BRTO-assisted endoscopic cyanoacrylate injection as a potential therapy for intractable acute gastric variceal bleeding with large SPSS: a retrospective single-center case series study.

BACKGROUND AND AIMS: Treatment of acute gastric variceal bleeding (AGVB) in patients with large spontaneous portosystemic shunts (SPSS) remains challenging due to the severe, refractory nature of bleeding and the limitations of guideline-recommended therapies, which are associated with difficulty in achieving hemostasis, procedure-related complications, and resource-limited settings. This study aimed to explore the feasibility of balloon-occluded retrograde transvenous obliteration (BRTO)-assisted endoscopic cyanoacrylate injection (ECI) as a potential therapy for AGVB with large SPSS. METHODS: This retrospective single-center case series included adult patients (aged 18 or older) who underwent BRTO-assisted ECI for the treatment of AGVB with large SPSS (≥1.2 cm) from March 2022 to December 2024, with a 1-year follow-up. RESULTS: A total of 12 patients were enrolled (mean age 57.8 years; 83.3% male). Among them, 8 were classified as GOV2 and 4 as IGV1, with a median SPSS diameter of 1.6 cm (IQR: 1.2-2.6). All cases of GVs (gastric varices) were attributed to liver cirrhosis, most commonly secondary to hepatitis B virus (58.3%). The majority of patients had Child-Pugh class B (50.0%) or C (41.7%). The clinical success rate was 91.6% (11/12), and no symptomatic embolism or organ dysfunction was observed. There was no early rebleeding (0/12), while the late rebleeding rate was 33.3% (4/12) due to GVs recurrence without regular secondary prophylaxis of bleeding. Although no procedure-related deaths occurred, the 1-year mortality from all causes was 41.7%, primarily from progression of primary liver diseases and co-morbidities. CONCLUSION: BRTO-assisted ECI appears to be a potential therapy for treating AGVB with large SPSS, with high clinical success and no observed ectopic embolization. Larger prospective multicenter studies are needed to confirm these findings and evaluate long-term outcomes.