subjects or patients with nonmalignant diseases. Clin Cancer Res
Catenacci DV, Chapman CG, Xu P, et al.
Acquisition of portal venous circulating tumor cells from patients with pancreaticobiliary cancers by endoscopic ultrasound. Gastroenterology
Matthes K, Sahani D, Holalkere NS, et al
. Feasibility of endoscopic ultrasound-guided portal vein embolization with enteryx. Acta Gastroenterol Belg
Vazquez-Sequeiros E, Olcina JR. Endoscopic ultrasound guided vascular access and therapy: A promising indication. World J Gastrointest Endosc
Faigel DO, Lake DF, Landreth TL, et al
. EUS-guided portal injection chemotherapy for treatment of hepatic metastases: Feasibility in the acute porcine model. Gastrointest Endosc
Faigel D, Lake D, Landreth T, et al
. Endoscopic ultrasonography-guided portal injection chemotherapy for hepatic metastases. Endosc Ultrasound
Zhang FJ, Li CX, Jiao DC, et al.
CT guided 125iodine seed implantation for portal vein tumor thrombus in primary hepatocellular carcinoma. Chin Med J (Engl)
Colombato L. The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension. J Clin Gastroenterol
2007;41 Suppl 3:S344-51.
D'Amico G, Pagliaro L, Bosch J. The treatment of portal hypertension: A meta-analytic review. Hepatology
Ginès P, Uriz J, Calahorra B, et al.
Transjugular intrahepatic portosystemic shunting versus paracentesis plus albumin for refractory ascites in cirrhosis. Gastroenterology
Buscaglia JM, Dray X, Shin EJ, et al.
A new alternative for a transjugular intrahepatic portosystemic shunt: EUS-guided creation of an intrahepatic portosystemic shunt (with video). Gastrointest Endosc
Binmoeller KF, Shah JN. Sa1428 EUS-guided transgastric intrahepatic portosystemic shunt using the axios stent. Gastrointest Endosc
Schulman AR, Ryou M, Aihara H, et al.
EUS-guided intrahepatic portosystemic shunt with direct portal pressure measurements: A novel alternative to transjugular intrahepatic portosystemic shunting. Gastrointest Endosc
Fritscher-Ravens A, Ganbari A, Mosse CA, et al.
Transesophageal endoscopic ultrasound-guided access to the heart. Endoscopy
Larghi A, Stobinski M, Galasso D, et al.
EUS-guided drainage of a pericardial cyst: Closer to the heart (with video). Gastrointest Endosc
Romero-Castro R, Rios-Martin JJ, Gallego-Garcia de Vinuesa P, et al.
Pericardial tumor diagnosed by EUS-guided FNA (with video). Gastrointest Endosc
Gornals JB, de la Hera M, de Albert M, et al
. EUS cardiac puncture-guided right atrial tumor. Gastrointest Endosc