Introduction
Gastric varices, which are less common but more severe than esophageal varices in
patients with decompensated cirrhosis due to portal hypertension, are concerning owing
to how challenging they are to control and their high rebleeding rates, which reach
up to 80%–90% in some studies [1 ]. Cyanoacrylate glue injection has been the conventional treatment since landmark
studies reported three to four decades ago [2 ]
[3 ]; however, the embolization risk remains uncertain [4 ]. Endoscopic ultrasonography (EUS), which offers accurate diagnostic evaluation and
therapeutics, has become a primary interventional modality [5 ], surpassing previous methods for safe and effective treatment of gastric varices,
despite its limitations.
EUS enhances the ability to accurately locate the varices and minimizes glue usage
for variceal obliteration, reducing the embolization risk. Refinements, such as combining
coils with glue, appear to enhance obliteration and decrease the embolization risk.
Binmoellar et al. conducted a study that suggested a 96% success rate after a single
session, without embolic events [5 ]. To scientifically validate this, a randomized comparative study was designed to
assess the efficacy of EUS-guided coil embolization with glue injection (Coil+CYA)
versus EUS-guided glue injection alone (CYA) in patients with gastric varices, aiming
for obliteration. The study aimed to assess the clinical success of the EUS intervention
in the two groups. Secondary objectives involved comparison of variceal recurrence,
rebleeding, reinterventions, complications, and overall survival between the two EUS
intervention groups.
Methods
The study was carried out in a single-blinded, prospective, parallel-group randomized
format in the gastroenterology department of a major tertiary referral center in north-west
India, with approval having been obtained from the institutional ethics committee.
The study was conducted from October 2022 to March 2024. Patients were randomly assigned in a 1:1 ratio by block randomization using a computer-generated
random sequence. Patients were allocated to either the Coil+CYA or CYA group, as depicted
in Fig. 1s , see online-only Supplementary material. Allocation concealment was done using sequentially
numbered opaque sealed envelopes, prepared using the computer-generated random sequence.
These envelopes were prepared by an individual who was not involved in patient selection,
allocation, or observation. The study adhered to the principles outlined in the Declaration
of Helsinki, and all patients provided written informed consent in an understandable
language.
The sample size for the study was calculated at an alpha error of 0.05 and study power
of 80%. The gastric variceal obliteration rate with cyanoacrylate injection alone
is expected to be 52% [6 ] Assuming the obliteration rate with the combined therapy increases by 40%, the sample
size was calculated as being a minimum of 46, which was enhanced to 50. The null hypothesis
considered for the study was that no difference exists in the efficacy of the combined
therapy compared with injection therapy alone.
The study included individuals aged 18 years and older, diagnosed with gastric varices
(gastroesophageal varices type 2 [GOV2] and isolated gastric varices type 1 [IGV1])
through endoscopic evaluation, according to the Sarin classification [7 ], who consented to undergo the endoscopic procedure. Patients presented with either
active bleeding from gastric varices, a history of prior bleeding due to gastric varices
(secondary prophylaxis), or were eligible for primary prophylaxis of larger and high
risk varices, in accordance with the Baveno VII, European Society of Gastrointestinal
Endoscopy (ESGE), and UK guidelines for gastric variceal management [8 ]
[9 ]
[10 ]. Exclusion criteria for this study included: patients concurrently experiencing
hepatorenal syndrome and/or multiorgan failure, pregnant or lactating women, individuals
with a platelet count <50 000/mL or an international normalized ratio (INR) ≥2, and
patients with a history of upper gastrointestinal tract surgery.
The primary objective of the study was to assess the clinical success of EUS intervention
in the two groups. Clinical success was determined by the immediate and complete obliteration
of the varix, confirmed by demonstration of the absence of flow signal on EUS Doppler
examination.
The secondary objectives comprised the technical success rate, rebleeding episodes,
gastric variceal reappearance during follow-up, reinterventions needed, time to reintervention,
mortality, and overall survival for the two EUS intervention groups. Technical success
was defined as the successful execution of the intended procedure. Patients who experienced
a repeat episode of bleeding after the initial intervention were categorized as having
a rebleeding episode. If a repeat intervention was performed within the same allocation
group, it was categorized as a reintervention. EUS was conducted on all patients at
the 12-week follow-up to assess for variceal reappearance.
