Argon Plasma Coagulation as Rescue Endoscopic Hemostasis for Acute Variceal Bleeding in Cirrhosis: A Retrospective...

Background and Objectives: Acute variceal bleeding (AVB) in cirrhotic patients remains associated with considerable early rebleeding and mortality despite guideline-based therapy. Endoscopic band ligation (EBL) is recommended as first-line therapy for esophageal variceal bleeding, while alternative endoscopic hemostasis strategies may be required when EBL is technically difficult or judged unsafe. Materials and Methods: We conducted a single, tertiary referral center retrospective cohort study of adults with cirrhosis and AVB undergoing emergency endoscopy. Hemostasis modality at index endoscopy was EBL or argon plasma coagulation (APC), used selectively at the endoscopist's discretion when bleeding was sourced to gastric varices or when EBL was technically difficult or unsafe. The primary endpoint was 5-day rebleeding, with key secondary endpoints set as 6-week mortality and in-hospital mortality. ICU admission and time to endoscopy were evaluated as process and outcome metrics. Multivariable models were used, adjusted for liver severity (MELD-Na, ALBI, PALBI) and bleeding and mortality scores (AIMS65, Rockall, Glasgow Blatchford). Results: Among 181 eligible AVB cases (APC n = 29, EBL n = 152), 5-day rebleeding was higher with APC (31%) than EBL (13.8%). In-hospital mortality (APC 20.7% vs. EBL 23.0%) and 6-week mortality (APC 31.0% vs. EBL 35.5%) were similar. In adjusted models (age, MELD-Na, time to endoscopy), APC was associated with increased odds of 5-day rebleeding (aOR 2.73, 95% CI 1.06-7.03), but not with in-hospital (aOR 0.51) or 6-week mortality (aOR 0.45). Time to endoscopy was not independently associated with mortality in adjusted models. Discrimination for in-hospital mortality was highest for MELD-Na (AUC 0.898) and ALBI (AUC 0.859). Conclusions: In this observational AVB cohort, APC, used as a rescue or alternative strategy, showed similar short-term mortality compared with EBL after adjustment for liver severity and was associated with higher 5-day rebleeding. APC may be a pragmatic option when EBL is not feasible or is judged unsafe. However, prospective evaluation and careful selection are warranted.