EUS-Guided Cyanoacrylate Injection With Balloon-Compression Sclerotherapy Versus Band Ligation for Gastroesophageal Varices: A Randomized Trial.

BACKGROUND AND OBJECTIVES: Gastroesophageal varices (GOV) is a life-threatening complication of portal hypertension. Endoscopic ultrasound-guided cyanoacrylate injection (EUS-CYA) improves gastric variceal treatment, but the optimal strategy for concomitant esophageal varices (EV) remains unclear. We compared EUS-CYA combined with balloon-compression endoscopic injection sclerotherapy (bc-EIS) versus EUS-CYA combined with endoscopic variceal ligation (EVL). METHODS: Single-center randomized controlled trial (July 2022-June 2025). Cirrhotic patients with GOV were assigned 1:1 to EUS-CYA + bc-EIS (n = 62) or EUS-CYA + EVL (n = 62). All received EUS-guided "sandwich technique" for gastric varices (GV). Then, bc-EIS (polidocanol under balloon compression for 10 min) or EVL (spiral ligation) was performed for EV. The primary endpoint was combined eradication rate of both GV and EV at 6 months. RESULTS: GV final eradication: 100% in both groups. EV eradication: 100% in the bc-EIS group versus 82.3% in the EVL group (p < 0.001). Fewer sessions needed for bc-EIS (1.4 ± 0.6 vs. 2.1 ± 1.1, p < 0.001). Rebleeding: 9.7% versus 21.0% (p = 0.081). Independent rebleeding risk factors: esophageal variceal diameter > 10 mm (HR = 6.98) and prior bleeding (HR = 4.57). No significant differences in hemostasis (100% both), complications (14.5% vs. 17.7%), or recurrence (0 vs. 3.2%). No severe adverse events. CONCLUSION: EUS-CYA combined with bc-EIS significantly improves esophageal variceal eradication and reduces treatment sessions compared with EUS-CYA + EVL, with comparable safety. TRIAL REGISTRATION: ChiCTR2000039974.