EUS-guided injection of cyanoacrylate for bleeding gastric varices

Bleeding gastric varices is a highly fatal condition. Recurrent bleeding after hemostasis achieved by endoscopic methods is common, and obliteration of gastric varices is difficult to assess. Our aim was to investigate the use of endosonography (EUS) in monitoring cyanoacrylate injection to obliterate gastric varices.

Patients who presented with bleeding gastric varices were treated with bolus injection(s) of cyanoacrylate (0.5 mL cyanoacrylate mixed with 0.7 mL Lipiodol) until bleeding was controlled; 47 patients received "on-demand" injection only in response to recurrent bleeding (on-demand group). Another group of 54 patients underwent biweekly EUS followed by repeated injection of cyanoacrylate (repeated-injection group) until all gastric varices were obliterated. The primary outcome was recurrent bleeding-free interval and survival rate.

The two groups of patients were comparable demographically. Although the rates of early (48 hour) was significantly reduced in the repeated-injection group (18.5% versus 44.7%, p = 0.0053, odds ratio 0.28 (95% CI [0.12, 0. 69]). Cumulative probability of recurrent bleeding-free interval was higher in the repeated-injection than the on-demand group (log-rank test, p = 0.0053). There was a numeric trend toward improved survival in the repeated-injection group.

Gastric varices obliteration with cyanoacrylate under EUS monitoring reduces recurrent bleeding and may improve survival.