Endoscopic variceal ligation versus cyanoacrylate injection for acute variceal bleeding from the cardia to the lesser curvature.

Abstract

Background: Current guidelines recommend endoscopic variceal ligation (EVL) and endoscopic cyanoacrylate injection (ECI) for esophageal and fundal variceal bleeding, respectively. However, the optimal strategy for treating acute variceal bleeding (AVB) from the cardia to the lesser curvature remains undefined. This study compared the efficacy of EVL and ECI for AVB in this region.

Methods: We retrospectively analyzed patients with AVB from the cardia to the lesser curvature treated with EVL or ECI. Varices were classified as type 1 gastroesophageal varices-cardiac varices (GOV1-CVs; 0-2 cm below the gastroesophageal junction) or conventional GOV1s (2-5 cm below). Outcomes, including 5-day treatment failure, 6-week rebleeding, and 6-week survival, were compared using Kaplan-Meier analysis. Independent predictors of rebleeding and mortality were identified via Cox regression and subgroup analyses by variceal location.

Results: We enrolled 129 patients (EVL: 59; ECI: 70) between 2006 and 2024. Both modalities achieved high hemostasis rates, with no significant differences in 5-day treatment failure (3.4% vs 4.3%; p = 1.000), 6-week rebleeding (10.2% vs 12.9%; p = 0.630), or 6-week survival (76.3% vs 77.1%; p = 0.956). On multivariable analysis, portal vein thrombosis (hazard ratio [HR]: 5.4; p = 0.020) and clinically significant bleeding (HR: 4.4; p = 0.016) predicted 6-week rebleeding, whereas Child-Pugh class C (HR: 4.3; p < 0.001) and creatinine >1.3 mg/dL (HR: 2.5; p = 0.024) predicted 6-week mortality. EVL demonstrated lower 6-week rebleeding than ECI for GOV1-CVs (9.8% vs 40.0%, p = 0.011), but not GOV1s ( p = 0.408). In the GOV1-CVs subgroup, EVL (HR: 0.2; p = 0.030) was the only independent predictor of rebleeding.

Conclusion: EVL and ECI demonstrated comparable efficacy for AVB from the cardia to the lesser curvature. Notably, EVL is superior to ECI in reducing 6-week rebleeding in GOV1-CVs, supporting EVL as the preferred approach and underscoring the importance of precise variceal classification.