N-butyl-2-cyanoacrylate pulmonary embolism after endoscopic injection sclerotherapy for gastric variceal bleeding

Care of the liver transplant candidate

Care of the liver transplant candidate is one of the most challenging, yet rewarding aspects of hepatology. Anticipation and intervention for the major complications of advanced liver disease increase the likelihood of survival until transplant.

Long-term result of endoscopic Histoacryl® (N-butyl-2-cyanoacrylate) injection for treatment of gastric varices

AIM: To evaluate the long-term efficacy and safety of endoscopic obliteration with Histoacryl^® for treatment of gastric variceal bleeding and prophylaxis.

METHODS: Between January 1994 and March 2010 at SoonChunHyang University Hospital, a total of 127 patients with gastric varices received Histoacryl^® injections endoscopically. One hundred patients underwent endoscopic Histoacryl^® injections because of variceal bleeding, the other 27 patients received such injections as a prophylactic procedure.

RESULTS: According to Sarin classification, 56 patients were GOV1, 61 patients were GOV2 and 10 patients were IGV. Most of the varices were large (F2 or F3, 111 patients). The average volume of Histoacryl^® per each session was 1.7 ± 1.3 cc and mean number of sessions was 1.3 ± 0.6. (1 session-98 patients, 2 sessions-25 patients, ≥ 3 sessions-4 patients). Twenty-seven patients with high risk of bleeding (large or fundal or RCS+ or Child C) received Histoacryl^® injection as a primary prophylactic procedure. In these patients, hepatitis B virus was the major etiology of cirrhosis, 25 patients showed GOV1 or 2 (92.6%) and F2 or F3 accounted for 88.9% (n = 24). The rate of initial hemostasis was 98.4% and recurrent bleeding within one year occurred in 18.1% of patients. Successful hemostasis during episodes of rebleeding was achieved in 73.9% of cases. Median survival was 50 mo (95% CI 30.5-69.5). Major complications occurred in 4 patients (3.1%). The rebleeding rate in patients with hepatocellular carcinoma or GOV2 was higher than in those with other conditions. None of the 27 subjects who were treated prophylactically experienced treatment-related complications. Cumulative survival rates of the 127 patients at 6 mo, 1, 3, and 5 years were 92.1%, 84.2%, 64.2%, and 45.3%, respectively. The 6 mo cumulative survival rate of the 27 patients treated prophylactically was 75%.

CONCLUSION: Histoacryl^® injection therapy is an effective treatment for gastric varices and also an effective prophylactic treatment of gastric varices which carry high risk of bleeding.

Long journey of sclerosant from the esophagus to the right atrium

A 34-year-old man, who had been treated with an endoscopic injection of a mixture of n-butyl-2-cyanoacrylate (Histoacryl) and Lipiodol for control of variceal bleeding 6 months previously, presented with an intracardiac mass in the right atrium (RA). Two-dimensional echocardiography revealed an intracardiac mass in the RA that appeared to extend from the inferior vena cava. The origin of the sclerosant was traced by computed tomography (CT). This is a very rare case in which the sclerosant migration route was demonstrated by CT scan. The findings of this case suggest that the systemic migration of sclerosant into an intracardiac chamber should be considered in patients with an intracardiac mass, especially with a history of previous sclerotherapy for variceal bleeding.

Undiluted N-butyl cyanoacrylate is safe and effective for gastric variceal bleeding

BACKGROUND

Gastric variceal bleeding is associated with significant morbidity and mortality in patients with portal hypertension. N-butyl cyanoacrylate (NBC), mixed with lipiodol, has been shown to be effective in controlling bleeding, but is associated with the risk of distal embolization.

OBJECTIVE

To study the efficacy and safety of undiluted NBC in the management of gastric varices (GV).

DESIGN

Prospective cohort study.

SETTING

Single tertiary care center.

PATIENTS

170 consecutive patients with GV.

INTERVENTION

Standardized technique of undiluted NBC injection for management of GV.