Endoscopic ultrasonography: technical aspects
The procedures were carried out in the gastroenterology department, which was fitted
out with requisite equipment and accessories for therapeutic interventions. To maintain
uniformity, EUS and esophagogastroduodenoscopy were done by a single endoscopist (A.J.).
Patients were administered sedation and underwent vital sign monitoring with premedication,
overseen by an anesthetist throughout the procedure. All patients underwent preprocedural
assessment and postintervention monitoring while remaining within the unit.
The EUS procedure employed a curved linear array transducer in conjunction with a
light source. Prior to the procedure, all patients received 2 g of ceftriaxone intravenously.
The echoendoscope was positioned in the lower esophagus and gastric cardia to aid
better location of the gastric varices and adjacent collaterals. Direct visualization
of the collaterals and turbulent blood flow was evaluated using color Doppler ([Fig. 1 ]). The locations of the feeding vessel and the convergence of collaterals were targeted
via the shortest feasible route. A 19-gauge EchoTip Ultra EUS needle was used to puncture
the varix under EUS guidance. The position of the needle was subsequently confirmed
visually and by the instillation of 3–5 mL of normal saline into the varix. This procedure
helps to prevent clot formation at the tip, thereby facilitating easy passage of the
pushable coils with a stylet. Adjacent organs were also screened to exclude the presence
of other vascular abnormalities, such as a cavernoma or pseudoaneurysm.
Fig. 1 Endoscopic ultrasonography (EUS) images showing: a gastric varices located by EUS; b confirmation of the flow signal on color Doppler; c the EUS needle (star) positioned within the varices; d EUS-guided coil deployment; e confirmation of the complete obliteration of the varices post-procedure.
In the combined (Coil+CYA) arm, EUS-guided coils (pushable using the stylet) of variable
sizes, namely 8×12 mm, 10×14 mm, and 12×17 mm, were deployed inside the varix under
direct
vision. The ideal size of the coils was determined by estimating the variceal diameter,
ensuring that the coil, after release, did not have dimensions greater than the widest
point
of the varix caliber. This was followed by the injection of n-Butyl-cyanoacrylate
until
maximum attainable obliteration of blood flow inside the varix had been achieved,
with color
Doppler being used to confirm this obliteration. Additionally, 1–2 mL of saline was
injected
after the glue to ensure complete flushing of the needle. Procedural refinements were
taken
into account while placing the needle tip and directing it to minimize the risks of
perforation or coil extrusion, a paradigm dependent solely on the endoscopist's
expertise.
In the other intervention arm using glue alone (CYA), EUS-guided glue injection was
performed in a similar fashion as described previously, aiming for complete visual
obliteration of blood flow inside the varices.
Follow-up
All patients were invited for follow-up appointments every 2–3 weeks for a comprehensive
evaluation of their condition, biochemical tests, and treatment. At 12 weeks following
the initial procedure, both groups underwent repeat EUS to assess for persistence
of varices or any signs of recurrence, and if necessary were planned for reintervention.
Long-term follow-up, extending up to 12 months from enrolment or until the date of
death for all patients, was scheduled to assess rebleeding, reintervention, complications,
and survival in both groups. If patients experienced variceal rebleeding that required
additional intervention during the follow-up period, they underwent a repeat of the
same EUS-guided procedure within their respective assigned group.
Statistical analysis
Categorical variables were described using frequencies and percentages. Quantitative
variables were described by their mean (SD) or median and range. The chi-squared test
or
Fisherʼs exact test were used to analyze categorical variables, as applicable, and
the
Mann–Whitney U test was used to compare quantitative
variables.
A comparison between the two study groups regarding survival time and duration until
reintervention was conducted using Kaplan–Meier estimates and log-rank analysis. The
relative risk (RR) was estimated by comparing the need for reintervention between
the two
groups. Statistical significance was determined using a threshold of P <0.05.
Results
The study included a total of 50 patients, with 24 allocated to the Coil+CYA group
and 26 to the CYA group. Baseline data, which included age, sex, etiology of chronic
liver disease, and severity scores (Child–Turcotte–Pugh [CTP] and Model for End-Stage
Liver Disease-Na [MELD-Na]), revealed no significant disparities between the two groups
([Table 1 ]). Additionally, blood characteristics, such as hemoglobin levels and platelet count,
and the size and location of the gastric varices were similar across the two groups.
Table 1 Sociodemographic and clinical characteristics of the two study groups.
