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Gastric variceal hemorrhage (GVH) is rare compared with esophageal variceal hemorrhage, but bleeding easily leads to massive hemorrhage and rebleeding rate and mortality rate are higher. Various types of treatment of GVH have been developed due to the diversity of gastric varices (GV) location, size and collateral veins of the GV. However, it is difficult to select the appropriate treatment method because the situation of each patient is different and these treatments are not available at all medical institutions. Data on prophylactic treatment of GV that have not been bleeding in the past are lacking, and preventive treatment for GV patients without bleeding has not been performed in general. The use of non-selective beta blocker (NSBB) has been reported to have little prophylactic effect in GV. In some studies, endoscopic vascular obturation (EVO) with cyanoacrylate in large and high risk GV has shown to reduce the risk of first bleeding and mortality compared to NSBB or non-treatment. However, due to the invasiveness of the EVO procedure and the associated complications risk, it is not widely applied in clinical practice. Gastroesophageal varices type 1 (GOV1) is associated with EV, and endoscopic band ligation (EBL) is often used for bleeding and prophylactic treatment. However, GV is larger, deeper and the covering mucosal layer is thicker than EV, and the risk of exposure to stomach acid and food is also higher than that of EV. Therefore, although the active GVH control success rate of EBL is similar to that of EVO, but the rate of rebleeding and related mortality are higher than in EVO. Therefore, EVO is considered as the first choice for GOV1 hemorrhage rather than EBL. In gastric fundic varices, endoscopic approach can be used with diagnosis and hemostasis. EVO is the primary treatment for active bleeding. The initial hemostasis rate of EVO is better than 90%, but the rate of rebleeding after the procedure is relatively high, which is over 30%. In addition, EVO is invasive and may cause complications such as systemic embolization including pulmonary embolism, stroke, and multi-organ infarction, so some institutes tend to avoid EVO. Recently, transjugular intrahepatic portosystemic shunt (TIPS) and balloon-occluded retrograde transvenous obliteration (BRTO) have been used instead of EVO. The studies of the therapeutic effect of TIPS on GVH were very limited and mostly small scales. In a non-randomized study comparing TIPS and EVO, both treatments showed an initial success rate of 90% or more. However, TIPS had more adverse effects such as hepatic encephalopathy and stent obstruction and higher treatment costs. However, TIPS was very effective as a salvage treatment for patients with GVH that failed initial treatment. In the past uncovered stents using, complications such as stent stenosis and obstruction occurred in more than half of the cases in one year, but the rate of occlusion was reduced to 8% in covered stent. BRTO is a treatment mainly applied in Asia and sclerosant is injected into GV through gastrorenal shunt. BRTO has a high success rate of 95% or more in hemostasis of fundal GVH, and it is reported that elimination of varices or no more rebreeding in more than 97% curred. However, EVs may recur or worsen in 20% to 41% of patients after the procedure. The BRTO is not possible when the diameter of gastrorenal shunt is larger than that of the balloon, and it is inconvenient to hold the balloon for several hours or more until the varices

The Choice of Interventional Treatment of Gastric Variceal Hemorrhage: What Is Better?