Endoscopic variceal obturation and retrograde transvenous obliteration for acute gastric cardiofundal variceal bleeding

Endoscopic variceal obturation and retrograde transvenous obliteration for acute gastric cardiofundal variceal bleeding | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Endoscopic variceal obturation and retrograde transvenous obliteration for acute gastric cardiofundal variceal bleeding Han Ah Lee, Jungwon Kwak, Sung Bum Cho, Young-Sun Lee, Young Kul Jung, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1546433/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background/Aims: We compared the efficacy of endoscopic variceal obturation (EVO) and retrograde transvenous obliteration (RTO) in acute cardiofundal variceal bleeding. Methods: Patients with acute cardiofundal variceal bleeding treated with EVO or RTO at two academic hospitals were included. Results: Ninety patients treated with EVO and 86 treated with RTO were analyzed. The mean model for end-stage liver disease score was significantly higher in EVO group than in RTO group (13.5 vs. 11.7, P=0.016). The bleeding control rates were high (97.8% vs. 96.5%), and the treatment-related complication rates were low in both EVO and RTO groups (2.2% vs. 3.5%). During the median follow-up of 18.0 months, gastric variceal (GV) and esophageal variceal rebleeding occurred in 34 (19.3%) and 7 (4.0%) patients, respectively. The all-variceal rebleeding rates were comparable between EVO and RTO groups (32.4% vs. 20.8% at 2-year, P =0.150), while the GV rebleeding rate was significantly higher in EVO group than in RTO group (32.4% vs. 12.8% at 2-year, P =0.003). On propensity score-matched analysis (71 patients in EVO vs. 71 patients in RTO group), both all-variceal and GV rebleeding rates were significantly higher in EVO group than in RTO group (all P <0.05). In Cox regression analysis, EVO (vs. RTO) was the only significant predictor of higher GV rebleeding risk (hazard ratio 3.132, P =0.005). The mortality rates were similar between two groups ( P =0.597). Conclusions: Both EVO and RTO effectively controlled acute cardiofundal variceal bleeding. RTO was superior to EVO in preventing all-variceal and GV rebleeding after treatment, with similar survival outcomes. Rebleeding prevention balloon-occluded retrograde transvenous obliteration vascular plug-assisted retrograde transvenous obliteration portal hypertension. Figures Figure 1 Figure 2 Figure 3 Introduction Gastric varices (GVs) are enlarged submucosal veins of the stomach that are present in approximately 20% of patients with liver cirrhosis ( 1 ). Bleeding from GVs is less frequent than from esophageal varices (EVs), with a bleeding rate of 25% over 2 years ( 1 ). However, GVs that bleed are mostly large and have high blood flow, which can result in severe bleeding ( 1 – 4 ). Moreover, rebleeding and mortality rates are also higher in GVs than in EVs ( 1 , 5 , 6 ). According to their location, gastroesophageal varices (GOV) 2 and isolated GV (IGV) 1 varices are usually classified as cardiofundal varices ( 7 ). Treatment of cardiofundal variceal bleeding can be difficult, since cardiofundal varices are larger and have more complicated blood circulation than GOV1s ( 8 – 10 ). Accompanied collateral shunts are other barriers to achieving a complete cure of cardiofundal varices ( 11 ). Current guidelines recommend endoscopic variceal obturation (EVO) as one of the treatment options for acute GV bleeding ( 7 , 12 , 13 ). The rate of hemostasis after EVO has been reported to be as high as 91–100%; however, the rebleeding rate from GVs after EVO remains at 3.6–41.0% ( 14 – 18 ). Recently, retrograde transvenous obliteration (RTO), including balloon-occluded (BRTO) and vascular plug-assisted RTO (PARTO), have been considered as the treatment options for acute cardiofundal variceal bleeding. High hemostasis rates (> 90%) and low rebleeding rate (0–7.43%) have been reported in patients treated with BRTO in acute GV bleeding ( 19 – 21 ). Further, PARTO showed high technical and clinical success rates and no rebleeding events in patients with GV bleeding ( 22 – 24 ). However, to date, an optimal treatment modality for acute cardiofundal variceal bleeding has not been confirmed. Accordingly, we compared the efficacy and safety of EVO and RTO for acute cardiofundal variceal bleeding in patients with cirrhosis. Materials And Methods Study population Patients with acute cardiofundal variceal bleeding who were treated with EVO or RTO between March 2006 and November 2018 at the Korea University Anam Hospital and Yonsei University Severance Hospital were considered eligible (Fig. 1 ). The exclusion criteria were as follows: (a) age < 18 years, (b) insufficient follow-up period (less than 6 months), (c) previous treatment with EVs or GVs, (d) non-cirrhotic portal hypertension, (e) portal vein thrombosis, (f) advanced malignancy including hepatocellular carcinoma (HCC), and (g) history of organ transplant. Definition Liver cirrhosis was diagnosed either clinically or histologically when typical ultrasonographic findings were present and consistent with a low platelet count (< 100,000/µL) or overt complications of liver cirrhosis ( 25 ). Acute cardiofundal variceal bleeding was diagnosed if the following were present on esophagastroduodenoscopy (EGD) ( 26 , 27 ): (a) active blood spurting or oozing from cardiofundal varices; (b) blood clots or white nipples on the surfaces of cardiofundal varices; (c) blood in the stomach without a potential bleeding cause other than cardiofundal varices. Treatments When acute cardiofundal variceal bleeding was suspected, vasoactive drugs such as terlipressin or somatostatin were administered, followed by diagnostic EGD within 12 hours. When acute cardiofundal variceal bleeding was detected on EGD, EVO or RTO was performed within 6 hours, depending on the presence of a gastrorenal shunt and the clinician’s decision. Patients who underwent EVO were classified into the EVO group, and those who underwent RTO, including BRTO or PARTO, were classified into the RTO group. Detailed procedures of EVO, BRTO, and PARTO are described in Supplementary Note . Outcomes The primary outcomes were all-variceal and GV rebleeding. Rebleeding was defined as recurrent bleeding after an absence of bleeding for at least 5 days following resolution of acute GV bleeding ( 28 ). The diagnosis of variceal rebleeding was the same as that for acute variceal bleeding. The secondary outcomes were bleeding control, treatment-related complications, and mortality. Patients were followed up until death, liver transplantation, or loss to follow-up. Statistical analysis Demographic and laboratory data are presented as mean ± standard deviation for continuous variables and numbers with percentages for categorical variables. Categorical and quantitative variables of the groups were compared using the chi-square test and Student's t -test, respectively. To minimize the potential bias according to the different baseline characteristics between the EVO and RTO groups, propensity score matching (PSM) was calculated by fitting a logistic regression model that included the following variables in both the EVO and RTO cohorts: age, sex, diabetes, HCC, type of varices, size of EVs, hemoglobin, platelet count, INR, serum levels of albumin, total bilirubin and ALT, and model for end-stage liver disease (MELD) score. A 1:1 ratio PSM was performed using the nearest neighbor method. Variceal rebleeding and mortality rates were estimated using the Kaplan–Meier method and compared using the log-rank test. The data of patients that died, received a liver transplantation, or were lost to follow-up were censored. Independent predictors for variceal rebleeding and mortality were evaluated using the Cox proportional hazard regression analysis. All statistical analyses were performed using the Statistical Package for the Social Sciences version 25.0 software (International Business Machines Corp.). Results Patient characteristics Among the 307 eligible patients, a total of 176 patients were finally selected for statistical analyses (90 [51.1%] in the EVO group and 86 [48.9%] in the RTO group). In the RTO group, 45 (52.3%) and 41 (47.7%) patients were treated with BRTO and PARTO, respectively. The baseline characteristics of the study population are shown in Table 1 . Ninety-nine (56.3%) patients had GOV2, and 77 (43.7%) patients had IGV1. The mean MELD score was 12.6. Beta-blockers were administered to 52 (29.5%) patients after bleeding control was achieved. Table 1 Baseline characteristics of all patients All patients (n = 176) EVO group (n = 90, 51.1%) RTO group (n = 86, 48.9%) P value Age 60.3 ± 11.7 60.5 ± 11.9 59.5 ± 11.7 0.704 Male, n (%) 125 (71.0) 69 (76.7) 56 (65.1) 0.091 Etiology, n (%) 0.395 Hepatitis B virus 50 (28.4) 22 (24.4) 28 (32.6) Hepatitis C virus 14 (8.0) 7 (7.8) 7 (8.1) Alcohol 83 (47.2) 48 (53.3) 35 (40.7) Other 29 (16.5) 13 (14.4) 16 (18.6) Diabetes, n (%) 50 (28.4) 24 (26.4) 26 (30.2) 0.298 Hepatocellular carcinoma, n (%) 50 (28.4) 24 (26.7) 26 (30.2) 0.600 Type of varices, n (%) 0.470 GOV2 99 (56.3) 53 (58.9) 46 (53.5) IGV1 77 (43.7) 37 (41.1) 40 (46.5) Size of esophageal varices, n (%) 0.244 F0-F1 102 (58.0) 47 (52.2) 55 (64.0) F2-F3 74 (42.0) 43 (47.8) 31 (36.0) Hemoglobin, g/dL 9.0 ± 5.3 8.9 ± 2.2 9.1 ± 2.4 0.504 Platelet count, ⋅ 10 9 /L 103.1 ± 52.6 106.0 ± 45.5 100.4 ± 59.7 0.935 INR 1.43 ± 0.32 1.44 ± 0.36 1.41 ± 0.71 0.362 Alanine aminotransferase, IU/L 38.5 ± 49.7 42.1 ± 60.9 35.1 ± 34.5 0.418 Total bilirubin, mg/dL 2.1 ± 3.2 2.3 ± 3.7 1.8 ± 2.5 0.154 Serum albumin, g/dL 2.9 ± 0.2 2.9 ± 0.5 3.0 ± 0.5 0.274 MELD score 12.6 ± 4.7 13.5 ± 4.5 11.7 ± 4.8 0.016 Beta-blockers, n (%) 52 (29.5) 11 (12.2) 41 (47.7) < 0.001 Variables are expressed as mean ± standard deviation or n (%). EVO, endoscopic variceal obturation; RTO, retrograde transvenous obliteration; GOV2, gastroesophageal varices type 2; IGV1, isolated gastric varices type 1; INR, international normalized ratio; MELD, model for end-stage liver disease. Comparison between the EVO and RTO group Baseline characteristics were statistically similar between the EVO and RTO groups (all P > 0.05), except for a significantly higher MELD score in the EVO group than in the RTO group (mean 13.5 vs. 11.7, P = 0.016) (Table 1 ). The proportions of GOV2 (58.9% vs. 53.5%) and IGV1 (41.1% vs. 46.5%) were statistically similar between the EVO and RTO groups ( P = 0.470). Seventy patients (77.8%) in EVO group had a gastrorenal shunt feasible for RTO procedure. The proportion of patients who were treated with beta-blockers after bleeding control was significantly higher in the RTO group than in the EVO group (47.7% vs. 12.2%, P < 0.001). The proportion of patients treated with propranolol and carvedilol was 75.0% and 25.0% in the EVO group and 73.2% and 26.8% in the RTO group, respectively ( P = 0.735). The mean doses of both propranolol (48.9 mg vs. 51.7 mg, P = 0.807) and carvedilol (12.5 mg vs. 14.7 mg, P = 0.567) were statistically similar between the two groups. Treatment outcomes Bleeding was successfully controlled in 171 patients (97.2%). The bleeding control rate was similar between the two groups (97.8% in the EVO group vs. 96.5% in the RTO group, P = 0.613) ( Supplementary Table 1 ). Technical success was achieved in all patients in the EVO and RTO groups. Among patients in the EVO group, 48 patients achieved obliteration of the GV with one session. The other 42 patients underwent additional endoscopic intervention within 1 week of the initial treatment. The mean number of performed EVO sessions was 1.5 ± 1.0, and the mean volume of cyanoacrylate mixture used in each patient was 4.4 ± 2.7 mL. Treatment-related complications were investigated. Two patients in the EVO group and one patient in the RTO group had worsening ascites, and two patients in the RTO