The Concept of ‘Personalized’ Argon Plasma Coagulation for Treating Angiodysplasias

Section Editors
Klaus Mergener, MD, PhD, MBA, MASGE Affiliate Professor of Medicine University of Washington School of Medicine Seattle, Washington			Klaus Mönkemüller, MD, PhD, FASGE, FJGES Professor of Medicine Virginia Tech Carilion School of Medicine Roanoke, Virginia Universidad de La República Montevideo, Uruguay
Contributors
Maren Haslach-Häfner, BA Berufsfachschule für Pflege Helios Bildungszentrum Kronach, Germany		Reid Wasserman, DO Carilion Roanoke Memorial Hospital Virginia Tesch Carilion School of Medicine Roanoke, Virginia		Klaus Mönkemüller, MD, PhD, FASGE, FJGES Professor of Medicine Virginia Tech Carilion School of Medicine Roanoke, Virginia Universidad de La Repüblica Montevideo, Uruguay

The classic therapy to eliminate angiodysplasias, also called arteriovenous malformations (AVMs), is argon plasma coagulation (APC), a noncontact electrical coagulation method that results in tissue damage via heat (thermocoagulation). APC allows for tissue ablation or destruction at different levels. In the setting of angiodysplasias, APC is used to ablate mainly the mucosa and superficial submucosa, but occasionally deep damage or perforation may occur, especially in thin areas of the luminal gastrointestinal tract, such as the cecum, duodenum, and jejunum. In addition, use of anticoagulant or antiplatelet agents may hamper the efficiency of monotherapy with APC.

For these reasons, we propose the concept of “personalized” APC therapy, which includes the use of additional therapies such as preinjection of the submucosa below the AVM with normal saline or placing clips after APC (Figures 1 and 2).

Figure 1. The submucosal injection–safety burst.

With this approach, preinjection of normal saline below the angiodysplasia is performed, followed by argon plasma coagulation. Saline will dissipate the electrical current, the submucosal cushion prevents deeper injuries, and the angiodysplasia is safely burned.

Figure 2. The clip-after-burst technique.

(A, D) Angiodysplasia. (B, E) First apply argon plasma coagulation and coagulate the angiodysplasia using short or long bursts. (C, F) Then place a clip on the coagulated area. This is a safety or preventive approach, used in lesions located in the cecum that underwent lots of burning or in high-risk patients. It also can be useful in angiodysplasias of any part of the gastrointestinal tract, especially in patients on anticoagulation.

Personalized therapy considers the patient’s condition and morbidities, use of anticoagulant or antiplatelet agents, lesion size, and lesion location. The patient’s condition, comorbidities, and use of anticoagulants will determine the aggressiveness of therapy as well as whether to use double or triple approaches, such as APC plus clips, submucosal injection followed by APC, or the submucosal cushion, APC, and clips (Figures 2 and 3).

When considering the lesion, one needs to determine its size, location, and stigmata of recent hemorrhage, and all of those factors are determinants for single, dual, or triple therapy (Figure 3).

Figure 3. Triple endoscopic therapy: submucosal cushion, argon plasma coagulation, and clipping.

This approach mainly is used in patients with multiple morbidities, those on anticoagulation, and in situations where application may be riskier (eg, a thin-walled cecum in an older patient).

An advantage of this concept is the wide availability of utensils such as injection needles, normal saline, and hemostatic clips. Indeed, novel APC catheters that also allow injection of saline or cap-assisted APC are under development. (See also a previous edition of EndoHacks, “Using Transparent Caps”; Gastroenterology & Endoscopy News 2022;73[5]:36.)

Although a potential disadvantage when using more than 1 method is higher cost, patient safety is the main aim, and one complication when using APC is one too many. Therefore, we prefer to personalize therapy and use safety steps and tricks to avoid complications such as rebleeding or perforation.

Images courtesy of EndoCollab.

Dr. Mergener is a member of the Gastroenterology & Endoscopy News editorial board.

See endocollab.com for more information, including videos, quick tips, and lectures on these and many other practical endoscopy tricks and techniques.

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This article is from the October 2024 print issue.