Efficacy and safety of clipping prior to cyanoacrylate embolization in gastric varices: a single-arm systematic review and meta-analysis

Gastric variceal bleeding is a life-threatening complication of portal hypertension. Cyanoacrylate injection is the standard endoscopic treatment that carries a significant risk of ectopic embolization, particularly in patients with gastrorenal shunts. Adding endoscopic clips before injection may enhance safety and efficacy, yet evidence remains limited. This study evaluates the safety and effectiveness of clip-assisted cyanoacrylate injection (clip-ECI). A systematic search was conducted on PubMed, Web of Science, CINAHL, Embase, Google Scholar, and the Cochrane Library on October 9, 2025, following the PRISMA 2020 guidelines. The protocol was registered on PROSPERO (CRD420251166002). The primary outcome was rebleeding. Secondary outcomes included technical success, adverse events, ectopic embolism, and procedure-related mortality. Meta-analysis was performed using R version 3.4.3 (R Core Team) with a random-effects model expressed as proportions and 95% confidence intervals (CIs). Six studies involving 465 participants treated with clip-ECI were included, four in the meta-analysis due to overlapping populations. Most participants were middle-aged males with cirrhosis from hepatitis B, presenting with GOV2 or IGV1 gastric varices; 41.7–100% had gastrorenal shunts. The pooled technical success rate was 99% (95% CI 0.97–1.0; p = 0.97; I2 = 0%), rebleeding 11% (95% CI 0.08–0.16; p = 0.1; I2 = 50.4%), adverse events 20% (95% CI 0.15–0.26; p = 0.37; I2 = 0%), ectopic embolism 3% (95% CI 0.00–0.37; p = 0.01; I2 = 85.1%), deaths attributable to ectopic embolism 1% (95% CI 0.00–0.04; p = 0.67; I2 = 0%) and overall mortality 4% (95% CI 0.01–0.14; p = 0.01; I2 = 80.6%). Compared with conventional injection, clip-ECI showed fewer embolic complications and a non-significant trend toward lower rebleeding. Clip-ECI appears highly effective with low rebleeding and embolic complication rates, supporting its safety for gastric varices, particularly in patients with gastrorenal shunts. Large multicenter randomized trials are needed to strengthen these findings and establish clinical protocols.