group developed hepatic encephalopathy. No systemic embolization or thrombus developed in either group. Change of esophageal varices after the treatment After the treatment for acute cardiofundal variceal bleeding, worsening of EVs was found in 12 (14.8%) patients in the EVO group and 24 (27.9%) patients in the RTO group ( P < 0.001). Among patients with F2-F3 EVs after the treatment for acute cardiofundal variceal bleeding, 25 of 36 (69.4%) in the EVO group and 25 of 32 (78.1%) in the RTO group underwent endoscopic variceal ligation (EVL) as a secondary prevention of EV bleeding. All-variceal rebleeding During the median follow-up period of 18.0 (interquartile range, 7.0–38.9) months, all-variceal rebleeding occurred in 41 (23.3%) patients (26 in the EVO group and 15 in the RTO group). The most common type of variceal rebleeding was GV bleeding (n = 34), followed by EV bleeding (n = 7). All EV rebleeding developed after RTO, and most cases (6 out of 7) did not receive EVL after RTO. All-variceal rebleeding rates at 6, 12, 18, and 24 months after treatment were 6.1%, 11.1%, 17.9%, and 26.3%, respectively ( Supplementary Table 1 ). The corresponding rates in the EVO and RTO groups were statistically similar (6.1%, 11.2%, 23.4%, and 32.4% vs. 6.1%, 11.1%, 12.9%, and 20.8%, respectively, P = 0.150 by log-rank test) (Fig. 1 A). There was no significant difference in all-variceal rebleeding rates between the BRTO and PARTO groups ( P = 0.891 by log-rank test). In the Cox regression analysis, no significant predictor of all-variceal rebleeding was found (Table 2 ). Table 2 Predictors for variceal rebleeding Variables Rating Univariate analysis for variceal bleeding Univariate analysis for gastric variceal bleeding Hazard ratio 95% CI P value Hazard ratio 95% CI P value Age years 0.997 0.969–1.025 0.814 1.000 0.970–1.032 0.992 Sex 0 = women; 1 = men 1.384 0.678–2.825 0.373 1.447 0.654–3.198 0.362 Diabetes 0 = no; 1 = yes 1.019 0.524–1.982 0.955 1.060 0.513–2.192 0.874 Etiology 0 = other; 1 = alcohol 1.195 0.644–2.219 0.573 1.242 0.630–2.450 0.531 Size of esophageal varices 0 = F0, F1; 1 = F2, F3 1.131 0.595–2.149 0.707 1.091 0.536–2.222 0.809 Hemoglobin g/dL 0.977 0.869–1098 0.695 0.976 0.859–1.109 0.707 Platelet count ⋅10 9 /L 1.003 0.998–1.009 0.261 1.002 0.995–1.008 0.628 INR 0.732 0.233–2.301 0.593 0.944 0.348–2.563 0.910 Alanine aminotransferase IU/L 1.002 0.995–1.008 0.642 1.002 0.994–1.009 0.679 Total bilirubin mg/dL 1.017 0.942–1.098 0.662 1.026 0.948–1.110 0.520 Serum albumin g/dL 1.106 0.590–2.073 0.754 0.808 0.402–1.627 0.551 MELD score 1.025 0.952–1.103 0.515 1.049 0.973–1.131 0.213 Type of varices 0 = GOV2; 1 = IGV1 1.190 0.6041–2.207 0.581 1.008 0.511–1.990 0.981 Type of treatment 0 = RTO; 1 = EVO 1.557 0.816–2.970 0.179 3.132 1.408–6.970 0.005 Beta-blocker 0 = no; 1 = yes 0.879 0.430–1.798 0.724 0.994 0.463–2.136 0.988 Post EVL 0 = no; 1 = yes 0.652 0.324–1.310 0.229 0.760 0.360–1.606 0.473 IGV1, isolated gastric varices type 1; GOV2, gastroesophageal varices type 2; INR, international normalized ratio; MELD, model for end-stage liver disease; EVO, endoscopic variceal obturation; RTO, retrograde transvenous obliteration; EVL, endoscopic variceal ligation We additionally evaluated whether this result was reproducible after PSM, and the clinical characteristics of patients balanced by PSM (71 patients in EVO group vs. 71 patients in RTO group) are presented in Supplementary Table 2 . On PSM analysis, all-variceal rebleeding rate was significantly higher in the EVO group than in the RTO group (6.0%, 12.1%, 26.4%, and 37.3% vs. 4.5%, 8.3%, 10.5%, and 20.0%, respectively, P = 0.032 by log-rank test) (Fig. 1 B, Supplementary Table 3) . GV rebleeding GV rebleeding was analyzed separately. GV rebleeding rates at 6, 12, 18, and 24 months after treatment were 4.9%, 8.3%, 15.2%, and 22.5%, respectively ( Supplementary Table 1 ). The corresponding rates in the EVO group were significantly higher than those in the RTO group (6.1%, 11.2%, 23.4%, and 32.4% vs. 3.7%, 5.4%, 7.2%, and 12.8%, respectively, P = 0.003 by log-rank test) (Fig. 2 A). No significant difference in GV rebleeding rate was observed between the BRTO and PARTO groups ( P = 0.838 by log-rank test). In the Cox regression analysis, EVO treatment (vs. RTO) was the only significant predictor of higher risk of GV rebleeding (hazard ratio [HR] = 3.132, 95% confidence interval [CI] 1.408–6.970, P = 0.005) (Table 2 ). On PSM analysis, GV rebleeding rate was significantly higher in the EVO group than in the RTO group (6.0%, 12.1%, 26.4%, and 37.3% vs. 1.6%, 3.6%, 5.8%, and 12.5%, respectively, P < 0.001 by log-rank test) (Fig. 2 B, Supplementary Table 3 ) Mortality During the follow-up period, 40 patients died (21 in the EVO group and 19 in the RTO group). The causes of death were variceal bleeding (27.5%), infection (30.0%), or liver failure (42.5%). Six patients received liver transplantation (three patients in the EVO group and three patients in the RTO group). The cumulative transplantation-free survival rates at 6, 12, 18, and 24 months after treatment were 87.5%, 84.8%, 82.2%, and 79.1%, respectively ( Supplementary Table 1 ). No significant difference in transplantation-free survival rates was observed between the EVO group (86.7%, 83.9%, 80.4%, and 78.4%) and the RTO group (88.4%, 85.8%, 84.1%, and 79.9%, P = 0.597 by log-rank test) (Fig. 3 A). In the Cox regression analysis, higher MELD score was the only independent predictor for higher risk of mortality (HR = 1.089, 95% CI 1.030–1.151, P = 0.002), whereas EVO (vs. RTO) was not ( P = 0.598) (Table 3 ). Table 3 Predictors for mortality Variables Rating Univariate analysis Hazard ratio 95% CI P value Age Years 1.005 0.979–1.031 0.721 Sex 0 = women; 1 = men 1.418 0.702–2.865 0.330 Diabetes 0 = no; 1 = yes 1.039 0.559–1.932 0.904 Etiology 0 = other; 1 = alcohol 1.750 0.959–3.195 0.068 Hemoglobin g/dL 1.003 0.896–1.124 0.955 Platelet count ⋅10 9 /L 0.998 0.992–1.005 0.613 INR 1.268 0.860–1.871 0.231 Alanine aminotransferase IU/L 1.001 0.995–1.007 0.748 Total bilirubin mg/dL 1.050 0.992–1.110 0.090 Serum albumin g/dL 0.674 0.363–1.252 0.212 MELD score 1.089 1.030–1.151 0.002 Type of varices 0 = GOV2; 1 = IGV1 1.696 0.932–3.085 0.084 Type of treatment 0 = RTO; 1 = EVO 1.174 0.648–2.127 0.598 Beta-blocker 0 = no; 1 = yes 1.381 0.741–2.574 0.309 Post EVL 0 = no; 1 = yes 1.570 0.859–2.866 0.142 IGV1, isolated gastric varices type 1; GOV2, gastroesophageal varices type 2; INR, international normalized ratio; MELD, model for end-stage liver disease; EVO, endoscopic variceal obturation; RTO, retrograde transvenous obliteration, EVL, endoscopic variceal ligation On PSM analysis, no significant difference in transplantation-free survival rates was observed between the EVO group (86.7%, 83.9%, 80.4%, and 78.4%) and the RTO group (88.4%, 85.8%, 84.1%, and 79.9%, P = 0.119 by log-rank test) (Fig. 3 B, Supplementary Table 3 ) Discussion Currently, an optimal treatment for acute cardiofundal variceal bleeding has not been confirmed. In this study, we directly compared EVO with RTO for acute cardiofundal variceal bleeding in patients with cirrhosis and found that all-variceal rebleeding rates at 2 years were statistically similar between the two groups ( P = 0.150). However, the GV rebleeding rate at 2 years was significantly higher in the EVO group than in the RTO group ( P = 0.003), and EVO (vs. RTO) was the only predictor of higher risk of GV rebleeding. On PSM analysis, both all-variceal and GV rebleeding rates were significantly higher in the EVO group than in the RTO group (all P 96.5%) and had low complication rates (< 3.5%). No difference was observed in the mortality between the two groups. This study has several important clinical implications. In the present study, 1- and 2-year all-variceal rebleeding rates were statistically similar between the two groups (11.2% and 32.4% in the EVO group vs. 11.1% and 20.8% in the RTO group, P = 0.150. However, when patients were analyzed for GV rebleeding, the EVO group had significantly higher 1- and 2-year GV rebleeding rates than those in the RTO group (11.2% and 32.4% vs. 5.4% and 12.8%, P = 0.003). In addition, EVO was the only predictor of higher GV rebleeding risk (HR = 3.132, P = 0.005), while it was not associated with all-variceal bleeding in the cox-regression analysis. The difference between all-variceal and GV rebleeding rates could be explained by the high EV rebleeding rate after RTO. Rebleeding from EVs developed in seven patients treated with RTO; 6 out of 7 did not receive EVL after RTO. In the present study, 14.8% of patients in the EVO group and 27.9% of patients in the RTO group developed worsening of EVs after bleeding control ( P < 0.001). A recent randomized controlled study reported an EV worsening rate of 30% and 43.5% in the EVO and BRTO groups, respectively ( 29 ), and similar results have been frequently reported in previous studies ( 9 , 30 – 33 ). Because RTO completely obliterates the portosystemic shunts that supply GVs, worsening of portal hypertension and its complications have been widely observed ( 34 , 35 ). Thus, screening endoscopy and appropriate prophylaxis with EVL could decrease EV rebleeding after RTO ( 29 ). To minimize the potential bias according to the differences in baseline characteristics between the EVO and RTO groups, particulary in MELD scores, PSM analysis was performed. On PSM analysis, both 1- and 2-year all-variceal and GV rebleeding rates were significantly higher in EVO group than in RTO group (12.1% and 37.3% vs. 8.3% and 20.0%, respectively, P = 0.032; 12.1% and 37.3% vs. 3.6% and 12.5%, respectively, P < 0.001). All these results suggest that RTO is superior to EVO in preventing all-variceal and GV rebleeding after treatment. To our knowledge, three studies directly compared EVO and BRTO in terms of GV bleeding, and all studies demonstrated the superiority of BRTO over EVO in preventing variceal rebleeding ( 27 , 29 , 36 ). A retrospective study of cardiofundal variceal bleeding found lower rates of rebleeding following BRTO compared to EVO; however, 16/71 patients who underwent BRTO had simultaneous transjugular intrahepatic portosystemic shunts, which could improve portal hypertension and further decrease GV rebleeding ( 36 ). Recently, a randomized controlled study compared EVO with BRTO for secondary prophylaxis of cardiofundal GV bleeding ( 29 ). However, the number of patients was small (32 patients in EVO group vs. 32 patients in BRTO group). Additionally, 67.2% of patients were transferred patients who had recovered from a previous GV bleeding within 4 weeks. A prospective study also found a higher variceal rebleeding rate for EVO than for BRTO (71.4% vs. 15.4%); however, BRTO was performed only in patients without active bleeding ( 27 ). The rates of recurrence and rebleeding of GVs after successful RTO are low, possibly because the injected sclerosing agent completely destroys the venous endothelium. ( 30 , 31 ). The higher rebleeding rate in patients treated with EVO may be related to incomplete impaction of cyanoacrylate, leading to less or delayed obturation of GVs and their feeding vessels. Additionally, the results of EVO vary according to the clinician’s experience. Therefore, clinicians should seek the best option for each patient based on the patient’s general condition and access to appropriate medical resources and expertise in clinical practice. In the present study, bleeding control rates of both treatments were sufficient (97.8% in the EVO group and 96.5% in RTO group). In addition, low prevalence of treatment-related complications (three patients had worsened ascites and two patients developed encephalopathy) was observed, supporting the safety of both modalities in patients with acute GV bleeding. The one of most common causes of death after acute cardiofundal variceal bleeding was