Endoscopic ultrasound-guided vascular interventions: An expanding paradigm

Abstract

Endoscopic ultrasound (EUS) has expanded its arena from a mere diagnostic modality to an essential therapeutic tool in managing gastrointestinal (GI) diseases. The proximity of the GI tract to the vascular structures in the mediastinum and the abdomen has facilitated the growth of EUS in the field of vascular interventions. EUS provides important clinical and anatomical information related to the vessels' size, appearance and location. Its excellent spatial resolution, use of colour doppler with or without contrast enhancement and ability to provide images “real-time” helps in precision while intervening vascular structures. Additionally, structures such as venous collaterals or varices can be dealt with optimally using EUS. EUS-guided vascular therapy with coil and glue combination has revolutionized the management of portal hypertension. It also helps to avoid radiation exposure in addition to being minimally invasive. These advantages have led EUS to become an upcoming modality to complement traditional interventional radiology in the field of vascular interventions. EUS-guided portal vein (PV) access and therapy is a new kid on the block. EUS-guided portal pressure gradient measurement, injecting chemotherapy in PV and intrahepatic portosystemic shunt has expanded the horizons of endo-hepatology. Lastly, EUS has also forayed into cardiac interventions allowing pericardial fluid aspiration and tumour biopsy with experimental data on access to valvular apparatus. Herein, we provide a comprehensive review of the expanding paradigm of EUS-guided vascular interventions in GI bleeding, portal vein access and its related therapeutic interventions, cardiac access, and therapy. A synopsis of all the technical details involving each procedure and the available data has been tabulated, and the future trends in this area have been highlighted.

Keywords: Gastrointestinal bleeding; Vascular intervention; Gastric varices; Pseudoaneurysm; Portal vein; Portal pressure gradient measurement

Core Tip: Therapeutic endoscopic ultrasound (EUS) has rapidly expanded into the field of vascular interventions. Published literature has shown that EUS-guided endovascular therapy is safe and scores over conventional endoscopic techniques achieving high obliteration rates with minimum re-intervention in variceal bleeding. EUS currently acts as a “rescue therapy” in cases of re-bleed or refractory bleeding from non-variceal sources, especially a pseudoaneurysm. In addition, portal vein access, portal pressure gradient measurement, and variceal assessment with liver biopsy have shown that EUS can act as a "one-stop-shop" for “Endo-hepatology”. This ever-expanding role of EUS-related vascular interventions has been thoroughly detailed in this comprehensive review.