Endoscopic ultrasound-guided cyanoacrylate injection for the treatment of gastric variceal bleeding after failed endoscopic embolization

Gastric variceal (GV) hemorrhage is one of the most life-threatening adverse events in cirrhotic patients with portal hypertension, with an annual incidence of 5–15% [1]. Although less common than esophageal variceal bleeding, GV bleeding is associated with higher severity and mortality, reaching a 6-week mortality rate of 20% [2]. Endoscopic cyanoacrylate (CYA) injection remains the standard treatment for GV bleeding. However, failure occurs in 15–30% of cases due to factors such as obscured deep perforating veins, inadequate glue dispersion, or vascular anatomical variations [3]. Endoscopic ultrasound-guided selective variceal devascularization (EUS-SVD) has emerged as a salvage therapy, offering real-time visualization of vascular structures and hemodynamics. While EUS-SVD is primarily used for prophylactic management, this case demonstrates its efficacy in achieving hemostasis after failed conventional endoscopic CYA injection.