variceal rebleeding (27.5%), emphasizing the need for proper prevention of variceal rebleeding after bleeding control is achieved. There was no significant difference in transplantation-free survival between the EVO and RTO groups (86.7% vs. 88.4% at 6 months; 83.9% vs. 85.8% at 12 months), and a higher MELD score was the only predictor of increased mortality, consistent with the results of previous studies ( 27 , 29 ). The major limitation of our study is its retrospective design, which could have resulted in selection bias. Therefore, we conducted robust PSM analysis with large number of variables to minimize potential bias. In addition, due to the small number of patients who received beta-blockers, whether adding beta-blockers can reduce rebleeding from GVs has not been elucidated by the current results. Finally, this study included both BRTO and PARTO, which are different treatment modalities that use different sclerosing agents. Only one patient developed variceal rebleeding after PARTO. This result suggests that PARTO could further improve the treatment outcome of GV bleeding. Further randomized controlled studies with larger numbers of patients are needed to confirm the optimal treatment strategy for patients with acute cardiofundal variceal bleeding. In conclusion, our study shows that both RTO and EVO are effective and safe methods, however, RTO is more effective than EVO in preventing all-variceal and GV rebleeding, with similar survival outcomes. The worsening of EVs after BRTO should be screened and managed appropriately. EVO could be another effective option for acute cardiofundal variceal bleeding, especially in a clinical setting that lacks resources or expertise for RTO. Abbreviations GVs gastric varices EVs esophageal varices GOV gastroesophageal varices IGV isolated gastric varices EVO endoscopic variceal obturation RTO retrograde transvenous obliteration BRTO balloon-occluded retrograde transvenous obliteration PARTO vascular plug-assisted retrograde transvenous obliteration HCC hepatocellular carcinoma EGD esophagastroduodenoscopy Declarations Ethics approval and consent to participate The study protocol conformed with the ethical guidelines of the 1975 Declaration of Helsinki and was approved by the human ethics committee of each hospital (Institutional Review Board of Korea University College of Medicine, Institutional Review Board of Yonsei University College of Medicine). The requirement for informed consent was waived due to the retrospective design of the study by the Institutional Review Board of Korea University College of Medicine, Institutional Review Board of Yonsei University College of Medicine. Consent for publication Not Applicable Availability of data and materials The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests Seung Up Kim served as an advisory committee member, Gilead Sciences, GSK, Bayer, and Eisai. He is a speaker for Gilead Sciences, GSK, Bayer, Eisai, Abbive, EchoSens, MSD, and Bristol–Myers Squibb. He also received a research grant from Abbive, Bristol–Myers Squibb. The other authors declare no conflicts of interest. Funding None Authors’ contributions Conception and design: S.U. Kim and Y.S. Seo; Development of methodology: S.U. Kim and Y.S. Seo; Acquisition, analysis, and interpretation of data: H.A. Lee, J. Kwak, S.B. Cho, Y. Lee, Y.K. Jung, J.H. Kim, H. An, H.J. Yim, Y.T. Jeen, J.E. Yeon, and K.S. Byun; Writing, review, and/or revision of the manuscript: H.A. Lee, J. Kwak, S.U. Kim and Y.S. Seo; Administrative, technical, or material support: S.U. Kim and Y.S. Seo; Study supervision: S.U. Kim and Y.S. Seo . Acknowledgements We would like to thank Editage (www.editage.co.kr) for English language editing. References Sarin SK, Lahoti D, Saxena SP, et al. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology 1992;16:1343–1349. Ryan BM, Stockbrugger RW, Ryan JM. A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices. Gastroenterology 2004;126:1175–1189. Thakeb F, Salem SA, Abdallah M, et al. Endoscopic diagnosis of gastric varices. Endoscopy 1994;26:287–291. Lesmana CRA, Raharjo M, Gani RA. Managing liver cirrhotic complications: Overview of esophageal and gastric varices. Clin Mol Hepatol 2020;26:444–460. de Franchis R, Primignani M. Natural history of portal hypertension in patients with cirrhosis. Clin Liver Dis 2001;5:645–663. Sarin SK. Long-term follow-up of gastric variceal sclerotherapy: an eleven-year experience. Gastrointest Endosc 1997;46:8–14. KASL clinical practice guidelines for liver cirrhosis: Varices, hepatic encephalopathy, and related complications. Clin Mol Hepatol 2020;26:83–127. Watanabe K, Kimura K, Matsutani S, et al. Portal hemodynamics in patients with gastric varices. A study in 230 patients with esophageal and/or gastric varices using portal vein catheterization. Gastroenterology 1988;95:434–440. Saad WE. Vascular anatomy and the morphologic and hemodynamic classifications of gastric varices and spontaneous portosystemic shunts relevant to the BRTO procedure. Tech Vasc Interv Radiol 2013;16:60–100. Lee HA, Goh HG, Seo YS, et al. Evaluation of Treatment Response after Endoscopic Variceal Obturation with Abdominal Computed Tomography. Gut Liver 2020;14:117–124. Maruyama H, Okugawa H, Yoshizumi H, et al. Hemodynamic features of gastrorenal shunt: a Doppler study in cirrhotic patients with gastric fundal varices. Acad Radiol 2008;15:1148–1154. Garcia-Tsao G, Abraldes JG, Berzigotti A, et al. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology 2017;65:310–335. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018;69:406–460. Park SJ, Seo YS, Lee HA, et al. Cyanoacrylate injection versus band ligation for bleeding from cardiac varices along the lesser curvature of the stomach. Clin Mol Hepatol 2016;22:487–494. Qiao W, Ren Y, Bai Y, et al. Cyanoacrylate Injection Versus Band Ligation in the Endoscopic Management of Acute Gastric Variceal Bleeding: Meta-Analysis of Randomized, Controlled Studies Based on the PRISMA Statement. Medicine (Baltimore) 2015;94:e1725. Caldwell SH, Hespenheide EE, Greenwald BD, et al. Enbucrilate for gastric varices: extended experience in 92 patients. Aliment Pharmacol Ther 2007;26:49–59. Hou MC, Lin HC, Lee HS, et al. A randomized trial of endoscopic cyanoacrylate injection for acute gastric variceal bleeding: 0.5 mL versus 1.0 mL. Gastrointest Endosc 2009;70:668–675. Marques P, Maluf-Filho F, Kumar A, et al. Long-term outcomes of acute gastric variceal bleeding in 48 patients following treatment with cyanoacrylate. Dig Dis Sci 2008;53:544–550. Choi YH, Yoon CJ, Park JH, et al. Balloon-occluded retrograde transvenous obliteration for gastric variceal bleeding: its feasibility compared with transjugular intrahepatic portosystemic shunt. Korean J Radiol 2003;4:109–116. Sabri SS, Abi-Jaoudeh N, Swee W, et al. Short-term rebleeding rates for isolated gastric varices managed by transjugular intrahepatic portosystemic shunt versus balloon-occluded retrograde transvenous obliteration. J Vasc Interv Radiol 2014;25:355–361. Wang YB, Zhang JY, Gong JP, et al. Balloon-occluded retrograde transvenous obliteration versus transjugular intrahepatic portosystemic shunt for treatment of gastric varices due to portal hypertension: A meta-analysis. J Gastroenterol Hepatol 2016;31:727–733. Kim T, Yang H, Lee CK, et al. Vascular Plug Assisted Retrograde Transvenous Obliteration (PARTO) for Gastric Varix Bleeding Patients in the Emergent Clinical Setting. Yonsei Med J 2016;57:973–979. Gwon DI, Ko GY, Kwon YB, et al. Plug-Assisted Retrograde Transvenous Obliteration for the Treatment of Gastric Varices: The Role of Intra-Procedural Cone-Beam Computed Tomography. Korean J Radiol 2018;19:223–229. Chang MY, Kim MD, Kim T, et al. Plug-Assisted Retrograde Transvenous Obliteration for the Treatment of Gastric Variceal Hemorrhage. Korean J Radiol 2016;17:230–238. Seo YS, Shah VH. Pathophysiology of portal hypertension and its clinical links. J Clin Exp Hepatol 2011;1:87–93. Seo YS. Prevention and management of gastroesophageal varices. Clin Mol Hepatol 2018;24:20–42. Hong CH, Kim HJ, Park JH, et al. Treatment of patients with gastric variceal hemorrhage: endoscopic N-butyl-2-cyanoacrylate injection versus balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol 2009;24:372–378. de Franchis R. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2010;53:762–768. Luo X, Xiang T, Wu J, et al. Endoscopic Cyanoacrylate Injection vs BRTO for Prevention of Gastric Variceal Bleeding: A Randomized Controlled Trial. Hepatology 2021. Garcia-Pagán JC, Barrufet M, Cardenas A, et al. Management of gastric varices. Clin Gastroenterol Hepatol 2014;12:919–928.e911; quiz e951-912. Lee EW, Shahrouki P, Alanis L, et al. Management Options for Gastric Variceal Hemorrhage. JAMA Surg 2019;154:540–548. Imai Y, Nakazawa M, Ando S, et al. Long-term outcome of 154 patients receiving balloon-occluded retrograde transvenous obliteration for gastric fundal varices. J Gastroenterol Hepatol 2016;31:1844–1850. Jang SY, Kim GH, Park SY, et al. Clinical outcomes of balloon-occluded retrograde transvenous obliteration for the treatment of gastric variceal hemorrhage in Korean patients with liver cirrhosis: a retrospective multicenter study. Clin Mol Hepatol 2012;18:368–374. Miyamoto Y, Oho K, Kumamoto M, et al. Balloon-occluded retrograde transvenous obliteration improves liver function in patients with cirrhosis and portal hypertension. J Gastroenterol Hepatol 2003;18:934–942. Uehara H, Akahoshi T, Tomikawa M, et al. Prediction of improved liver function after balloon-occluded retrograde transvenous obliteration: relation to hepatic vein pressure gradient. J Gastroenterol Hepatol 2012;27:137–141. Stein DJ, Salinas C, Sabri S, et al. Balloon Retrograde Transvenous Obliteration Versus Endoscopic Cyanoacrylate in Bleeding Gastric Varices: Comparison of Rebleeding and Mortality with Extended Follow-up. J Vasc Interv Radiol 2019;30:187–194. Additional Declarations No competing interests reported. Supplementary Files EVOSuppFigure1.tif Supplementarymaterials.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 13 Jun, 2022 Reviews received at journal 04 Jun, 2022 Reviews received at journal 09 May, 2022 Reviewers agreed at journal 04 May, 2022 Reviewers invited by journal 04 May, 2022 Editor assigned by journal 04 May, 2022 Editor invited by journal 25 Apr, 2022 Submission checks completed at journal 25 Apr, 2022 First submitted to journal 11 Apr, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1546433","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":101243301,"identity":"36fe564d-19bd-4872-8a33-90bd230ed0b2","order_by":0,"name":"Han Ah Lee","email":"","orcid":"","institution":"Ewha Womans University College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Han","middleName":"Ah","lastName":"Lee","suffix":""},{"id":101243302,"identity":"87381c51-51fc-4a97-b0cd-dd3c5e713e91","order_by":1,"name":"Jungwon Kwak","email":"","orcid":"","institution":"Korea University College of 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Seo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAw0lEQVRIiWNgGAWjYDCCAyCiIgHONyBSyxmStTC2kaKF7/bxhw8+zkuTM29vfsDwo4bB2LyBgBbJcznGhjO35RjLnDlmwNhzjMFM5gABLQZneNikebdVJM6QSDBg4G1gsJEg5DCDM+zPf/POAWqRf/6B8S9xWhjMmHkbcoC28BgAGQxmBLVInuExlpxxLM1Ygien4LDMMQljglr4zrA//PChJllOgv34xodvamwMZxDSggIOMDAQtGMUjIJRMApGATEAALdYOkXmcTBHAAAAAElFTkSuQmCC","orcid":"","institution":"Korea University College of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Yeon","middleName":"Seok","lastName":"Seo","suffix":""}],"badges":[],"createdAt":"2022-04-11 13:44:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1546433/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1546433/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":20837011,"identity":"c5b2c367-705e-4e52-b9ac-eab8995dec97","added_by":"auto","created_at":"2022-04-27 