Cost-Effectiveness of N-Butyl-2-Cyanoacrylate (Histoacryl) Glue Injections Versus Transjugular Intrahepatic Portosystemic Shunt in the Management of Acute Gastric Variceal Bleeding S. Mahadeva, M.B., M.R.C.P., M. C. Bellamy, M.A., M.B., F.R.C.A., D. Kessel, M.A., M.R.C.P., F.R.C.R., M. H. Davies, M.D., F.R.C.P., and C. E. Millson, M.D., F.R.C.P. Departments of Hepatology and Liver Transplantation, Intensive Care Medicine, and Radiology, St. James’s University Hospital, Leeds, United Kingdom ABSTRACT The management of bleeding gastric varices has not been standardized. Although transjugular intrahepatic portosys- temic shunt (TIPS) is used in most centers, endoscopic treatment with N-butyl-2-cyanoacrylate (cyanoacrylate) glue has recently been shown to be effective. Cost-effec- tiveness analyses of these methods are lacking. METHODS: We performed a retrospective review of patients with bleeding gastric varices treated either by TIPS or cyanoacrylate glue injection. Economic analysis was based on direct costs for a fixed financial year. The two groups were compared for a period of 6 months follow-up, to liver transplantation, or death for each patient. RESULTS: Between January, 1995 and December, 1999, 20 patients with bleeding gastric varices had TIPS; 23 patients had cyanoacrylate glue injection from January, 2000 to October, 2001. There were no significant differences be- tween the two groups in patient characteristics, transfusion requirement, and gastric variceal anatomy. In the TIPS group, 15/20 patients had the procedure performed within 24 h of hemorrhage, and 90% of stent insertions were successful. Complications consisted of two cases of pulmo- nary edema, two cases of severe encephalopathy, and a 15% stenosis rate at 6 months. In the glue group, there were 3  1.5 endoscopies and 2  1 injections per patient, with a 96% initial hemostasis. There was one case of (glue) pulmonary embolism and one blocked front endoscope lens, which required repair. The initial rebleed rate was significantly lower in patients who had TIPS (15% vs 30%, p = 0.005). The inpatient stay was shorter in the glue group (13  1 vs 18  2 days, p = 0.05), but there was no difference in the overall mortality rate. The median cost within 6 months of initial gastric variceal bleeding was $4,138 ($3,009 –$8,290) for glue versus $11,906 ($8,200 –$16,770) for TIPS (p  0.0001). CONCLUSION: In this comparable group of patients, cyano- acrylate glue injection was more cost effective than TIPS in the management of acute gastric variceal bleeding. A pro- spective, randomized trial would be required to confirm our analysis. (Am J Gastroenterol 2003;98:2688-2693. © 2003 by Am. Coll. of Gastroenterology) INTRODUCTION The optimal management of bleeding gastric varices re- mains uncertain. Standard endoscopic techniques do not seem to be effective (1–3), and surgical shunting is associ- ated with a high mortality (4, 5); hence, transjugular intra- hepatic portosystemic shunt (TIPS) has emerged as the recommended treatment. Although TIPS achieves hemosta- sis in more than 90% of bleeding gastric varices (6, 7), the early mortality rate for emergently placed TIPS in patients with advanced liver disease has been reported to be between 40% and 60% (8, 9), and recurrent bleeding ranges from 29% (6) to 53% (10). Recently, endoscopic treatment with cyanoacrylate glue has been reported as an effective option in the management of bleeding gastric varices (11, 12). Large series from Asia and Europe have shown primary hemostasis rates of 94 – 97%, low rebleeding rates, and early mortality rates of only 12–20% (13–15), prompting several authors to propose cy- anoacrylate glue as the first choice for bleeding gastric varices (11–13). Because neither TIPS nor endoscopic cy- anoacrylate injection actually treats the underlying cause of the gastric varices, the effectiveness and economic impact of the technique should influence the clinician’s choice of therapy. It has been suggested that endoscopic treatment with cyanoacrylate is probably cheaper than TIPS (12), but this has not been proved to date. The aim of this study was to compare, retrospectively, the outcomes and health care costs of patients treated with either cyanoacrylate glue or TIPS as the primary treatment. Costs were evaluated with an intent-to-treat analysis and included rescue therapies for both modalities in the evaluation. Out- THE AMERICAN JOURNAL OF GASTROENTEROLOGY Vol. 98, No. 12, 2003 © 2003 by Am. Coll. of Gastroenterology ISSN 0002-9270/03/$30.00 Published by Elsevier Inc. doi:10.1016/j.amjgastroenterol.2003.09.039