Gastroesophageal varices (GOVs) hemorrhage is a severe complication of decompensated hepatic cirrhosis. Despite improvements in therapy, the six-week mortality is 15%–25% [1], [2]. In addition, absent secondary prophylaxis after the first variceal bleeding, repeat bleeding occurred in approximately 60%–70% of patients over the next 1–2 years [3].

The Sarin classification scheme further subdivides GOVs into GOV1—extending 2–5 cm along the stomach’s lesser curve—and GOV2, which extends beyond the gastroesophageal junction into the stomach’s fundus. IGV1 was defined as isolated GOVs in the fundus [4]. GOV2 presents in 21% of patients with hepatic cirrhosis, whereas IGV1 presents in only 7%. GOV2 and IGV1 bleed less frequently. However, hemorrhage from fundal GVs is often more severe and difficult to control. It increases the risk of recurrent bleeding (55% for GOV2, 78% for IGV1) and mortality (up to 45%) compared with EVs [5]. Sclerotherapy and ligation were effective secondary prophylactic treatments for esophageal varices (EVs) hemorrhage. GOV1 can be managed by the same treatments for EVs. Cyanoacrylate injection effectively treated acute bleeding of GOV2 and IGV; its hemostasis rate exceeded 90% [6] and was recommended by BAVONO VII [4]. However, gastric varices (GVs) are associated with gastrorenal shunts (GRS) in 60%–85% of patients [7]; in some cases, cyanoacrylate flows via GRS to the lung, brain, spleen, or intestine, resulting in ectopic embolism or organ infarction [8], [9], [10], [11].

Balloon-occluded retrograde transvenous obliteration (BRTO) uses a balloon occluding the GRS, then uses hemodynamic changes to retrogradely inject ethanolamine oleate (EO) via balloon or microcatheter into the GVs. The sclerosing agent displaces red blood cells and damages venous endothelium, leading to thrombus precipitation and varix eradication [12]. Although EO is approved for IGV in Japan, adverse events like hematuria, hemolysis, renal tubular disturbance, and renal insufficiency are not rare [13]. The BRTO procedure requires 12–30 h or more, which may result in poor tolerance by patients. Other modified BRTOs were recently developed, such as plug-assisted retrograde transvenous obliteration and coil-assisted retrograde transvenous obliteration (CARTO). These modified treatments required much less time than the traditional BRTO. However, all forms of BRTO permanently occluded GRS, potentially increasing portal pressure, causing or worsening EVs, and exacerbating gastropathy [13]. If the GVs recur, BRTO would not be a choice.

BRTO-assisted endoscopic cyanoacrylate injection (E-BRTO) treats GOV2 and IGV1 by temporarily occluding GRS with a balloon, then injecting cyanoacrylate through the endoscope after that retrieving the balloon. This technique combines the advantages of both BRTO and endoscopic cyanoacrylate injection. Herein, we retroactively explore the safety and feasibility of E-BRTO and analyze its efficacy for reducing the rate of recurrent bleeding.