Endoscopy International Open EUS-guided cyanoacrylate injection into the perforating vein versus direct endoscopic injection in the treatment of high-risk gastric varices

: Background and aims: Endoscopic injection of gastric varices (GVs) using cyanoacrylate (CYA) is associated with significant adverse events. We aimed to compare the efficacy and safety of EUS-guided CYA injection into the perforating vein versus direct endoscopic injection (DEI) of CYA in treatment of high-risk GVs. Patients and methods: A randomized controlled trial that included 52 patients with high-risk GVs. Group A underwent EUS-guided injection into the perforator vein and Group B underwent DEI of 1 ml CYA. Endoscopic examination and doppler EUS were repeated after 3 months to confirm eradication. Obliteration by doppler EUS was considered by absence of doppler flow within the varix. Repeated injection was performed in the absence of obliteration. Doppler EUS examination was repeated at 3 and 6 months after each injection. Results: 43 patients including 27 males and 16 females with mean age 57 years completed the study. Variceal obliteration was achieved during the index session after 3 months in 8/21 (38.1%) in group B compared to 17/22 (77.2%) in group A (p=0.014). There was significant difference in the amount of CYA needed to achieve obliteration in group B compared to group A (2 vs.1 ml, p=0.027). There was no statistically significant difference in the overall adverse events rate between group A and group B (4.5% vs. 14.3%, p=0.345). Conclusion: EUS-guided CYA injection into the perforating veins achieved less amount of CYA, fewer number of sessions to obliteration, and similar overall adverse events rate in the treatment of high-risk GVs compared to DEI. Abstract Background and aims: Endoscopic injection of gastric varices (GVs) using cyanoacrylate (CYA) is associated with significant adverse events. We aimed to compare the efficacy and safety of EUS-guided CYA injection into the perforating vein versus direct endoscopic injection (DEI) of CYA in treatment of high-risk GVs. Patients and methods: A randomized controlled trial that included 52 patients with high-risk GVs. Group A underwent EUS-guided injection into the perforator vein and Group B underwent DEI of 1 ml CYA. Endoscopic examination and doppler EUS were repeated after 3 months to confirm eradication. Obliteration by doppler EUS was considered by absence of doppler flow within the varix. Repeated injection was performed in the absence of obliteration. Doppler EUS examination was repeated at 3 and 6 months after each injection. Results: 43 patients including 27 males and 16 females with mean age 57 years completed the study. Variceal obliteration was achieved during the index session after 3 months in 8/21 (38.1%) in group B compared to 17/22 (77.2%) in group A (p=0.014). There was significant difference in the amount of CYA needed to achieve obliteration in group B compared to group A (2 vs.1 ml, p=0.027). There was no statistically significant difference in the overall adverse events rate between group A and group B (4.5% vs. 14.3%, p=0.345). Conclusion: EUS-guided CYA injection into the perforating veins achieved less amount of CYA, fewer number of sessions to obliteration, and similar overall adverse events rate in the treatment of high-risk GVs compared to DEI.