Use of Thrombin for the Treatment of Esophageal Varices
Esophageal varices are varicosities of the branches of the azygous vein which anastomoses with the tributaries of the portal vein in the lower esophagous (1). Esophageal varices occur in patients with portal hypertension most often secondary to liver cirrhosis with the cirrhosis most commonly associated with alcohol abuse. These varicosities are occasionally referred to as uphill varices to differentiate this pathology from the much rarer downhill varices caused by superior vena cava obstruction. Varices of either origin have substantial risk of rupture and hemorrhage (2-4). Patients with liver cirrhosis may have esophageal varices at the time of presentation with the incidence dependent on the severity of the cirrhosis (2-6). Patients with compensated cirrhosis have 30% incidence while 70% of the patients with decompensated cirrhosis have esophageal varices. Individuals who do not present with varices have a substantial risk of development of varices following initial presentation. Bleeding from the varices is a common problem and quite difficult to control. In one of the earlier studies in this area, Graham and Smith (4) suggested a mortality rate in excess of 30% during the initial hospitalization with a substantial risk of rebleeding. Wu and Sun have reported that variceal hemorrhage is responsible for one-third of the mortality associated with cirrhosis (7). Ferguson and colleagues noted a mortality rate of 30-50% for variceal hemorrhage (8). Krige and colleagues (9) reported that even with control of variceal bleeding, there was only a 26% survival in their treatment group after five years. Despite these gloomy statistics, there has been a significant decrease in the reduction of mortality in this population in the last twenty years (10). This positive news must be balanced against a perception of increased alcohol abuse (11).
The treatment of bleeding gastric varices presents a considerable challenge to the physician (5,6, 12). While a pharmacological approach using beta-blockers and other anti-hypertension drugs is available (13), most interest is directed at endoscopic approaches to the management of bleeding gastric varices (5,6,14) including banding or variceal ligation and injection sclerotherapy. These two techniques are in addition to the use of a transjugular intrahepatic portosystemic stent shunt (TIPS/TIPSS) (15-19) or a distal spleno-renal shunt (DSRS)(20,21).
Injection sclerotherapy for esophageal varices was introduced by Crafoord and Frenckner in 1939 (22). These investigators administered quinine-uretan with an oesophagealscope to treat esophageal variceal bleeding. Subsequently Hunt and coworkers used ethanolamine oleate as the sclerosing agent with a MacBeth needle as the administration device (23). Subsequent studies (24-26) validated this therapeutic approach. Studies in the last twenty years have focused on the development of more effective sclerosing agents.
The focus of this article is the use of thrombin in the treatment of esophageal varices as a form of injection sclerotherapy. The purpose of injection sclerotherapy is to "harden" the blood vessels leading to their eventual resolution (27-30). Basic injection sclerotherapy uses a variety of sclerosing agents including ethanolamine oleate, saline, tetradecyl sulfate, or alcohol, or a combination (31,32) . In addition to the basis injection sclerotherapy, there has been the use of tissue adhesives or glue including cyanoacrylates (10, 33-35) and fibrin glue (36, 37). A discussion of fibrin glue/fibrin sealant is shown below. Cyanoacrylates are popular but will polymerize prior to entrance into the varicosity (32, 38). There is also the issue of the cyanoacrylate plug embolizing into the circulation (39). There are also other complications arising from cyanoacrylate use including sepsis (40) and formation of an inflammatory tissue tumor (41)
Thrombin, while well accepted for the treatment of vascular pseudoaneurysms via percutaneous administration, has a somewhat less-substantial status in the treatment of gastric varices (32, 35, 42-44). This situation exists despite a significant history which seems longer than the record of thrombin use in vascular pseudoaneurysms. Sunderquist and Vang injected thrombin in hypertonic glucose into esophageal varices in 1974 (45, 46). A number of studies followed (47-50) including some which used gel foam and thrombin (51, 52).
The current use of thrombin for the treatment of esophageal bleeding appears to be based on studies by Williams and coworkers (42) in 1994. These investigators used bovine thrombin (1000 U/mL) in 11 patients with bleeding gastric varices. A mean volume of 5.5 mL (5,500 U) was used and produced initial hemostasis in all subjects. Varices were thrombosed and/or obliterated after several injections. There was one incident of a rebleed during the nine month followup period. A subsequent study using human material(43) also demonstrated the effectiveness of thrombin in the treatment of gastric varices. In another study, Kojima and colleagues (44) als0 used human thrombin (described as thrombin glue and referred to in units; this might reflect the use of thrombin "cannibalized" from a fibrin sealant kit) to seal the scleroscent injection site rather than a thrombosing agent within the varicosity. To the best of my knowledge, a free-standing human thrombin commercial product has not been available since the second World War. Physicians who have used thrombin have either canabilized the material from a fibrin sealant kit or used autologous thrombin.
