A 37-year-old patient with cirrhosis secondary to hepatitis B, complicated by hepatocellular carcinoma previously treated with right hepatectomy, presented with recurrence in the remnant liver requiring chemoembolization and treatment with Atezolizumab–Bevacizumab. He had a history of multiple episodes of gastrointestinal bleeding refractory to repeated endoscopic band ligation since 2017, with no other complications related to portal hypertension. CT imaging demonstrated multiple portosystemic collaterals and partial splenic vein thrombosis, managed with anticoagulation without resolution after 6 months.

Following discussion at the multidisciplinary tumor board, and given the contraindication to beta-blockers due to dilated cardiomyopathy, endoscopic ultrasound (EUS)-guided treatment of the varices was recommended prior to initiating systemic therapy. EUS re-evaluation in July 2025 revealed esophageal varices and residual gastric varices. The decision was made to perform glue injection of the esophageal varices first, followed by treatment of the gastric varices.

During the initial procedure, EUS identified a perforating vein (5 mm diameter) feeding the esophageal collateral system, confirmed by lipiodol injection. Using a 19G FNA needle, 2 cc of glue were injected, resulting in immediate cessation of flow within the esophageal varices. One month later, resolution of the esophageal varices was confirmed, with persistence of collateral gastric flow; therefore, treatment was completed with placement of one coil (14 cm × 10 mm) plus 1 cc of glue—also delivered through a 19G FNA needle—leading to significant flow reduction.

No complications or new bleeding episodes have occurred to date, with no evidence of intraluminal collateral flow on follow-up EUS at 3 months.