LAUSR

The procedure is performed under orotracheal intubation. The echoendoscope is positioned in the distal esophagus or in the gastric fundus to visualize the gastric varices; if necessary, water may be instilled into the fundus to improve visualization. Detection of the feeding vessel is unnecessary owing to the complexity of the vessel network and is time-consuming. 1. Preparation: a fine-needle aspiration (FNA) needle is prepared by withdrawing the stylet and flushing with saline (> 2mL) to avoid the risk of injecting air into the vessel. The coil is preloaded into the needle catheter. Once the needle is confirmed by endoscopic ultrasound (EUS) to be inside the gastric varix, no checking of blood return is needed to avoid blood clotting and no contrast filling (varicealography) is necessary to confirm correct insertion into the target vessel. 2. Coil deployment (Nester Coils; Cook Medical, Bloomington, Indiana, USA): deployment is performed under EUS and fluoroscopic guidance. Larger coils (0.035 inch) are used with 19 G needles, and smaller ones (0.018 inch) with 22 G if needed. The coiled diameter is 10–20mm and the straight length is 7–20mm. Coils are delivered into the varices through the EUS needle, using the FNA stylet as a pusher. The initial coil must be larger to occupy the varix as much as possible to prevent coil migration [1]. Size selection of subsequent coils is based on the remaining vessel space (must be at least larger than the varix diameter on EUS). No special direction of coil deployment is needed (▶Fig. 1, ▶Video 1). 3. After several minutes, Doppler is used to confirm absence of flow within the varix; any additional large vessels with persistent Doppler are treated using the same technique. Some Doppler flow may remain; this will reduce with time as a clot is induced by the coil hairs (▶Fig. 2). There is no standardized approach for EUS-guided coil embolization, and many questions remain about the optimal techE-Videos