16:22:12","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":59924,"visible":true,"origin":"","legend":"\u003cp\u003eCumulative variceal rebleeding rate according to the type of treatment in all patients (A) and in patients balanced by propensity score matching (B)\u003c/p\u003e","description":"","filename":"OnlineEVOFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-1546433/v1/528fc237711b0434d09a4533.png"},{"id":20837012,"identity":"424630c5-ea31-40a3-a731-b3c1f94d695a","added_by":"auto","created_at":"2022-04-27 16:22:12","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":59783,"visible":true,"origin":"","legend":"\u003cp\u003eCumulative gastric variceal rebleeding rate according to the type of treatment in all patients (A) and in patients balanced by propensity score matching (B)\u003c/p\u003e","description":"","filename":"OnlineEVOFigure2.png","url":"https://assets-eu.researchsquare.com/files/rs-1546433/v1/b63314ec5e0589b76ea7d105.png"},{"id":20837014,"identity":"3258b49f-44c4-4ec3-8a8a-d18f179451b0","added_by":"auto","created_at":"2022-04-27 16:22:12","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":21614,"visible":true,"origin":"","legend":"\u003cp\u003eCumulative transplantation-free survival rates according to the type of treatment in all patients (A) and in patients balanced by propensity score matching (B)\u003c/p\u003e","description":"","filename":"OnlineEVOFigure3.png","url":"https://assets-eu.researchsquare.com/files/rs-1546433/v1/f09731e1494ad1fbc34369ea.png"},{"id":20837016,"identity":"f29876b5-eea4-4f43-9e87-36685dbfc09e","added_by":"auto","created_at":"2022-04-27 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16:22:12","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":26471,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterials.docx","url":"https://assets-eu.researchsquare.com/files/rs-1546433/v1/f9e23a9350c917e3e8883415.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Endoscopic variceal obturation and retrograde transvenous obliteration for acute gastric cardiofundal variceal bleeding","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGastric varices (GVs) are enlarged submucosal veins of the stomach that are present in approximately 20% of patients with liver cirrhosis (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Bleeding from GVs is less frequent than from esophageal varices (EVs), with a bleeding rate of 25% over 2 years (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). However, GVs that bleed are mostly large and have high blood flow, which can result in severe bleeding (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Moreover, rebleeding and mortality rates are also higher in GVs than in EVs (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccording to their location, gastroesophageal varices (GOV) 2 and isolated GV (IGV) 1 varices are usually classified as cardiofundal varices (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Treatment of cardiofundal variceal bleeding can be difficult, since cardiofundal varices are larger and have more complicated blood circulation than GOV1s (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Accompanied collateral shunts are other barriers to achieving a complete cure of cardiofundal varices (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCurrent guidelines recommend endoscopic variceal obturation (EVO) as one of the treatment options for acute GV bleeding (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The rate of hemostasis after EVO has been reported to be as high as 91\u0026ndash;100%; however, the rebleeding rate from GVs after EVO remains at 3.6\u0026ndash;41.0% (\u003cspan additionalcitationids=\"CR15 CR16 CR17\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRecently, retrograde transvenous obliteration (RTO), including balloon-occluded (BRTO) and vascular plug-assisted RTO (PARTO), have been considered as the treatment options for acute cardiofundal variceal bleeding. High hemostasis rates (\u0026gt;\u0026thinsp;90%) and low rebleeding rate (0\u0026ndash;7.43%) have been reported in patients treated with BRTO in acute GV bleeding (\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Further, PARTO showed high technical and clinical success rates and no rebleeding events in patients with GV bleeding (\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, to date, an optimal treatment modality for acute cardiofundal variceal bleeding has not been confirmed. Accordingly, we compared the efficacy and safety of EVO and RTO for acute cardiofundal variceal bleeding in patients with cirrhosis.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003ePatients with acute cardiofundal variceal bleeding who were treated with EVO or RTO between March 2006 and November 2018 at the Korea University Anam Hospital and Yonsei University Severance Hospital were considered eligible (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The exclusion criteria were as follows: (a) age\u0026thinsp;\u0026lt;\u0026thinsp;18 years, (b) insufficient follow-up period (less than 6 months), (c) previous treatment with EVs or GVs, (d) non-cirrhotic portal hypertension, (e) portal vein thrombosis, (f) advanced malignancy including hepatocellular carcinoma (HCC), and (g) history of organ transplant.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eDefinition\u003c/h2\u003e \u003cp\u003eLiver cirrhosis was diagnosed either clinically or histologically when typical ultrasonographic findings were present and consistent with a low platelet count (\u0026lt;\u0026thinsp;100,000/\u0026micro;L) or overt complications of liver cirrhosis (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Acute cardiofundal variceal bleeding was diagnosed if the following were present on esophagastroduodenoscopy (EGD) (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e): (a) active blood spurting or oozing from cardiofundal varices; (b) blood clots or white nipples on the surfaces of cardiofundal varices; (c) blood in the stomach without a potential bleeding cause other than cardiofundal varices.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eTreatments\u003c/h2\u003e \u003cp\u003eWhen acute cardiofundal variceal bleeding was suspected, vasoactive drugs such as terlipressin or somatostatin were administered, followed by diagnostic EGD within 12 hours. When acute cardiofundal variceal bleeding was detected on EGD, EVO or RTO was performed within 6 hours, depending on the presence of a gastrorenal shunt and the clinician\u0026rsquo;s decision. Patients who underwent EVO were classified into the EVO group, and those who underwent RTO, including BRTO or PARTO, were classified into the RTO group. Detailed procedures of EVO, BRTO, and PARTO are described in \u003cb\u003eSupplementary Note\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes\u003c/h2\u003e \u003cp\u003eThe primary outcomes were all-variceal and GV rebleeding. Rebleeding was defined as recurrent bleeding after an absence of bleeding for at least 5 days following resolution of acute GV bleeding (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The diagnosis of variceal rebleeding was the same as that for acute variceal bleeding. The secondary outcomes were bleeding control, treatment-related complications, and mortality. Patients were followed up until death, liver transplantation, or loss to follow-up.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eDemographic and laboratory data are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation for continuous variables and numbers with percentages for categorical variables. Categorical and quantitative variables of the groups were compared using the chi-square test and Student's \u003cem\u003et\u003c/em\u003e-test, respectively.\u003c/p\u003e \u003cp\u003eTo minimize the potential bias according to the different baseline characteristics between the EVO and RTO groups, propensity score matching (PSM) was calculated by fitting a logistic regression model that included the following variables in both the EVO and RTO cohorts: age, sex, diabetes, HCC, type of varices, size of EVs, hemoglobin, platelet count, INR, serum levels of albumin, total bilirubin and ALT, and model for end-stage liver disease (MELD) score. A 1:1 ratio PSM was performed using the nearest neighbor method.\u003c/p\u003e \u003cp\u003eVariceal rebleeding and mortality rates were estimated using the Kaplan\u0026ndash;Meier method and compared using the log-rank test. The data of patients that died, received a liver transplantation, or were lost to follow-up were censored. Independent predictors for variceal rebleeding and mortality were evaluated using the Cox proportional hazard regression analysis. All statistical analyses were performed using the Statistical Package for the Social Sciences version 25.0 software (International Business Machines Corp.).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics\u003c/h2\u003e \u003cp\u003eAmong the 307 eligible patients, a total of 176 patients were finally selected for statistical analyses (90 [51.1%] in the EVO group and 86 [48.9%] in the RTO group). In the RTO group, 45 (52.3%) and 41 (47.7%) patients were treated with BRTO and PARTO, respectively. The baseline characteristics of the study population are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Ninety-nine (56.3%) patients had GOV2, and 77 (43.7%) patients had IGV1. The mean MELD score was 12.6. Beta-blockers were administered to 52 (29.5%) patients after bleeding control was achieved.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of all patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll patients\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;176)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEVO group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;90, 51.1%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRTO group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;86, 48.9%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.3\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.5\u0026thinsp;\u0026plusmn;\u0026thinsp;11.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59.5\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.704\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e125 (71.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69 (76.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56 (65.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.091\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEtiology, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.395\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHepatitis B virus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (28.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (24.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (32.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHepatitis C virus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (7.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlcohol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83 (47.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (53.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (40.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (16.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (14.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (18.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (28.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (26.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 (30.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.298\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHepatocellular carcinoma, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (28.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (26.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 (30.