Bleeding from ruptured fundic varices (GFV) is often treated with endoscopic tissue glue injection, which has a high rate of hemostasis and a low incidence of rebleeding compared with snare and sclerotherapy. Ultrasound endoscopic (EUS) guidance has been investigated for more accurate injection of tissue glue into varicose veins and for more effective assessment of post-treatment venous occlusion. However, ectopic embolism can occur with ultrasound endoscopic tissue glue injection as its serious complication. Spring coils, made of synthetic fibers, are injected into varicose veins together with tissue glue to act as an anchor to keep the tissue glue in the varicose vein and reduce the amount of tissue glue used and the occurrence of ectopic embolism complications. In this regard, Yasser M et al. from Pacific Medical Center, California, USA, summarized their 6-year experience with the spring-ring combined with tissue glue injection method and published it in a recent issue of GIE. The study began in March 2009 with EUS-induced tissue glue combined with spring-ring injections in patients with GFV, and the entire procedure was videotaped. Inclusion criteria: active or recent bleeding due to GFV; high-risk GFV primary prevention; failure of TIPS treatment; patient preference for EUS-guided treatment. Exclusion criteria: those who did not sign the informed consent form; those with concomitant hepatorenal syndrome and/or multi-organ failure; pregnant women. This procedure was performed by one of the three physicians at the Endoscopy Center. The operation was performed under deep sedation and anesthesia, and broad-spectrum antibiotics were applied prophylactically before the operation. Routine gastroscopy was performed and Sarin/Kumar staging was applied for fundic varices. Type I: isolated fundic varices (IGV), fundus combined with esophageal varices (GOV); Type II: GFV with continuation of esophageal varices. Ultrasound endoscopy with anterior or oblique view was applied to record the red sign of varices, and ultrasound Doppler examination was performed to confirm the blood flow signal in varices before treatment. Procedure 1.Inject water into the stomach to facilitate better observation of the GFV by the EUS; 2.Place the head of the EUS at the distal esophagus (transesophageal route) or the fundus (transgastric route), and the EUS observes the vessels in the gastric wall and their supply vessels; if both routes can be observed, the transesophageal route is preferred; 3.Apply a standard 19 G or 22 G puncture needle and puncture to the GFV under the guidance of the EUS; 4.Push through the injection needle core The spring ring, 10 mm to 20 mm in diameter depending on the shortest diameter of the varicose vein, is initially 14 cm long and later changed to a 7 cm long spring ring to facilitate pushing out the needle; 5. 1 ml of tissue gel is injected 30-45 seconds after the spring ring is placed, and then the needle is flushed with 1 ml of saline. After 10 minutes, EUS is performed to check the blood flow in the varicose vein. After tissue gel injection, the needle casing is pushed out 2-3 cm to avoid contact between the end of the ultrasound lens and the working channel and the tissue gel. Successful hemostasis was defined as immediate cessation of active bleeding without early signs of rebleeding, such as vomiting, black stool, or need for transfusion within 120 hours; rebleeding was defined as reoccurrence of upper gastrointestinal bleeding after 120 hours of treatment, classified as minor or significant bleeding. Complete vascular embolization was defined as no flow signal on follow-up EUS Doppler. If esophageal varices were present, a snare was applied to the degree II or III esophageal varices after treatment of the fundic veins was completed. Postoperative follow-up was performed at months 1, 3, and 6, with immediate examination if bleeding was suspected. Each bleed was recorded, and the primary study endpoints included the success rate of hemostasis, variceal occlusion rate, adverse events, and rebleeding rate. From March 2009 to March 2015, 152 patients with GFV were treated with this regimen. Of these, 139 had clinical records available prior to treatment, 74 (53%) were treated with nonselective β-blockers, 7 (5%) had active bleeding, 105 (69%) had a history of bleeding or recent bleeding, and 40 (26%) had no history of bleeding but were at high risk for bleeding and required prophylactic treatment. The success rate of the procedure was 99% (151/152). The average number of spring coils applied per patient was 1.4 (1-4) and the amount of tissue gel injected was 2 ml (0.5-6 ml). 86 patients were injected through the esophageal route and 66 through the gastric route. The success rate of hemostasis using this method in patients with acute bleeding was 100% (7/7). One failed case was a large GFV mass with a thick splenorenal shunt vessel, which failed to stop the hemorrhage and was eventually treated with TIPS. Three patients died within 30 days due to multi-organ failure on the basis of acute exacerbation of chronic liver failure. 125 patients were followed up for more than 30 days, with a mean follow-up of 436 days. 100 patients had an EUS examination at follow-up, and the vascular occlusion rate was 93%. The rate of vessel occlusion after a single treatment was 79%, 10 required a second treatment, 2 required a third and fourth treatment each, and 3 patients had incomplete vessel occlusion. Of the 40 patients with primary prevention, 37 had complete follow-up data with a mean follow-up of 449 days. 2 had mild bleeding after treatment, which occurred at 62 and 278 weeks after treatment, and a review showed new varicose veins near the original vessel. A total of 28 patients underwent EUS, 27 had complete occlusion of the varicose vein, and one had residual varicose vein and was re-treated with a 10 mm spring coil with 1 ml of tissue adhesive at follow-up. Re-bleeding occurred in 20 patients, with a mean time to re-bleeding of 8 weeks (2-278 weeks). Twelve of them occurred within 6 weeks of treatment. 4 cases were related to the spring coil and tissue glue treatment, and the varicose veins completely disappeared after the re-treatment. Other causes of bleeding included portal hypertensive gastropathy, esophageal varices, and arteriovenous malformations. 9 cases (7%) had adverse effects, including 4 cases of self-limiting abdominal pain, 4 cases of mild delayed bleeding, and 1 patient had a pulmonary embolism 1 week after discharge and was treated with warfarin, which could not be confirmed to be treatment-related because no definite pulmonary embolism occurred during the patient’s post-treatment hospitalization. In conclusion, the investigators have demonstrated in a large sample study that EUS-guided treatment with spring coils combined with tissue gel injection is safe and effective for hemostasis of active bleeding and primary prevention of GFV, and that EUS follow-up is an important follow-up tool to assess variceal occlusion and to intervene directly if rebleeding is detected during EUS follow-up. In addition, combination therapy may reduce the risk of tissue adhesive ectopic embolism.