Endoscopic Cyanoacrylate Injection Versus Balloon‐Occluded Retrograde Transvenous Obliteration for Prevention of Gastric Variceal Bleeding: A Randomized Controlled Trial

Abstract

Background and Aims The optimal treatment for gastric varices (GVs) is a topic that remains open for study. This study compared the efficacy and safety of endoscopic cyanoacrylate injection and balloon‐occluded retrograde transvenous obliteration (BRTO) to prevent rebleeding in patients with cirrhosis and GVs after primary hemostasis. Approach and Results Patients with cirrhosis and history of bleeding from gastroesophageal varices type 2 or isolated gastric varices type 1 were randomized to cyanoacrylate injection (n = 32) or BRTO treatment (n = 32). Primary outcomes were gastric variceal rebleeding or all‐cause rebleeding. Patient characteristics were well balanced between two groups. Mean follow‐up time was 27.1 ± 12.0 months in a cyanoacrylate injection group and 27.6 ± 14.3 months in a BRTO group. Probability of gastric variceal rebleeding was higher in the cyanoacrylate injection group than in the BRTO group (P = 0.024). Probability of remaining free of all‐cause rebleeding at 1 and 2 years for cyanoacrylate injection versus BRTO was 77% versus 96.3% and 65.2% versus 92.6% (P = 0.004). Survival rates, frequency of complications, and worsening of esophageal varices were similar in both groups. BRTO resulted in fewer hospitalizations, inpatient stays, and lower medical costs. Conclusions BRTO is more effective than cyanoacrylate injection in preventing rebleeding from GVs, with similar frequencies of complications and mortalities.

Friend or Foe? Spontaneous Portosystemic Shunts in Cirrhosis—Current Understanding and Future Prospects

“…A very recent study was the first randomized controlled trial to demonstrate the superiority of BRTO in the management of (re)bleeding from GVs. In this study, Luo and colleagues found that BRTO as the therapeutic modality for bleeding GVs resulted in fewer hospitalizations, in-patient stays, and lower medical costs [ 83 ].…”

Safety, Efficacy, and Outcomes of N-Butyl Cyanoacrylate Glue Injection through the Endoscopic or Radiologic Route for Variceal Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis

“…BRTO is currently recognized as an alternative to TIPS for treatment of fundal varices associated with a large gastro/splenorenal collateral when the patient is not an appropriate candidate for TIPS because of hepatic encephalopathy or poor hepatic reserve [ 15 , 79 ]. A recent trial showed that BRTO was more effective than endoscopic cyanoacrylate injection in preventing rebleeding from gastric variceal bleeding [ 80 ]. During the BRTO procedure, sclerosing agents, such as ethanolamine oleate or sodium tetradecyl sulfate mixed with water-soluble contrast media or Lipiodol ® , are used for gastric varix obturation [ 81 , 82 ].…”

Letter to the Editor: Endoscopic Ultrasound–Guided Coil Therapy for Secondary Prevention After Gastric Variceal Bleeding: A Promising Alternative

“…We read with interest the recent article (1) comparing endoscopic cyanoacrylate injection to balloon retrograde transvenous obliteration (BRTO) for the prevention of bleeding in patients with cirrhosis and gastric varices (GV) after primary hemostasis. The authors conclude that BRTO for secondary prophylaxis resulted in a lower risk of rebleeding compared to cyanoacrylate injection.…”