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.600\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of varices, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.470\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGOV2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99 (56.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (58.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46 (53.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIGV1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77 (43.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (41.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40 (46.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSize of esophageal varices, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.244\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF0-F1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e102 (58.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 (52.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55 (64.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF2-F3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74 (42.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (47.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (36.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin, g/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.504\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlatelet count, \u0026sdot; 10\u003csup\u003e9\u003c/sup\u003e/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e103.1\u0026thinsp;\u0026plusmn;\u0026thinsp;52.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e106.0\u0026thinsp;\u0026plusmn;\u0026thinsp;45.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.4\u0026thinsp;\u0026plusmn;\u0026thinsp;59.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.935\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eINR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.44\u0026thinsp;\u0026plusmn;\u0026thinsp;0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.41\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.362\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlanine aminotransferase, IU/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.5\u0026thinsp;\u0026plusmn;\u0026thinsp;49.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.1\u0026thinsp;\u0026plusmn;\u0026thinsp;60.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35.1\u0026thinsp;\u0026plusmn;\u0026thinsp;34.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.418\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal bilirubin, mg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.154\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum albumin, g/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.274\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMELD score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.7\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBeta-blockers, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52 (29.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (12.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41 (47.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eVariables are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or n (%). EVO, endoscopic variceal obturation; RTO, retrograde transvenous obliteration; GOV2, gastroesophageal varices type 2; IGV1, isolated gastric varices type 1; INR, international normalized ratio; MELD, model for end-stage liver disease.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eComparison between the EVO and RTO group\u003c/h2\u003e \u003cp\u003eBaseline characteristics were statistically similar between the EVO and RTO groups (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), except for a significantly higher MELD score in the EVO group than in the RTO group (mean 13.5 vs. 11.7, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.016) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The proportions of GOV2 (58.9% vs. 53.5%) and IGV1 (41.1% vs. 46.5%) were statistically similar between the EVO and RTO groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.470). Seventy patients (77.8%) in EVO group had a gastrorenal shunt feasible for RTO procedure.\u003c/p\u003e \u003cp\u003eThe proportion of patients who were treated with beta-blockers after bleeding control was significantly higher in the RTO group than in the EVO group (47.7% vs. 12.2%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The proportion of patients treated with propranolol and carvedilol was 75.0% and 25.0% in the EVO group and 73.2% and 26.8% in the RTO group, respectively (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.735). The mean doses of both propranolol (48.9 mg vs. 51.7 mg, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.807) and carvedilol (12.5 mg vs. 14.7 mg, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.567) were statistically similar between the two groups.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eTreatment outcomes\u003c/h2\u003e \u003cp\u003eBleeding was successfully controlled in 171 patients (97.2%). The bleeding control rate was similar between the two groups (97.8% in the EVO group vs. 96.5% in the RTO group, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.613) (\u003cb\u003eSupplementary Table\u0026nbsp;1\u003c/b\u003e). Technical success was achieved in all patients in the EVO and RTO groups. Among patients in the EVO group, 48 patients achieved obliteration of the GV with one session. The other 42 patients underwent additional endoscopic intervention within 1 week of the initial treatment. The mean number of performed EVO sessions was 1.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0, and the mean volume of cyanoacrylate mixture used in each patient was 4.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7 mL.\u003c/p\u003e \u003cp\u003eTreatment-related complications were investigated. Two patients in the EVO group and one patient in the RTO group had worsening ascites, and two patients in the RTO group developed hepatic encephalopathy. No systemic embolization or thrombus developed in either group.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eChange of esophageal varices after the treatment\u003c/h2\u003e \u003cp\u003eAfter the treatment for acute cardiofundal variceal bleeding, worsening of EVs was found in 12 (14.8%) patients in the EVO group and 24 (27.9%) patients in the RTO group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Among patients with F2-F3 EVs after the treatment for acute cardiofundal variceal bleeding, 25 of 36 (69.4%) in the EVO group and 25 of 32 (78.1%) in the RTO group underwent endoscopic variceal ligation (EVL) as a secondary prevention of EV bleeding.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eAll-variceal rebleeding\u003c/h2\u003e \u003cp\u003eDuring the median follow-up period of 18.0 (interquartile range, 7.0\u0026ndash;38.9) months, all-variceal rebleeding occurred in 41 (23.3%) patients (26 in the EVO group and 15 in the RTO group). The most common type of variceal rebleeding was GV bleeding (n\u0026thinsp;=\u0026thinsp;34), followed by EV bleeding (n\u0026thinsp;=\u0026thinsp;7). All EV rebleeding developed after RTO, and most cases (6 out of 7) did not receive EVL after RTO.\u003c/p\u003e \u003cp\u003eAll-variceal rebleeding rates at 6, 12, 18, and 24 months after treatment were 6.1%, 11.1%, 17.9%, and 26.3%, respectively (\u003cb\u003eSupplementary Table\u0026nbsp;1\u003c/b\u003e). The corresponding rates in the EVO and RTO groups were statistically similar (6.1%, 11.2%, 23.4%, and 32.4% vs. 6.1%, 11.1%, 12.9%, and 20.8%, respectively, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.150 by log-rank test) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). There was no significant difference in all-variceal rebleeding rates between the BRTO and PARTO groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.891 by log-rank test). In the Cox regression analysis, no significant predictor of all-variceal rebleeding was found (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePredictors for variceal rebleeding\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRating\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eUnivariate analysis for variceal bleeding\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eUnivariate analysis for gastric variceal bleeding\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHazard ratio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHazard ratio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyears\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.997\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.969\u0026ndash;1.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.814\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.970\u0026ndash;1.032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.992\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026thinsp;=\u0026thinsp;women; 1\u0026thinsp;=\u0026thinsp;men\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.384\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.678\u0026ndash;2.825\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.373\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.447\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.654\u0026ndash;3.198\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.362\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026thinsp;=\u0026thinsp;no; 1\u0026thinsp;=\u0026thinsp;yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.524\u0026ndash;1.982\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.955\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.060\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.513\u0026ndash;2.192\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.874\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEtiology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026thinsp;=\u0026thinsp;other; 1\u0026thinsp;=\u0026thinsp;alcohol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.195\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.644\u0026ndash;2.219\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.573\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.242\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.630\u0026ndash;2.450\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.531\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSize of esophageal varices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026thinsp;=\u0026thinsp;F0, F1; 1\u0026thinsp;=\u0026thinsp;F2, F3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.595\u0026ndash;2.149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.707\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.091\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.536\u0026ndash;2.222\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.809\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.977\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.869\u0026ndash;1098\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.695\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.976\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.859\u0026ndash;1.109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.707\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlatelet count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026sdot;10\u003csup\u003e9\u003c/sup\u003e/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.998\u0026ndash;1.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.261\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.995\u0026ndash;1.