Gastric varices management: Is clip-assisted glue injection a real-world alternative to endoscopic ultrasound-guided therapy?

Gastric variceal (GV) bleeding remains a life-threatening complication of portal hypertension, with ongoing debate regarding the optimal endoscopic therapy. Conventional endoscopic cyanoacrylate injection (ECI) is effective but limited by the risk of ectopic embolism, particularly in the presence of gastrorenal shunts. Clip-assisted ECI (clip-ECI) has emerged as a novel modification designed to reduce embolic risk while maintaining hemostatic efficacy. We appraised the recent study by Xiong et al, which compared clip-ECI with endoscopic ultrasound-guided coil and cyanoacrylate injection in 108 propensity-matched patients with cardiofundal varices and shunts. Both techniques demonstrated comparable efficacy, with obliteration rates exceeding 90% and similar one-year rebleeding rates. Importantly, no embolic events were reported. These findings are consistent with prior studies, including multicenter cohorts and a recent randomized controlled trial, which highlight clip-ECI as a safe, effective, and efficient technique, with advantages of shorter procedure times, fewer sessions, and lower costs. While endoscopic ultrasound (EUS)-guided therapy offers precision in expert hands, clip-ECI provides a practical, accessible alternative, particularly in resource-limited settings. Larger prospective studies with standardized definitions and cost-effectiveness analyses are needed to refine treatment algorithms. Clip-ECI represents a promising "flow-control assisted" strategy and a real-world alternative to EUS-based therapies for GV.