Endoscopic treatment of gastric varices with N-BU-TYL-2-cyanoacrylate: A long term follow-up

Gastric varices have been reported in 10-30% of patients with portal hypertension and variceal hemorrage. Conventional sclerotherapy provides disappointing results in this condition with serious complications and deaths due to the procedure exeeding 25% of cases treated. Tissue adhesives have been used in uncontrolled series with hemostasis in over 90% of the patients. We treated 60 patients (40 M, 20 F, mean age 57.6%, range 17-78) who had gastric varices due to portal hypertension with injection of N-butyl-2-cyanoacrylate. Twenty-four patients were treated for active variceal bleeding, 31 were treated electively and the remaining 5 underwent to a prophylactic procedure. Gastric varices were located in the fundus in all patients and were F2 and F3 grade in the majority of them. Hemostasis was obtained in 23 out of 25 patients (92%) (24 treated for active bleeding and 1 treated electively who developed active hemorrage during the procedure). The two patients in whom hemostasis was not achieved died because of uncontrolled bleeding. Other three of the 60 patients treated died during hospitalization because of irreversible liver failure. Overall complications due to the procedure occurred in 5 patients: in two of them distal embolization was suspected but not demonstrated, one patient had asymptomatic peripheral embolization and in the other two cases the needle remained stucked in the newly-formed polymer of cyanoacrylate, with fatal consequences in one case. Eradication of gastric varices was obtained in 52 out of the 55 patients discharged from hospital (94.5%). Fifty-one patients were prospectively followed for a mean follow-up period of 24 months (range 3-82). Gastric varices relapsed in 19 patients (38%) but only 12 of them (23.5%) rebled: 8 of these patients were retreated with hemostasis and the other 4 patients died for fatal hemorrage (3 without treatment and 1 despite endoscopic retreatment). Nine-teen patients died during follow-up period (37.2%) but only 5 of them (9.8%) died because of gastric variceal hemorrage. In conclusion, endoscopic injection of N-butyl-2-cyanoacrylate is a safe and effective treatment for gastric varices due to portal hypertension, both to achieve hemostasis and to obtain a definitive eradication with a limited incidence of variceal relapses and rebleeding in a long-term follow-up.