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.628\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eINR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.732\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.233\u0026ndash;2.301\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.593\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.944\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.348\u0026ndash;2.563\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.910\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlanine aminotransferase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIU/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.995\u0026ndash;1.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.642\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.994\u0026ndash;1.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.679\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal bilirubin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.942\u0026ndash;1.098\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.662\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.948\u0026ndash;1.110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.520\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum albumin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.590\u0026ndash;2.073\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.754\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.808\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.402\u0026ndash;1.627\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.551\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMELD score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.952\u0026ndash;1.103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.515\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.049\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.973\u0026ndash;1.131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.213\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of varices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026thinsp;=\u0026thinsp;GOV2; 1\u0026thinsp;=\u0026thinsp;IGV1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.190\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.6041\u0026ndash;2.207\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.581\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.511\u0026ndash;1.990\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.981\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026thinsp;=\u0026thinsp;RTO; 1\u0026thinsp;=\u0026thinsp;EVO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.557\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.816\u0026ndash;2.970\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.179\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.132\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.408\u0026ndash;6.970\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBeta-blocker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026thinsp;=\u0026thinsp;no; 1\u0026thinsp;=\u0026thinsp;yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.879\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.430\u0026ndash;1.798\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.724\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.994\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.463\u0026ndash;2.136\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.988\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost EVL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026thinsp;=\u0026thinsp;no; 1\u0026thinsp;=\u0026thinsp;yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.652\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.324\u0026ndash;1.310\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.229\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.760\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.360\u0026ndash;1.606\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.473\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eIGV1, isolated gastric varices type 1; GOV2, gastroesophageal varices type 2; INR, international normalized ratio; MELD, model for end-stage liver disease; EVO, endoscopic variceal obturation; RTO, retrograde transvenous obliteration; EVL, endoscopic variceal ligation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWe additionally evaluated whether this result was reproducible after PSM, and the clinical characteristics of patients balanced by PSM (71 patients in EVO group vs. 71 patients in RTO group) are presented in \u003cb\u003eSupplementary Table\u0026nbsp;2\u003c/b\u003e. On PSM analysis, all-variceal rebleeding rate was significantly higher in the EVO group than in the RTO group (6.0%, 12.1%, 26.4%, and 37.3% vs. 4.5%, 8.3%, 10.5%, and 20.0%, respectively, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.032 by log-rank test) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB, \u003cb\u003eSupplementary Table\u0026nbsp;3)\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eGV rebleeding\u003c/h2\u003e \u003cp\u003eGV rebleeding was analyzed separately. GV rebleeding rates at 6, 12, 18, and 24 months after treatment were 4.9%, 8.3%, 15.2%, and 22.5%, respectively (\u003cb\u003eSupplementary Table\u0026nbsp;1\u003c/b\u003e). The corresponding rates in the EVO group were significantly higher than those in the RTO group (6.1%, 11.2%, 23.4%, and 32.4% vs. 3.7%, 5.4%, 7.2%, and 12.8%, respectively, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003 by log-rank test) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). No significant difference in GV rebleeding rate was observed between the BRTO and PARTO groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.838 by log-rank test). In the Cox regression analysis, EVO treatment (vs. RTO) was the only significant predictor of higher risk of GV rebleeding (hazard ratio [HR]\u0026thinsp;=\u0026thinsp;3.132, 95% confidence interval [CI] 1.408\u0026ndash;6.970, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOn PSM analysis, GV rebleeding rate was significantly higher in the EVO group than in the RTO group (6.0%, 12.1%, 26.4%, and 37.3% vs. 1.6%, 3.6%, 5.8%, and 12.5%, respectively, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001 by log-rank test) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB, \u003cb\u003eSupplementary Table\u0026nbsp;3\u003c/b\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eMortality\u003c/h2\u003e \u003cp\u003eDuring the follow-up period, 40 patients died (21 in the EVO group and 19 in the RTO group). The causes of death were variceal bleeding (27.5%), infection (30.0%), or liver failure (42.5%). Six patients received liver transplantation (three patients in the EVO group and three patients in the RTO group). The cumulative transplantation-free survival rates at 6, 12, 18, and 24 months after treatment were 87.5%, 84.8%, 82.2%, and 79.1%, respectively (\u003cb\u003eSupplementary Table\u0026nbsp;1\u003c/b\u003e). No significant difference in transplantation-free survival rates was observed between the EVO group (86.7%, 83.9%, 80.4%, and 78.4%) and the RTO group (88.4%, 85.8%, 84.1%, and 79.9%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.597 by log-rank test) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA). In the Cox regression analysis, higher MELD score was the only independent predictor for higher risk of mortality (HR\u0026thinsp;=\u0026thinsp;1.089, 95% CI 1.030\u0026ndash;1.151, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002), whereas EVO (vs. RTO) was not (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.598) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePredictors for mortality\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRating\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eUnivariate analysis\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHazard ratio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYears\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.979\u0026ndash;1.031\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.721\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026thinsp;=\u0026thinsp;women; 1\u0026thinsp;=\u0026thinsp;men\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.418\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.702\u0026ndash;2.865\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.330\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026thinsp;=\u0026thinsp;no; 1\u0026thinsp;=\u0026thinsp;yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.039\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.559\u0026ndash;1.932\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.904\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEtiology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026thinsp;=\u0026thinsp;other; 1\u0026thinsp;=\u0026thinsp;alcohol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.750\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.959\u0026ndash;3.195\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.896\u0026ndash;1.124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.955\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlatelet count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026sdot;10\u003csup\u003e9\u003c/sup\u003e/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.998\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.992\u0026ndash;1.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.613\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eINR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.268\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.860\u0026ndash;1.871\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.231\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlanine aminotransferase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIU/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.995\u0026ndash;1.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.748\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal bilirubin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.050\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.992\u0026ndash;1.110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.090\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum albumin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.674\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.363\u0026ndash;1.252\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.212\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMELD score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.089\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.030\u0026ndash;1.151\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of varices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026thinsp;=\u0026thinsp;GOV2; 1\u0026thinsp;=\u0026thinsp;IGV1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.696\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.932\u0026ndash;3.085\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.084\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026thinsp;=\u0026thinsp;RTO; 1\u0026thinsp;=\u0026thinsp;EVO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.174\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.648\u0026ndash;2.127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.598\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBeta-blocker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026thinsp;=\u0026thinsp;no; 1\u0026thinsp;=\u0026thinsp;yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.381\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.741\u0026ndash;2.574\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.309\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost EVL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026thinsp;=\u0026thinsp;no; 1\u0026thinsp;=\u0026thinsp;yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.570\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.859\u0026ndash;2.866\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.142\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eIGV1, isolated