COIL+CYA (n = 24)
CYA (n = 26)
P value
Coil+CYA, coil embolization with cyanoacrylate injection; CYA, cyanoacrylate injection
alone; GOV2, gastroesophageal varices type 2; HBV, hepatitis B virus; HCV, hepatitis
C virus; IGV1, isolated gastric varices type 1; MELD-Na, Model for End-Stage Liver
Disease-Na; NASH, nonalcoholic steatohepatitis.
1 Mann–Whitney U test.
2 Chi-squared test.
3 Fisher’s exact test.
Age, mean (SD), years; [95%CI]
40.2 (4.88); [39.1–42.7]
41.1 (5.23); [39.9–43.9]
0.641
Sex, male, n (%)
17 (70.8%)
19 (73.1%)
0.852
Etiology, n (%)
11 (45.8%)
14 (53.8%)
0.872
2 (8.3%)
1 (3.8%)
1 (4.2%)
1 (3.8%)
6 (25.0%)
4 (15.4%)
2 (8.3%)
3 (11.5%)
2 (8.3%)
3 (11.5%)
0.712
Cirrhosis severity
Child–Pugh score, median (range) [95%CI]
9 (6–10) [8.1–9.2]
9 (6–12) [8.3–9.7]
0.511
Child–Pugh grade, n (%)
0.272
2 (9.1)
2 (8.7%)
5 (22.7)
3 (13.0%)
15 (68.2%)
18 (78.2%)
MELD-Na score, median (range) [95%CI]
19.6 (17–23) [19.0–20.3]
20.2 (16–22) [18.7–20.3]
0.861
Indication, n (%)
7 (29.2%)
4 (15.4%)
0.313
5 (20.8%)
6 (23.1%)
0.893
12 (50.0%)
16 (61.5%)
0.573
Sarin type, n (%)
0.852
16 (66.7%)
18 (69.2%)
8 (33.3%)
8 (30.8%)
Variceal size, n (%), mm
–
24 (100%)
26 (100%)
Platelet count, mean (SD), 1000/mm3 [95%CI]
66 (12.8) [62.9–73.0]
71 (9.8) [68.9–76.5]
0.201
Hemoglobin, mean (SD), g/dL [95%CI]
7.8 (0.92) [7.5–8.1]
7.6 (0.68) [7.4–7.9]
0.501
Within the Coil+CYA group, there were five active bleeders (20.8%), whereas in the
CYA group, there were six (23.1%). Secondary prophylactic intervention, for patients
with a history of prior bleeding, was administered to 12 individuals (50.0%) in the
Coil+CYA group and 16 (61.5%) in the CYA group. Seven patients (29.2%) in the Coil+CYA
group and four (15.4%) in the CYA group underwent EUS intervention as primary prophylaxis
owing to larger variceal size and increased risk of bleeding.
The Coil+CYA group required fewer sessions to achieve complete gastric variceal
obliteration compared with the CYA group (P = 0.01). The median
volume of cyanoacrylate glue used in the Coil+CYA group was 1.5 mL (95%CI 1.3–1.7
mL), while
in CYA group it was 3.5 mL (95%CI 2.6–3.3 mL). The Coil+CYA group needed a lower volume
of
cyanoacrylate glue for complete obliteration compared with the CYA group (P <0.001) ([Table 2 ]). In the Coil+CYA group, the number of coils inserted per patient ranged from one
to
four. The intended procedure was successfully completed in 100% of patients in both
groups.
During the initial intervention, complete cessation of blood flow was observed via
EUS in 24
patients (100%) in the Coil+CYA group and 24 (92.3%) in the CYA group (P = 0.49).
Table 2 Endoscopic ultrasonography-guided interventions and primary outcomes of the two study
groups.
COIL+CYA
(n = 24)
CYA
(n = 26)
P value
Coil+CYA, coil embolization with cyanoacrylate injection; CYA, cyanoacrylate injection
alone; EUS, endoscopic ultrasonography.