MAIN OUTCOME MEASUREMENTS

Achievement of initial hemostasis, rate of rebleeding, procedure-related complications, and mortality.

RESULTS

GV were identified in 170 patients, 87 of whom were treated with 261 injections of undiluted NBC. Among 46 patients with active bleeding of GV, initial hemostasis was achieved in 84.8%. Rebleeding was seen in 23.4% patients over a mean follow-up of 16 months. No case of clinical distal embolization was seen. Large GV size, fundal location, and large esophageal variceal size were predictive of GV bleed. The mortality was 8.8% for all patients with GV; 10.3% for patients with GV treated with NBC, and 7.2% for those with GV not treated with NBC. Child-Pugh status was the only predictor of mortality.

LIMITATION

Only 1 intervention group.

CONCLUSION

Undiluted NBC is safe and effective in the management of gastric variceal bleeding.

Low incidence of complications from endoscopic gastric variceal obturation with butyl cyanoacrylate

BACKGROUND & AIMS

Endoscopic variceal obturation with tissue adhesive is used to control gastric variceal bleeding. We investigated the prevalence of serious complications from this therapy.

METHODS

We performed a retrospective analysis of complications that occurred in 753 patients with gastric variceal hemorrhages who were hospitalized in 2 tertiary referral hospitals. All patients received N-butyl-2-cyanoacrylate as therapy for endoscopic variceal obturation.

RESULTS

Complications occurred in 51 patients. Thirty-three patients experienced rebleeding because of early-onset (within 3 months) extrusion of the N-butyl-2-cyanoacrylate glue cast (4.4%), 10 patients developed sepsis (1.3%), and 5 patients developed distant embolisms (0.7%; 1 pulmonary, 1 brain, and 3 splenic). One patient had major gastric variceal bleeding after endoscopic variceal obturation (0.1%), 1 developed a large gastric ulcer (0.1%), and 1 had mesentery hematoma, hemoperitoneum, and infection in the abdominal cavity (0.1%). The complication-related mortality was 0.53% (3 deaths from sepsis and 1 death from rebleeding after early-onset glue cast extrusion).

CONCLUSIONS

The occurrence of complications after endoscopic variceal obturation with N-butyl-2-cyanoacrylate in gastric varices treatment is rare.

Evaluation of therapeutic effects and serious complications following endoscopic obliterative therapy with Histoacryl

Background and aims:

Our aim was to evaluate the utility of endoscopic obliterative therapy with Histoacryl for gastric varices and to investigate the incidence of serious complications.

Methods:

Endoscopic obliterative therapy with Histoacryl was performed on 129 gastric variceal patients. Sixty-five patients had cardiofornical varices, and 64 had fundal varices. Forty-five of 129 patients were emergency cases and the other 84 patients were prophylactic cases. Endoscopic therapy was performed under fluoroscopy using 70% Histoacryl (Histoacryl diluted with 5% Lipiodol).

Results:

Endoscopic hemostasis of gastric varices was successful in 45/45 (100%) emergency cases. The recurrence rate of gastric varices was 17/120 (14.2%) among patients whose variceal eradication was achieved. Additional treatment was successfully performed in all recurrent cases. The incidence of serious complications was 4/129 (3.1%), including two cases of splenic infarction, one case of pulmonary embolism, and one case of an inflammatory tumor of pancreatic tail. The two patients with splenic infarction improved with conservative medical treatment. The patient with pulmonary embolism showed no respiratory symptoms, and died of liver failure. The patient with the pancreatic tumor, which was diagnosed as an inflammatory tumor, was treated surgically.

Conclusions:

Endoscopic obliterative therapy with Histoacryl is a useful and relatively safe method for treatment of bleeding gastric varices. Nonetheless, careful attention must be paid to avoid potentially serious complications.