gastric varices type 1; GOV2, gastroesophageal varices type 2; INR, international normalized ratio; MELD, model for end-stage liver disease; EVO, endoscopic variceal obturation; RTO, retrograde transvenous obliteration, EVL, endoscopic variceal ligation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOn PSM analysis, no significant difference in transplantation-free survival rates was observed between the EVO group (86.7%, 83.9%, 80.4%, and 78.4%) and the RTO group (88.4%, 85.8%, 84.1%, and 79.9%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.119 by log-rank test) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB, \u003cb\u003eSupplementary Table\u0026nbsp;3\u003c/b\u003e)\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eCurrently, an optimal treatment for acute cardiofundal variceal bleeding has not been confirmed. In this study, we directly compared EVO with RTO for acute cardiofundal variceal bleeding in patients with cirrhosis and found that all-variceal rebleeding rates at 2 years were statistically similar between the two groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.150). However, the GV rebleeding rate at 2 years was significantly higher in the EVO group than in the RTO group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003), and EVO (vs. RTO) was the only predictor of higher risk of GV rebleeding. On PSM analysis, both all-variceal and GV rebleeding rates were significantly higher in the EVO group than in the RTO group (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Finally, we found that both EVO and RTO were effective for bleeding control (\u0026gt;\u0026thinsp;96.5%) and had low complication rates (\u0026lt;\u0026thinsp;3.5%). No difference was observed in the mortality between the two groups.\u003c/p\u003e \u003cp\u003eThis study has several important clinical implications. In the present study, 1- and 2-year all-variceal rebleeding rates were statistically similar between the two groups (11.2% and 32.4% in the EVO group vs. 11.1% and 20.8% in the RTO group, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.150. However, when patients were analyzed for GV rebleeding, the EVO group had significantly higher 1- and 2-year GV rebleeding rates than those in the RTO group (11.2% and 32.4% vs. 5.4% and 12.8%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003). In addition, EVO was the only predictor of higher GV rebleeding risk (HR\u0026thinsp;=\u0026thinsp;3.132, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005), while it was not associated with all-variceal bleeding in the cox-regression analysis.\u003c/p\u003e \u003cp\u003eThe difference between all-variceal and GV rebleeding rates could be explained by the high EV rebleeding rate after RTO. Rebleeding from EVs developed in seven patients treated with RTO; 6 out of 7 did not receive EVL after RTO. In the present study, 14.8% of patients in the EVO group and 27.9% of patients in the RTO group developed worsening of EVs after bleeding control (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). A recent randomized controlled study reported an EV worsening rate of 30% and 43.5% in the EVO and BRTO groups, respectively (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), and similar results have been frequently reported in previous studies (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR31 CR32\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Because RTO completely obliterates the portosystemic shunts that supply GVs, worsening of portal hypertension and its complications have been widely observed (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Thus, screening endoscopy and appropriate prophylaxis with EVL could decrease EV rebleeding after RTO (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo minimize the potential bias according to the differences in baseline characteristics between the EVO and RTO groups, particulary in MELD scores, PSM analysis was performed. On PSM analysis, both 1- and 2-year all-variceal and GV rebleeding rates were significantly higher in EVO group than in RTO group (12.1% and 37.3% vs. 8.3% and 20.0%, respectively, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.032; 12.1% and 37.3% vs. 3.6% and 12.5%, respectively, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). All these results suggest that RTO is superior to EVO in preventing all-variceal and GV rebleeding after treatment.\u003c/p\u003e \u003cp\u003eTo our knowledge, three studies directly compared EVO and BRTO in terms of GV bleeding, and all studies demonstrated the superiority of BRTO over EVO in preventing variceal rebleeding (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). A retrospective study of cardiofundal variceal bleeding found lower rates of rebleeding following BRTO compared to EVO; however, 16/71 patients who underwent BRTO had simultaneous transjugular intrahepatic portosystemic shunts, which could improve portal hypertension and further decrease GV rebleeding (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Recently, a randomized controlled study compared EVO with BRTO for secondary prophylaxis of cardiofundal GV bleeding (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). However, the number of patients was small (32 patients in EVO group vs. 32 patients in BRTO group). Additionally, 67.2% of patients were transferred patients who had recovered from a previous GV bleeding within 4 weeks. A prospective study also found a higher variceal rebleeding rate for EVO than for BRTO (71.4% vs. 15.4%); however, BRTO was performed only in patients without active bleeding (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe rates of recurrence and rebleeding of GVs after successful RTO are low, possibly because the injected sclerosing agent completely destroys the venous endothelium. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). The higher rebleeding rate in patients treated with EVO may be related to incomplete impaction of cyanoacrylate, leading to less or delayed obturation of GVs and their feeding vessels. Additionally, the results of EVO vary according to the clinician\u0026rsquo;s experience. Therefore, clinicians should seek the best option for each patient based on the patient\u0026rsquo;s general condition and access to appropriate medical resources and expertise in clinical practice.\u003c/p\u003e \u003cp\u003eIn the present study, bleeding control rates of both treatments were sufficient (97.8% in the EVO group and 96.5% in RTO group). In addition, low prevalence of treatment-related complications (three patients had worsened ascites and two patients developed encephalopathy) was observed, supporting the safety of both modalities in patients with acute GV bleeding.\u003c/p\u003e \u003cp\u003eThe one of most common causes of death after acute cardiofundal variceal bleeding was variceal rebleeding (27.5%), emphasizing the need for proper prevention of variceal rebleeding after bleeding control is achieved. There was no significant difference in transplantation-free survival between the EVO and RTO groups (86.7% vs. 88.4% at 6 months; 83.9% vs. 85.8% at 12 months), and a higher MELD score was the only predictor of increased mortality, consistent with the results of previous studies (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe major limitation of our study is its retrospective design, which could have resulted in selection bias. Therefore, we conducted robust PSM analysis with large number of variables to minimize potential bias. In addition, due to the small number of patients who received beta-blockers, whether adding beta-blockers can reduce rebleeding from GVs has not been elucidated by the current results. Finally, this study included both BRTO and PARTO, which are different treatment modalities that use different sclerosing agents. Only one patient developed variceal rebleeding after PARTO. This result suggests that PARTO could further improve the treatment outcome of GV bleeding. Further randomized controlled studies with larger numbers of patients are needed to confirm the optimal treatment strategy for patients with acute cardiofundal variceal bleeding.\u003c/p\u003e \u003cp\u003eIn conclusion, our study shows that both RTO and EVO are effective and safe methods, however, RTO is more effective than EVO in preventing all-variceal and GV rebleeding, with similar survival outcomes. The worsening of EVs after BRTO should be screened and managed appropriately. EVO could be another effective option for acute cardiofundal variceal bleeding, especially in a clinical setting that lacks resources or expertise for RTO.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGVs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003egastric varices\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEVs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eesophageal varices\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGOV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003egastroesophageal varices\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIGV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eisolated gastric varices\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEVO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eendoscopic variceal obturation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRTO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eretrograde transvenous obliteration\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBRTO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eballoon-occluded retrograde transvenous obliteration\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePARTO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003evascular plug-assisted retrograde transvenous obliteration\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHCC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ehepatocellular carcinoma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEGD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eesophagastroduodenoscopy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol\u0026nbsp;conformed\u0026nbsp;with the ethical guidelines of the 1975 Declaration of Helsinki and was approved by the human\u0026nbsp;ethics\u0026nbsp;committee of each hospital (Institutional Review Board of Korea University College of Medicine, Institutional Review Board of Yonsei University College of Medicine). The requirement for informed consent was waived due to the retrospective design of the study by the Institutional Review Board of Korea University College of Medicine, Institutional Review Board of Yonsei University College of Medicine.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeung Up Kim served as an advisory committee member, Gilead Sciences, GSK, Bayer, and Eisai. He is a speaker for Gilead Sciences, GSK, Bayer, Eisai, Abbive, EchoSens, MSD, and Bristol\u0026ndash;Myers\u0026nbsp;Squibb. He also received a research grant from Abbive, Bristol\u0026ndash;Myers\u0026nbsp;Squibb. The other authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConception and design: S.U. Kim and Y.S. Seo; Development of methodology: S.U. Kim and Y.S. Seo; Acquisition, analysis,\u0026nbsp;and interpretation of data: H.A. Lee, J. Kwak, S.B. Cho, Y. Lee, Y.K. Jung, J.H. Kim, H. An, H.J. Yim, Y.T. Jeen, J.E. Yeon,\u0026nbsp;and\u0026nbsp;K.S. Byun; Writing, review, and/or revision of the manuscript: H.A. Lee, J. Kwak, S.U. Kim and Y.S. Seo; Administrative, technical, or material support: S.U. Kim and Y.S. Seo; Study supervision: S.U. Kim and Y.S. Seo\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Editage (www.editage.co.kr) for English language editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSarin SK, Lahoti D, Saxena SP, et al. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology 1992;16:1343\u0026ndash;1349.