1 Fisher’s exact test.
2 Mann–Whitney U test.
Sessions, n (%)
0.011
16 (66.7%)
8 (30.7%)
8 (33.3%)
7 (26.9%)
0
6 (23.1%)
0
5 (19.2%)
Glue volume, median (range), mL [95%CI]
1.5 (1.0–2.5) [1.3–1.7]
3.5 (1.5–4.0) [2.6–3.3]
<0.0012
Coils placed, n (%)
–
–
6 (25.0%)
8 (33.3%)
4 (16.6%)
6 (25.0%)
Size of coils placed, n, mm
–
–
11
40
7
Adverse events, n (%)
3 (12.5%)
5 (19.2%)
0.701
2
2
1
3
Primary outcome
Complete obliteration (on EUS), n (%)
24 (100)
24 (92.3)
0.491
Rebleeding incidents were assessed within the specified time intervals (0–12 weeks
and 12–24 weeks post-procedure) in both groups, as a part of the secondary outcomes
([Table 3 ]). During the initial 12-week period, in the Coil+CYA group, one patient (4.2%) exhibited
a rebleeding episode compared with four patients (15.4%) in the CYA group (P = 0.35). During the subsequent period (weeks 12–24), one patient (5.0%) from the
Coil+CYA group experienced rebleeding, whereas five individuals (29.4%) did so in
the CYA group (P = 0.08). EUS conducted at 12 weeks post-procedure demonstrated variceal reappearance
in three patients (12.5%) within the Coil+CYA group and five patients (19.2%) within
the CYA group (P = 0.70) ([Fig. 2 ]).
Table 3 Comparison of the secondary outcomes across the two study groups.
COIL+CYA (n = 24)
CYA (n = 26)
P value
Coil+CYA, coil embolization with cyanoacrylate injection; CYA, cyanoacrylate injection
alone; EUS, endoscopic ultrasonography.
1 Fisher’s exact test.
2 Excludes patients who underwent reintervention during the first 3 months.
3 Log-rank test.
Technical success, n (%)
24 (100%)
26 (100%)
–
Rebleeding (0–12 weeks), n (%)
1 (4.2%)
4 (15.4%)
0.351
Rebleeding (12–24 weeks), n (%)2
1 (5.0%)
5 (29.4%)
0.081
Varix reappearance on EUS at 12-week follow-up, n (%)
3 (12.5%)
5 (19.2%)
0.701
Reinterventions, n (%)
5 (20.8%)
14 (53.8%)
0.031
Time to reintervention, mean (SD), weeks
[95%CI]
44.3 (3.4) [37.5–51.1]
24.6 (3.1) [18.4–30.9]
0.013
Mortality, n (%)
7 (29.2%)
9 (34.6%)
0.771
Cause of death, n (%)
–
2 (28.6%)
3 (33.3%)
4 (57.1%)
4 (44.4%)
1 (14.3%)
2 (22.2%)
Survival time, mean (SD), weeks
[95%CI]
48.3 (1.8) [44.6–51.9]
42.0 (1.4) [39.1–44.9]
0.043
Fig. 2 Bar chart of outcomes within the two groups. CYA, EUS-guided cyanoacrylate injection
alone; Coil+CYA, EUS-guided coil embolization with cyanoacrylate injection.
Significantly fewer reinterventions were performed in the Coil+CYA group (20.8%) compared
with the CYA group (53.8%; P = 0.03). The RR of reintervention in the Coil+CYA group compared with the CYA group
was calculated as being 0.387. This indicates that the risk of reintervention in the
Coil+CYA group was 38.7% of the risk in the CYA group, which corresponds to a relative
risk reduction (1 − RR) of 0.613.
Kaplan–Meier analysis was conducted to compare the cumulative incidence of reintervention
between the two groups ([Fig. 3 ]). The cumulative incidence of reintervention was significantly lower in Coil+CYA
group compared with the CYA group. The log-rank test suggested a significant difference
in the cumulative incidence of reintervention between the groups (P = 0.01). The mean time to reintervention in the CYA group was 24.6 weeks (95%CI 18.4–30.9
weeks); in the Coil+CYA group, it was 44.3 weeks (95%CI 37.5–51.1 weeks). Reinterventions
were attempted either for rebleeding episodes during the follow-up period or for variceal
reappearance observed with EUS at 12 weeks.
Fig. 3 Kaplan-Meier curves for the cumulative incidence of reintervention in the two groups.
Five patients (20.8%) in the combined therapy group and 14 patients (53.8%) in the
cyanoacrylate injection alone group underwent reintervention during the follow-up
period (P = 0.01, by log-rank test). CYA, EUS-guided cyanoacrylate injection alone; Coil+CYA,
EUS-guided coil embolization with cyanoacrylate injection.
