IS EUS-GUIDED ANGIOEMBOLISATION A COMPARABLE ALTERNATIVE TO BALLOON-OCCLUDED RETROGRADE TRANSVENOUS OBLITERATION (BRTO) FOR THE MANAGEMENT OF GASTRIC VARICES WITH SIGNIFICANT PORTOSYSTEMIC SHUNTS: A MULTICENTER TERTIARY-CARE EXPERIENCE

Introduction: Gastric fundal varices (GV) have a higher propensity to rebleed, specifically in the setting of significant portosystemic shunts (PSS). Balloon-occluded Retrograde Transvenous Obliteration (BRTO) is a viable option for managing such cases. While endoscopic ultrasound (EUS) guided therapy using combination of coils and glue is a relatively recent modality, sparse data exist on the comparison between the two modalities with respect to safety and efficacy on follow-up. Hence this study was designed to compare these two modalities for management of GV with significant PSS.
Methods: This multicenter study included patients of GV having significant PSS from 3 tertiary-care academic centers, presenting with bleeding or requiring secondary prophylaxis. Baseline imaging and EUS was performed to assess the size of the varices and the type and size of the shunt. Patients were divided into 2 arms: EUS vs BRTO. Patients were followed up in the post procedure for adverse events. Procedural details such as amount of glue, number of coils used, obliteration rates, number of sessions required for obliteration were documented. Follow-up data collected included obliteration at 4 weeks, bleeding after index procedure, and need for re-intervention.
Results: Of the 107 patients (male 83, 77.6%; mean age- 52.59±12.5 years) included in the study, 53 underwent EUS-guided therapy while BRTO was done in 54 patients. GOV2 was the most common GV type (n=65;60.7%) while the commonest shunt type was gastro-renal shunts (n=80;74.8%). At baseline, the type of presentation and etiology of liver disease were similar between the two arms. While the EUS-arm had significantly larger-sized GV (23.92±5.9 vs 19.37±6.5 mm; p<0.001), BRTO-arm had larger shunts (14 vs 12 mm; p=0.014).
The technical success, immediate obliteration rates, and obliteration rate at 4 weeks were similar between the two arms. However, the overall adverse events rates were significantly higher in the BRTO-arm (38.9% vs 11.3%; p=0.001). Specifically, worsening of ascites (22.2% vs 1.9%;p=0.002), sepsis (13.0% vs 0%; p=0.013) and worsening of esophageal varices (24.1% vs 0%; p<0.0001) were noted significantly in the BRTO-arm. Over a median follow-up of 704 days, bleeding episodes after index procedure and re-intervention requirements for GV were similar between the two arms (Table 1,2).
On multivariate analysis, size of the shunt (p=0.012) and size of GV (p=0.006) were significant predictors for achieving complete obliteration at 4-weeks even after adjusting for age, etiology of the disease, the CTP class and the type of procedure (EUS vs. BRTO).
Conclusion: EUS-guided therapy is a safer alternative with comparable efficacy compared to BRTO for the management of GV with significant PSS. Size of the shunt and GV are key factors governing complete obliteration variceal obliteration on follow-up.