Westaby (53) has reviewed variceal injection sclerotherapy and concluded that while cyanoacrylates are effective in sealing the varicosities, there are technical challenges with the use of this material in the injection process which can result in irreversible damage to the endoscope. Westaby notes that thrombin does not present this problem, does not cause mucosal damage as is the case with cyanoacrylates, and can be injected with the sclerosing agent.
The injection of thrombin for endoscopic sclerotherapy has not, to the best of my knowledge, been associated with any adverse event of clinical significance. Gardner and Brooks (54) used a mixture of sodium morrhuate, topical thrombin, and cephalothin sodium with 50% dextrose as a sclerosing agent in 11 patients with esophageal varices. There was no effect on panel of blood coagulation factors including factor V and factor VIII. These investigators also reported the lack of effect on the prothrombin time, the partial thromboplastin time, platelet count, or fibrinogen split products. The studies, as with most of the studies, were performed with bovine topical thrombin which has been associated with immunological side reactions (55). Several subsequent studies on the use of bovine thrombin in the treatment of esophageal varices were equivocal in theirs results. de Franchis and colleagues (56) reported that global coagulation assays such as the prothrombin time and partial thromboplastin time did not change. There was a marked increase in fibrinopeptide A levels after treatment. This effect was not sustained with FPA levels returning to normal after 24 hours. These investigators did report abnormally high basal levels of FPA in approximately half of the patients in this study. Fugii and colleagues (57) used thrombin with tetradecyl sodium and cafzolium as a sclerosing solutions in 24 patients with esophageal varices. There was a transient elevation of fibrinogen D-dimer and thrombin-antithrombin in the treated patients. There were no thrombotic or bleeding complications. These investigators also reported elevation of D-dimer, tissue plasminogen activator, and plasminogen activator inhibitor-1 in most patients prior to treatment. Koyama and colleagues (58) also observed an increase in thrombin-antithrombin, D-dimer, and plasminogen activator inhibitor-1 following the administration of thrombin for the treatment of esophageal varices. Elevation of thrombin-antithrombin and D-dimer was more persistent than that observed by others lasting seven days. Biagi and colleagues (59) observed transient changes in β-thromboglobulin, platelet factor 4, and fibrinopeptide A following sclerotherapy with ethanolamine oleate without thrombin. In another study (60) which also used ethanolamine oleate without thrombin, Takada and coworkers observed a transient increase in thrombin-antithrombin complex following sclerotherapy. The extent of the increased was dependent on the amount of sclerosant used.
In one of the exceptions to the use of bovine thrombin, Kitano and coworkers (61) used human thrombin (100-150 U) in 5% ethanolamine oleate for endoscopic sclerotherapy of esophageal varices and did not observed any signs of coagulation disorders such as disseminated intravascular coagulation. The quality of the human thrombin used in these studies is not known but it would be unlikely to contain factor V/Va which is notable contaminant of bovine thrombin preparations (55).
Pseudoanerysms secondary to cardiac catheterization is a problem with some similarity to gastric varices in that hemorrhage is an unwanted consequence. In a study on the use of thrombin for the treatment of pseudoaneurysms, Kruger and colleague (62) reported an increase in thrombin-antithrombin complexes after ultrasonographically (US)guided thrombin injection. There were no other laboratory or clinical changes. In a subsequent larger study with 240 patients with simple and complex pseudoanerysms (63), there were two thrombotic episodes which resolved spontaneously. A mild allergic response was observed in one subject. This study used bovine thrombin which, as noted above, has been associated with immunological side reactions. It is also likely that the amount of thrombin used with the sclerosing agent can be reduced as has been observed for the use of thrombin with the percutaneous treatment of vascular pseudoaneurysms (64).
It is noted that another hemostatic agent, recombinant factor VIIa, has been used without success (65) and in one case with an accompanying cerebrovascular event (66). It is not clear as to why recombinant VIIa would have a functional advantage over thrombin in this clinical situation. Recombinant factor VIIa would also likely be more expensive than thrombin.
The various investigators who have used thrombin have been mostly successful in the use of the thrombin as a hemostatic agent for gastic variceal bleeding but there is the sense that a randomized clinical trial would be useful which would compare the various approaches.
A final note on thrombin and fibrin sealant
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