S1342 EUS-Guided Coil + Cyanoacrylate Cuts Post-Procedure Failures by Two-Thirds Versus Single-Agent Therapy for Gastric Varices: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Introduction: Gastric variceal bleeding remains one of the most lethal sequelae of portal hypertension, with mortality that can exceed esophageal varices despite lower incidence. Endoscopic injection of cyanoacrylate or deployment of embolization coils under EUS guidance have each improved hemostasis, yet both modalities alone still permit re-bleeding and variceal recurrence that demand repeat intervention. Combining coils providing a durable scaffold with cyanoacrylate and achieving rapid thrombosis promises synergistic obliteration, but its incremental benefit has not been clearly quantified. Methods: A systematic search of PubMed, Embase, Scopus, and Cochrane Library identified randomized controlled trials (RCTs) comparing EUS-guided coil + cyanoacrylate Vs either alone for gastric varices through May 2025. Data were analyzed using RevMan 4.2.1. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using Mantel-Haenszel methods. Random- or fixed-effects models were applied based on heterogeneity (Higgins’ I²). Statistical significance was set at P < 0.05. Risk of bias was assessed using RoB 2.0. Results: Across 3 randomized trials (n = 142), EUS-guided coil + cyanoacrylate (Coil + CYA) achieved the same high technical success as single-agent therapy—complete ultrasound-confirmed obliteration in 93% vs 88% of cases (RR 1.06, 95% CI 0.95-1.18)—yet delivered markedly better clinical durability: re-bleeding fell from 17% to 3% (RR 0.21, 0.06-0.77), variceal recurrence from 28% to 10% (RR 0.38, 0.18-0.80) and the need for re-intervention from 42% to 20% (RR 0.48, 0.28-0.83). Heterogeneity was absent for every endpoint (I² = 0%), translating into a robust, roughly 2-thirds reduction in post-procedure failures without compromising initial eradication. Conclusion: EUS-guided Coil + CYA maintains the same near-universal obliteration achieved by monotherapy yet cuts re-bleeding, variceal recurrence, and re-intervention by roughly 2-thirds—consistently across trials without heterogeneity. This dual approach therefore addresses both the mechanical and hemostatic vulnerabilities of single-agent therapy, offering an immediate strategy to reduce emergency re-endoscopies and associated transfusion, ICU stay, and mortality. Our pooled RCT-level evidence provides a compelling signal strong enough to inform guideline updates, and it sets the stage for larger multicenter trials powered for survival and cost-effectiveness.