The mean survival differed significantly between the Coil+CYA group (48.3 weeks, 95%CI
44.6–51.9 weeks) and the CYA group (42.0 weeks, 95%CI 39.1–44.9 weeks; P = 0.04), as shown in the Kaplan–Meier curve ([Fig. 4 ]). Overall, the mortality rates were 29.2% (n = 7) in the Coil+CYA group and 34.6%
(n = 9) in the CYA group (P = 0.77). The causes of death in both groups are detailed in [Table 3 ], with two of the patients who died (28.6%) in the Coil+CYA group and three (33.3%)
in the CYA group succumbing to bleeding events. Hepatic encephalopathy and hepatocellular
carcinoma accounted for the remaining fatalities.
Fig. 4 Kaplan-Meier curves for cumulative survival in the two groups during the follow-up
period. Survival time was longer with the combined therapy (P = 0.04, by log-rank test). CYA, EUS-guided cyanoacrylate injection alone; Coil+CYA,
EUS-guided coil embolization with cyanoacrylate injection.
Complications
After the completion of the intended procedure, adverse events, including pain, fever,
bleeding, hemodynamic instability, and perforation, were monitored. In the Coil+CYA
group, only three patients (12.5%) experienced early complications: two had abdominal
pain that was managed conservatively and one had a fever that persisted for 3 days
before subsiding with antipyretics. Similarly, in the CYA group, five patients (19.2%)
experienced fever (n = 3) or abdominal pain (n = 2). No patients experienced a major
adverse event.
Discussion
Gastric varices develop in 20% of individuals with intrahepatic portal hypertension
associated with liver cirrhosis [11 ]; however, certain extrahepatic conditions like splenic vein thrombosis, pancreatitis,
pancreatic malignancy, and myeloproliferative neoplasms, among others, can also contribute
to their formation. Individuals with these extrahepatic conditions tend to experience
lesser long-term morbidity owing to their improved liver physiology [12 ]. In this study, 8.3% (n = 2) of the combined group and 11.5% (n = 3) of the CYA
group developed gastric varices due to the pancreatitis spectrum, while the rest were
cirrhosis related. Sarin et al. reviewed 568 portal hypertension patients, categorizing
gastric varices by location, incidence, bleeding risks, and mortality [7 ]. Our study followed the Sarin classification. While GOV1 is common [13 ], we included GOV2 and IGV1 patients, as GOV1 often responds to standard band ligation.
Mortality from gastric variceal bleeding can reach up to 20% [14 ]. The bleeding risk associated with gastric varices can be predicted by assessing
factors such as their location (IGV1 > GOV2), size (>5 mm), hepatic venous pressure
gradient (>12 mmHg), CTP grade B or C, and endoscopic evidence of recent bleed stigmata
(red spot, ulcer, visible bleed) [13 ]. In this study, the CTP grades in the combined therapy group were A (n = 2), B (n
= 5), and C (n = 15); in the CYA group, they were A (n = 2), B (n = 3), and C (n =
18). Transjugular intrahepatic portosystemic shunt or balloon-occluded retrograde
transvenous obliteration are relatively contraindicated in end-stage liver disease
with higher CTP and MELD-Na scores. The limitations of conventional glue therapy restricts
its widespread usage. Further analysis, particularly through head-to-head comparisons
using EUS approaches as attempted in this study, is warranted owing to the lack of
conclusive data in this regard.
EUS surpasses conventional endoscopy for gastric variceal management in locating superficial
varices and identifying deep collaterals, including perforators, within the mucosa,
submucosa, or perivisceral area [15 ]. Both groups demonstrated comparable technical success and excellent variceal obliteration
in this study, serving as indicators of the efficacy of the modality, endoscopist
expertise, and facility resources, consistent with prior research by Binmoeller et
al. and Koziel et al. [5 ]
[16 ].