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRyan BM, Stockbrugger RW, Ryan JM. A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices. Gastroenterology 2004;126:1175\u0026ndash;1189.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThakeb F, Salem SA, Abdallah M, et al. Endoscopic diagnosis of gastric varices. Endoscopy 1994;26:287\u0026ndash;291.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLesmana CRA, Raharjo M, Gani RA. Managing liver cirrhotic complications: Overview of esophageal and gastric varices. Clin Mol Hepatol 2020;26:444\u0026ndash;460.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede Franchis R, Primignani M. Natural history of portal hypertension in patients with cirrhosis. Clin Liver Dis 2001;5:645\u0026ndash;663.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSarin SK. Long-term follow-up of gastric variceal sclerotherapy: an eleven-year experience. Gastrointest Endosc 1997;46:8\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKASL clinical practice guidelines for liver cirrhosis: Varices, hepatic encephalopathy, and related complications. Clin Mol Hepatol 2020;26:83\u0026ndash;127.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWatanabe K, Kimura K, Matsutani S, et al. Portal hemodynamics in patients with gastric varices. A study in 230 patients with esophageal and/or gastric varices using portal vein catheterization. Gastroenterology 1988;95:434\u0026ndash;440.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaad WE. Vascular anatomy and the morphologic and hemodynamic classifications of gastric varices and spontaneous portosystemic shunts relevant to the BRTO procedure. Tech Vasc Interv Radiol 2013;16:60\u0026ndash;100.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee HA, Goh HG, Seo YS, et al. Evaluation of Treatment Response after Endoscopic Variceal Obturation with Abdominal Computed Tomography. Gut Liver 2020;14:117\u0026ndash;124.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaruyama H, Okugawa H, Yoshizumi H, et al. Hemodynamic features of gastrorenal shunt: a Doppler study in cirrhotic patients with gastric fundal varices. Acad Radiol 2008;15:1148\u0026ndash;1154.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarcia-Tsao G, Abraldes JG, Berzigotti A, et al. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology 2017;65:310\u0026ndash;335.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018;69:406\u0026ndash;460.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark SJ, Seo YS, Lee HA, et al. Cyanoacrylate injection versus band ligation for bleeding from cardiac varices along the lesser curvature of the stomach. Clin Mol Hepatol 2016;22:487\u0026ndash;494.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQiao W, Ren Y, Bai Y, et al. Cyanoacrylate Injection Versus Band Ligation in the Endoscopic Management of Acute Gastric Variceal Bleeding: Meta-Analysis of Randomized, Controlled Studies Based on the PRISMA Statement. Medicine (Baltimore) 2015;94:e1725.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaldwell SH, Hespenheide EE, Greenwald BD, et al. Enbucrilate for gastric varices: extended experience in 92 patients. Aliment Pharmacol Ther 2007;26:49\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHou MC, Lin HC, Lee HS, et al. A randomized trial of endoscopic cyanoacrylate injection for acute gastric variceal bleeding: 0.5 mL versus 1.0 mL. Gastrointest Endosc 2009;70:668\u0026ndash;675.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarques P, Maluf-Filho F, Kumar A, et al. Long-term outcomes of acute gastric variceal bleeding in 48 patients following treatment with cyanoacrylate. Dig Dis Sci 2008;53:544\u0026ndash;550.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoi YH, Yoon CJ, Park JH, et al. Balloon-occluded retrograde transvenous obliteration for gastric variceal bleeding: its feasibility compared with transjugular intrahepatic portosystemic shunt. Korean J Radiol 2003;4:109\u0026ndash;116.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSabri SS, Abi-Jaoudeh N, Swee W, et al. Short-term rebleeding rates for isolated gastric varices managed by transjugular intrahepatic portosystemic shunt versus balloon-occluded retrograde transvenous obliteration. J Vasc Interv Radiol 2014;25:355\u0026ndash;361.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang YB, Zhang JY, Gong JP, et al. Balloon-occluded retrograde transvenous obliteration versus transjugular intrahepatic portosystemic shunt for treatment of gastric varices due to portal hypertension: A meta-analysis. J Gastroenterol Hepatol 2016;31:727\u0026ndash;733.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim T, Yang H, Lee CK, et al. Vascular Plug Assisted Retrograde Transvenous Obliteration (PARTO) for Gastric Varix Bleeding Patients in the Emergent Clinical Setting. Yonsei Med J 2016;57:973\u0026ndash;979.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGwon DI, Ko GY, Kwon YB, et al. Plug-Assisted Retrograde Transvenous Obliteration for the Treatment of Gastric Varices: The Role of Intra-Procedural Cone-Beam Computed Tomography. Korean J Radiol 2018;19:223\u0026ndash;229.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang MY, Kim MD, Kim T, et al. Plug-Assisted Retrograde Transvenous Obliteration for the Treatment of Gastric Variceal Hemorrhage. Korean J Radiol 2016;17:230\u0026ndash;238.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeo YS, Shah VH. Pathophysiology of portal hypertension and its clinical links. J Clin Exp Hepatol 2011;1:87\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeo YS. Prevention and management of gastroesophageal varices. Clin Mol Hepatol 2018;24:20\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHong CH, Kim HJ, Park JH, et al. Treatment of patients with gastric variceal hemorrhage: endoscopic N-butyl-2-cyanoacrylate injection versus balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol 2009;24:372\u0026ndash;378.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede Franchis R. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2010;53:762\u0026ndash;768.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuo X, Xiang T, Wu J, et al. Endoscopic Cyanoacrylate Injection vs BRTO for Prevention of Gastric Variceal Bleeding: A Randomized Controlled Trial. Hepatology 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarcia-Pag\u0026aacute;n JC, Barrufet M, Cardenas A, et al. Management of gastric varices. Clin Gastroenterol Hepatol 2014;12:919\u0026ndash;928.e911; quiz e951-912.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee EW, Shahrouki P, Alanis L, et al. Management Options for Gastric Variceal Hemorrhage. JAMA Surg 2019;154:540\u0026ndash;548.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eImai Y, Nakazawa M, Ando S, et al. Long-term outcome of 154 patients receiving balloon-occluded retrograde transvenous obliteration for gastric fundal varices. J Gastroenterol Hepatol 2016;31:1844\u0026ndash;1850.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJang SY, Kim GH, Park SY, et al. Clinical outcomes of balloon-occluded retrograde transvenous obliteration for the treatment of gastric variceal hemorrhage in Korean patients with liver cirrhosis: a retrospective multicenter study. Clin Mol Hepatol 2012;18:368\u0026ndash;374.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiyamoto Y, Oho K, Kumamoto M, et al. Balloon-occluded retrograde transvenous obliteration improves liver function in patients with cirrhosis and portal hypertension. J Gastroenterol Hepatol 2003;18:934\u0026ndash;942.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUehara H, Akahoshi T, Tomikawa M, et al. Prediction of improved liver function after balloon-occluded retrograde transvenous obliteration: relation to hepatic vein pressure gradient. J Gastroenterol Hepatol 2012;27:137\u0026ndash;141.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStein DJ, Salinas C, Sabri S, et al. Balloon Retrograde Transvenous Obliteration Versus Endoscopic Cyanoacrylate in Bleeding Gastric Varices: Comparison of Rebleeding and Mortality with Extended Follow-up. J Vasc Interv Radiol 2019;30:187\u0026ndash;194.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Rebleeding, prevention, balloon-occluded retrograde transvenous obliteration, vascular plug-assisted retrograde transvenous obliteration, portal hypertension.","lastPublishedDoi":"10.21203/rs.3.rs-1546433/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1546433/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground/Aims: \u003c/strong\u003eWe compared the efficacy of endoscopic variceal obturation (EVO) and retrograde transvenous obliteration (RTO) in acute cardiofundal variceal bleeding.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003ePatients with acute cardiofundal variceal bleeding treated with EVO or RTO at two academic hospitals were included.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eNinety patients treated with EVO and 86 treated with RTO were analyzed. The mean model for end-stage liver disease score was significantly higher in EVO group than in RTO group (13.5 vs. 11.7, P=0.016). The bleeding control rates were high (97.8% vs. 96.5%), and the treatment-related complication rates were low in both EVO and RTO groups (2.2% vs. 3.5%). During the median follow-up of 18.0 months, gastric variceal (GV) and esophageal variceal rebleeding occurred in 34 (19.3%) and 7 (4.0%) patients, respectively. The all-variceal rebleeding rates were comparable between EVO and RTO groups (32.4% vs. 20.8% at 2-year, \u003cem\u003eP\u003c/em\u003e=0.150), while the GV rebleeding rate was significantly higher in EVO group than in RTO group (32.4% vs. 12.8% at 2-year, \u003cem\u003eP\u003c/em\u003e=0.003). On propensity score-matched analysis (71 patients in EVO vs. 71 patients in RTO group), both all-variceal and GV rebleeding rates were significantly higher in EVO group than in RTO group (all P \u0026lt;0.05). In Cox regression analysis, EVO (vs. RTO) was the only significant predictor of higher GV rebleeding risk (hazard ratio 3.132, \u003cem\u003eP\u003c/em\u003e=0.005). The mortality rates were similar between two groups (\u003cem\u003eP\u003c/em\u003e=0.597).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Both EVO and RTO effectively controlled acute cardiofundal variceal bleeding. RTO was superior to EVO in preventing all-variceal and GV rebleeding after treatment, with similar survival outcomes.\u003c/p\u003e","manuscriptTitle":"Endoscopic variceal obturation and retrograde transvenous obliteration for acute gastric cardiofundal variceal bleeding","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-04-27 16:22:10","doi":"10.21203/rs.3.rs-1546433/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-06-13T17:01:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-06-04T04:15:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-05-09T13:23:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"26916f99-bfcc-4d97-b57e-d406a8e1e848","date":"2022-05-05T01:53:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-05-04T17:02:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-05-04T16:38:26+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-04-25T13:53:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-04-25T13:48:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Gastroenterology","date":"2022-04-11T13:42:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"57f93bfe-19c1-4fa9-843b-c7f916c6850c","owner":[],"postedDate":"April 27th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2022-07-12T10:59:07+00:00","versionOfRecord":[],"versionCreatedAt":"2022-04-27 16:22:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1546433","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1546433","identity":"rs-1546433","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}