Endoscopic ultrasound-guided embolization of a gastric varix by injection of RADA16 self-assembling peptide and coils

Gastric variceal bleeding accounts for 10%–30% of variceal bleeding and has higher mortality than esophageal variceal bleeding [1]. Endoscopic ultrasound (EUS) offers new modalities for treatment and prevention of gastric variceal bleeding. Acrylate polymers such as cyanoacrylate are traditionally injected into gastric varices under EUS guidance. However, adverse events, such as systemic embolization, ulceration with rebleeding, and failed withdrawal of the needle, are drawbacks to cyanoacrylate use. Coil embolization is more effective with fewer adverse events than cyanoacrylate injection and with high technical and clinical success [2]. The combination of cyanoacrylate and coil embolization appears more effective than monotherapy [3]. Because of the particular handling and side-effect profile of cyanoacrylate, alternative agents have been used for treatment of gastric varices [4]. We present the use of a novel hemostatic gel (PuraStat; 3-D Matrix, Newton, Massachusetts, USA) injected for treatment of gastric variceal bleeding. PuraStat is composed of 2.5% RADA16, a synthetic hemostatic material that forms a 3D matrix mimicking human extracellular matrix [5]. It has been used in a variety of clinical scenarios with promising results [5].