Endoscopic ultrasound-guided vascular interventions: An expanding paradigm

Table 4 Steps for endoscopic ultrasound-guided management of visceral artery pseudoaneurysm

EUS-guided angioembolization of visceral artery pseudoaneurysm
Pre-procedure requirements
All procedures are done under the cover of pre/peri-procedural antibiotics
Patient is usually kept fasting for 4-6 h before the procedure
Adequate resuscitation of the patient, in case of active bleeding is ensured, prior to the procedure
Informed consent prior to the procedure
What is needed prior to the procedure
Linear echoendoscope with at least a 3.7 mm working channel
Needle size: depends on the choice of the endoscopist; usually a 19-G needle is used with 0.035’coil. However, a 22-G needle with 0.018’ coils may be used
Diameter of the coils: Smaller than the shortest diameter of the PsA
Number of coils: depends on size of the PsA
Amount of glue: depends on the size of the PsA
Technical aspects
A proper diagnostic EUS is performed
The echoendoscope is positioned optimally for a stable PsA access
Optimum examination of the PsA, the feeding vessel and the anatomy is delineated
The approach should always be through parenchyma, either pancreatic or hepatic. Bare puncture of the PsA without supporting parenchyma should not be performed
EUS-guided coil and glue embolization is usually performed using a 22-G/19-G (gauge) FNA needle
The size of the coil is determined by the short axis of the diameter of the PsA
After puncture of the varix, blood is aspirated to confirm the location. This is followed by flushing of the needle with saline. The pressure is high in the aneurysm, hence care should be taken to avoid creeping of blood along the hollow of the needle and causing needle block
The coils are then deployed into the varix using the stylet as a pusher. Packing with coils slows the flow inside the PsA, which can be visualized and further requirement of coils is assessed. Once the coils are deployed, flushing of the needle is done with normal saline
After coil deployment, cyanoacrylate glue is injected using the coils as scaffold
Once, the PsA is obliterated, visualized by absence of flow on colour Doppler, the sheath of the needle is advanced beyond the endoscope tip for 2-3 cm before withdrawing the scope. This avoids contact of glue with the endoscope tip
Post procedure
The patients are kept under observation for 12 h
Post embolization X-ray would help visualize the coils and also look for complications
Repeat EUS can be done after 48 hrs. to look for residual flow
Cross-sectional imaging is usually done after 72 h. to document success of therapy
Follow-up EUS may be performed at 1-mo

G: Gauge; PsA: Pseudoaneurysm; EUS: Endoscopic ultrasound; FNA: Fine needle aspiration.