Endoscopic ultrasound-guided cyanoacrylate injection into the perforating vein for high-risk gastric varices

Direct endoscopic injection of gastric varices using cyanoacrylate (CYA) is associated with significant adverse events such as bleeding from the post-injection ulcer, needle sticking in the varix, adherence of the glue to the endoscope, and embolization into pulmonary or systemic vessels [1]. Targeting the perforating vessel by endoscopic ultrasound (EUS) rather than the varix lumen may theoretically minimize the amount of CYA and thereby reduce complications [2]. A randomized controlled trial performed by our group concluded that EUS-guided CYA injection into the perforating veins achieved excellent technical success with a lesser amount of CYA, fewer number of sessions to obliteration, and fewer complications compared to direct endoscopic injection [3].