The established use of cyanoacrylate glue for gastric variceal prophylaxis and management
is supported by Mishra et al., who suggested its superiority over nonselective beta-blockers
for prophylaxis [17 ]. ESGE and Baveno VII recommend endoscopic therapy with tissue adhesives (e.g. n-Butyl-cyanoacrylate)
for acute bleeding from IGV1 and GOV2 varices [8 ]
[9 ]. UK guidelines also endorse cyanoacrylate injection for the prevention of rebleeding
and primary prophylaxis [10 ]. Levy et al. studied coil usage for ectopic varices, and this was followed by the
study of Binmoeller et al. on combined coil and adhesive usage for better and longer
lasting obliteration [5 ]
[18 ]. Coils provide a scaffold with interwoven synthetic fibers for the cyanoacrylate
glue, enhancing adherence and clotting, while reducing the embolization risk. In our
study, the median glue volume used was significantly lower in the combined group,
and fewer sessions were needed for complete flow obliteration compared with the CYA
group. Previous studies by Lobo et al. and Binmoeller et al. have emphasized the efficacy
of combined coil and glue usage in a single session [5 ]
[19 ]. Koziel et al. also proposed less favorable long-term outcomes with coils alone
[16 ], although this was not an aspect analyzed in our study.
In our study, three patients (12.5%) in the Coil+CYA group and five (19.2%) in the
CYA group experienced minor adverse events, such as fever and abdominal pain, consistent
with findings from the previous literature. No symptomatic embolism occurred in our
study, contrasting with the study of Lobo et al., where 25% of patients in the glue
group exhibited embolic manifestations [19 ]. Another study with a similar design also reported no instances of embolism, affirming
the efficacy of coils in reducing embolic events when used in conjunction with glue
and thereby ensuring successful obliteration [16 ].
Rebleeding episodes, indicative of long-term efficacy, were assessed in two periods:
the initial 3 months (0–12 weeks) and the subsequent 3 months (12–24 weeks). The CYA
group exhibited a higher number of rebleeding episodes in both periods. EUS conducted
at 12 weeks on patients who had not experienced prior rebleeding indicated similar
rates of variceal reappearance: three patients (12.5%) in the Coil+CYA group and five
(19.2%) in the CYA group. A total of five patients (20.8%) in the Coil+CYA group and
14 (53.8%) in the CYA group required reintervention during the follow-up period, showing
a significant difference. Reintervention was performed while ensuring allocation to
the same group as the initial procedure.
Following the initial procedure, the median time observed until the first reintervention
was significantly longer in the combined therapy group compared with the injection
alone group. In a comparable study examining the use of coils alone for gastric varices,
a greater need for reintervention was observed in the coil alone group compared with
the combined therapy group [20 ].
These findings unequivocally endorse the combined use of coils with cyanoacrylate
glue to achieve effective and comprehensive gastric variceal obliteration compared
with either approach alone, and notably glue therapy alone as demonstrated in the
present study. However, before these findings can be generalized, it is imperative
to evaluate resource availability and cost-effectiveness of the combined procedure
relative to glue therapy alone.
Despite the inherent risk of EUS scope dysfunction associated with glue usage, an
EUS-guided approach was chosen for the glue arm of this study to mitigate any confounding
factors stemming from the superior efficacy of the EUS scope in locating the varices
compared with a conventional upper gastrointestinal endoscope with an injector. In
the context of a comparative study, efforts were made to enhance uniformity by using
the EUS scope in both study arms.
Mortality throughout the follow-up period, while not a predetermined outcome, was
similar across the two groups, which is attributable to the systemic impact of the
underlying disease. Moreover, the duration of follow-up, serving as an auxiliary measure
of median survival time, displayed superiority for the Coil+CYA group.
The principal limitation of this study stemmed from its small sample size, rendering
it underpowered and difficult to generalize the analysis. Another important consideration
was the necessity for an EUS scope and accessories, and an equally skilled endoscopist
for the successful execution of this intervention. This highlights the crucial requirement
for a resource-rich setting during the procedure. Throughout the follow-up period,
additional attention was given to drug and dietary compliance through periodic visits;
however, this aspect is influenced by multiple factors, including a patient’s lifestyle,
education, and economic status, which ultimately affects the outcome of the disease
spectrum.
In conclusion, gastric variceal bleeding, a significant concern for all cirrhotic
patients, can be addressed with advancements such as EUS. The implementation of EUS-guided
techniques for variceal obliteration is safe and contributes to an effective therapeutic
toolkit, ultimately improving survival rates. Within the therapeutic options, cyanoacrylate
glue can be administered directly or volume reduction can be achieved by combining
it with coils, with comparable efficacy; however, the combined approach (Coil+CYA)
stands out for its ability to minimize embolic complications, enhance efficacy, reduce
reinterventions, and consequently delay the need for reintervention in the long term.
This is well-supported by the current study, although it is of small size. Further
large-scale multicenter trials with blinded designs are warranted to validate the
management algorithm for broader applicability.
