EUS-guided versus direct endoscopic cyanoacrylate injection for variceal eradication: A systematic review and meta-analysis of randomized controlled trials
In brief
EUS-guided cyanoacrylate injection cuts late rebleeding by 60%
In a meta-analysis of five RCTs (440 patients), EUS-guided cyanoacrylate injection lowered late variceal rebleeding to about four out of ten compared with standard direct injection, while early rebleeding and overall eradication rates were similar. It also used less glue, required fewer sessions, and reduced post-injection ulcers, but the evidence quality is very low.
- Journal
- Endoscopic ultrasound (Q1)
- Published
- 15 July 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Mohamed Abuelazm, Abdelrahman Awad, Omar Elkoumi, Mohamed S Elgendy, Ahmed A Ibrahim, Mohamed Saad Rakab, et al.
- PMID
- 42499519
- DOI
- 10.1097/eus.0000000000000207
Why clinicians should know about it
- Picked for Hepatology (paper of the day, 26 July 2026).
- Picked for Epidemiology (top studies of the week, 26 July 2026).
- Picked for Gastroenterology (top studies of the week, 26 July 2026): Systematic review of EUS‑guided cyanoacrylate vs direct injection for varices
- Picked for Radiology, Radiation Oncology, Nuclear Medicine, Medical Physics and Imaging (top studies of the week, 26 July 2026): EUS‑CYA reduces late rebleeding compared with DEI‑CYA
Abstract
While direct endoscopic cyanoacrylate injection (DEI-CYA) is the standard hemostatic therapy, it is associated with risks of ectopic embolization and ulceration. EUS-guided injection (EUS-CYA) allows for precise targeting of feeder vessels, potentially improving outcomes. A comprehensive search was conducted across PubMed, Web of Science, CENTRAL, and Scopus for RCTs up to January 2026. Primary outcomes included early and late rebleeding rates and variceal eradication. Risk ratios (RRs) and standardized mean differences (SMD) were pooled using a random-effects model. Five RCTs involving 440 patients were included. EUS-CYA was associated with a significant reduction in late rebleeding compared with DEI-CYA (RR: 0.40; 95% confidence intervals [CI]: 0.27-0.60; P < 0.001). However, there was no significant difference in early rebleeding (P = 0.53) or overall variceal eradication rates (RR: 1.13; 95% CI: 0.97-1.31; P = 0.11). Regarding safety, EUS-CYA significantly reduced the risk of postinjection ulcers (RR: 0.32; 95% CI: 0.11-0.93; P = 0.04), while rates of ectopic embolism (P = 0.75) and mortality (P = 0.65) were comparable. Procedurally, EUS-CYA was more efficient, requiring significantly less cyanoacrylate (SMD: -0.35; 95% CI: -0.61 to -0.09; P = 0.01) and fewer sessions for eradication (SMD: -1.28; 95% CI: -2.50 to -0.05; P = 0.04). Current evidence suggests that EUS-CYA likely reduces the risk of late rebleeding compared with DEI-CYA. While the data indicate potential benefits regarding procedural efficiency (reduced cyanoacrylate volume and fewer sessions) and a lower incidence of postinjection ulcers, the certainty of evidence for these outcomes remains very low.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.