Endoscopic Ultrasound-Guided Variceal Therapy for Gastric Variceal Rupture After Failed Endoscopic Injection Sclerotherapy: A Case Report.

Endoscopic ultrasound (EUS) has become an essential tool in vascular interventions due to its imaging potential in the proximity of various vascular structures in the mediastinum and abdominal cavity. EUS-guided variceal therapy (EUS-VT) has emerged as a promising approach for treating gastric varices (GV). Although still underused, EUS-VT offers such advantages as precise targeting and real-time variceal puncture visualization, making it a valuable alternative when conventional therapies fail. We report the case of a 63-year-old man with GVs secondary to fatty liver cirrhosis, who experienced repeated variceal ruptures despite multiple prior interventions (e.g., balloon-occluded retrograde transvenous obliteration, percutaneous transhepatic obliteration, partial splenic embolization, and several endoscopic injection sclerotherapy (EIS) sessions). During his most recent variceal rupture episode, EUS-VT was performed. A 23-gauge sclerotherapy needle failed to reach the target varix under EUS guidance. However, successful puncture and obliteration could be achieved using a 22-gauge fine-needle aspiration needle and cyanoacrylate glue. Doppler imaging confirmed lipiodol distribution and the absence of blood flow, indicating successful embolization. No adverse events occurred or rebleeding was observed during the one-month follow-up. This case demonstrates the clinical utility of EUS-VT as a rescue therapy for gastric variceal bleeding in patients with anatomically complex lesions refractory to standard treatments. EUS-VT should be considered a viable option in selected cases when conventional EIS is unsuccessful due to anatomical limitations.