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Introduction Gastric variceal bleeding is associated with high morbidity and mortality. Conventional endoscopic cyanoacrylate glue injection (EGI) is widely used but carries risks of rebleeding and embolic complications. Endoscopic ultrasound–guided coiling combined with glue injection (EUS-CG) has emerged as an alternative strategy, potentially improving efficacy and safety by targeting the variceal inflow.We performed a systematic review and meta-analysis to compare the efficacy and safety of EUS-guided coiling plus glue with standard endoscopic interventions.Methods A systematic review and meta-analysis was conducted in accordance with PRISMA guidelines. PubMed, Scopus, and Google Scholar were searched for comparative studies, including randomised controlled trials and high-quality observational studies, evaluating EUS-CG versus other endoscopic treatments for gastric varices. Outcomes included technical success, variceal obliteration, rebleeding, adverse events, and need for rescue therapy (TIPS) Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using random-effects models.Results Seven studies with 623 patients(RCTs, multicentre cohorts, meta-analyses; n = 623) met inclusion criteria. Technical success with EUS-guided coiling plus glue ranged from 92–100% versus 80–85% for conventional therapy. Variceal obliteration was superior with EUS-guided therapy (RR 1.15; 95% CI 1.06–1.24). Rebleeding was lower with EUS-guided therapy (7–10%) compared with conventional therapy (15–20%), with pooled RR 0.52 (95% CI 0.35–0.78). Adverse events were low (5–8%) and similar between groups. EUS-guided therapy reduced the need for rescue TIPS, with successful salvage rates >85%. Procedure efficiency was improved due to higher initial obliteration.Conclusions EUS-guided coiling plus glue is safe, highly effective, and superior to conventional endoscopic therapy for gastric varices, achieving higher obliteration and lower rebleeding. These findings support its adoption in centres with EUS expertise and may reduce the need for rescue interventions.Recommendations Endoscopic ultrasound–guided coiling combined with glue injection (EUS-CG) should be considered first-line therapy for gastric varices in centres with expertise, improving variceal obliteration and reducing rebleeding compared with conventional methods.Abstract P35 Table 1Key outcomes - summaryOutcomeEUS-guided Coiling + GlueConventional Endoscopic TherapyEffect Estimate Technical success92–100%80–85%Superior with EUSVariceal obliteration92–100%80–85%Superior with EUSRebleeding7–10%15–20%Reduced with EUSAdverse events5–8%5–8%ComparableRescue TIPS required<15%>20%Reduced with EUSNotesHigher initial obliterationLower initial successEUS improves efficiency