Steps to EUS coiling

 EUS:

Keep 0.5 ml Glubran + 0.5 ml sterile water ready in Syringe A. Keep 10 ml of sterile water ready in Syringe B.

Step 1 - Confirm the varices are 'intraluminal'

Decide target of intervention (feeder / main varix)

Step 2: Stab the varix with 19G FNB needle. Attach a 10 ml syringe with sterile water to FNB needle

Step 3: To confirm location inside varix, flush some water. Then aspirate to confirm blood. Then flush back to 'wash blood' from the needle lumen

Step 4: Attach white hub of the Nester loading cannula to needle tip. Using Needle stylet, advance the coil from the Nester catheter to, inside the needle lumen. Then detach the Nester catheter from FNB needle. Insert the stylet again, to continue to push the coil across the needle lumen in to varix

Step 5: By continuing to advance the needle stylet, push the coil in to the varix under EUS guidance. Once completely deployed, remove the needle stylet. 

Step 5a - further coil can be deployed based on size of varix, before finally injecting glue.

Step 6: Immediately, push 1 ml (Glue + water) through FNB needle, immediately followed by gentle flush of 5-7 ml of sterile water from Syringe B

Ensure eradication of varix using color doppler.

Step 7:  Further glue can be injected if desired. If not, retract the needle, take it out of scope and discard.





Usually, suggestion is to use the 20-40% more length of the coil, than the diameter of the varix - and use multiple of these coils. 

For example, in one case-series, 7,14, 21 cms, 12-20 mm diameter coils were used. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6986946/)

Comments

Post a Comment

Popular posts from this blog

Pancreatic Cyst

Image
 MCN - (Mother cyst) >95% in pre-menopausal women Mostly in body and tail of pancreas Thick-walled cyst, lined by Ovarian type stroma. Cyst contains mucinous / hemorrhagic material. Does not communicate with PD (unlike IPMN) 10-20% have in-dwelling cancer One review found - no dysplasia in cysts <3 cm in size LN mets is rare. Distal pancreatectomy usually suffices.  Doesnt result in metachronous lesions. Surveillance isnt really necessary SCA - (Grandmother cyst) 75% of SCAs seen in post-menopausal women Can be anywhere in pancreas Honeycombing, with tiny cysts containing clear fluid distributed around central scarring. Central scarring may bear calcification in 30% cases Microcystic SCAs can undergo degeneration and become macrocystic variants zero risk of malignancy, but they can continue to grow and cause obstructive symptoms SPN - (daughter lesion) - Solid Pseudopapillary Neoplasm 90% of lesion occur in young women, in teens / twenties Anywhere  in pancreas Solid / Solid-cys
Read more

Pancreatic cyst fluid examiantion

  CEA Levels:   CEA >192 is 60% sensitive and 90% specific for mucinous cysts (ipmn/mcn) This was based on a study of 70 lesions in 2004 and has stuck till date   CEA < 5 has excellent negative predictive value for mucinous cysts   CEA > 5, therefore can still be a mucinous neoplasm and needs to be taken in context. Other markers such as Ca 72-4, CA 19-9, CA 15-3, CA 125 have lower accuracy than CEA   Amylase levels: ·        Amylase < 250 IU/L is highly unlikely to be connected to PD (eg  SCA) ·        MCN usually have very low / low amylase (one study suggested it has similar amylase to ipmn)   Glucose: ·        Glucose is very low in mucinous tumors & pseudocysts (those with communication to PD)– usually less than 2.8 mmol/l     Glucose < 2.8 mmol/l has Sens/Spec of 90/90 ( more accurate)  compared to CEA >192 (sens/spec 60/90) for identification of mucinous cysts
Read more

Iron deficiency anaemia

IDA   Ferritin: (BSG 2021 / UTD)   Ferritin is the universal intracellular protein containing Iron – a soluble and non-toxic form. It is the primary iron storage protein in prokaryotes and eukaryotes. Ferritin w/o iron is called apo-ferritin . Each ferritin molecule can store up to 4,500 atoms of iron within it.     Iron deficiency anaemia:   1)     Low MCH is more sensitiv e for Iron deficiency than Low MCV. 2)     Low Ferritin is single most important serological marker of IDA. Serum ferritin assessed by assays is usually apo-ferritin, but reflects intra-cellular ferritin stores in RES (macrophages in liver, spleen, LN etc ) in absence of inflammation.   Fe < 15 – indicative of absent iron stores Fe <45 – indicative of low iron stores   In anaemia of chronic disease / CHF  - TSat <20% with Fe <100 is suggestive of Fe deficiency     Fe > 150 unlikely to represent low iron stores even in face of inflammation .   3)     Transf
Read more