Endoscopic therapy for gastric varices

Bleeding from gastric varices (GVs) is generally more severe than bleeding from esophageal varices (EVs), but is thought to occur less frequently. Although several recent developments in the agents and the techniques have improved the outcome of GV bleeds no consensus has been reached on the optimum treatment. Because the blood flow in the GVs is relatively large and the bleeding is rapid and often profuse endoscopic means of treating bleeding GVs are the treatments of choice. Endoscopic injection of cyanoacrylate glue is the treatment of choice for the control of active bleeding of gastric avarices and to prevent rebleeding. This article reviews the current endoscopic treatment modalities used in gastric variceal bleeding, and the primary and secondary prophylaxis of gastric variceal bleeding.

A randomized trial of endoscopic cyanoacrylate injection for acute gastric variceal bleeding: 0.5 mL versus 1.0 mL

BACKGROUND

Endoscopic injection of N-butyl-2-cyanoacrylate is the preferred method to treat acute gastric variceal bleeding (GVB). However, its rebleeding rate remains high.

OBJECTIVE

To compare an injection containing 0.5 mL of cyanoacrylate (group A) with an injection containing 1.0 mL of cyanoacrylate (group B).

DESIGN

A single-center, randomized, controlled trial.

SETTING

A tertiary referral center.

MAIN OUTCOME MEASUREMENT

Occurrence of rebleeding.

PATIENTS

Patients with acute gastric variceal bleeding.

RESULTS

Forty-four patients in group A and 47 patients in group B were studied; their clinical characteristics were similar. The treatment stopped active bleeding in approximately 90% of cases in both groups. The rebleeding rate was 29.8% (14/47) in group B compared with 38.6% (17/44) in group A (P = .504; 95% CI, -10.592 to 28.280). On multivariate analysis, concomitant hepatocellular carcinoma, infection, and the size of the gastric varices were independent determinants of rebleeding. More patients in group B than in group A had postinjection fever (>37.5 degrees C) (23/47 vs 12/44, P = .059). Treatment failure, complications, 30-day mortality, and survival did not differ between the 2 groups.

CONCLUSIONS

Due to the small number of study patients, a double dose of cyanoacrylate injection for GVB cannot be proven to have better hemostatic efficacy than a single dose. Multicenter studies with larger patient numbers are necessary to determine whether a double dose is in fact more efficacious.

Cerebral embolism following N-butyl-2-cyanoacrylate injection for esophageal postbanding ulcer bleed: a case report

Systemic embolization is a rare but serious complication of variceal injection with cyanoacrylate. We report a case of cerebral embolism a few hours after an injection of Histoacryl into a bleeding esophageal post-banding ulcer. Echocardiogram revealed patent foramen ovale.

Endoscopic treatment of bleeding gastric varices using large amount of N-butyl-2-cyanoacrylate under fluoroscopic guidance

PURPOSE

We propose the use of fluoroscopic guidance for endoscopic injection of n-butyl-2-cyanoacrylate to treat gastric variceal hemorrhage to achieve placement of the safest quantity of tissue adhesive.

METHODS

Ten patients with gastric varices were treated with n-butyl-2-cyanoacrylate endoscopic injection under fluoroscopic guidance for the purpose of hemostasis or prevention of recurrent bleeding. The glue was infused into the varices in the quantities needed to achieve complete obliteration of the gastric varices.

RESULTS

The median quantity of tissue adhesive required in this series was 6.6 mL. The procedure was initially considered successful in all patients. There were no complications relating to the procedure. The mean duration of follow-up was 20 months.

CONCLUSIONS

Injection of suitable quantities of cyanoacrylate under fluoroscopic guidance seems to be safe and effective for controlling hemorrhagic gastric varices.

A standardized injection technique and regimen ensures success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices (with videos)

BACKGROUND

N-butyl-2-cyanoacrylate has been successfully used for the treatment of bleeding from gastric fundal varices (FV). However, significant rebleeding rates and serious complications including embolism have been reported.

OBJECTIVE

Our purpose was to analyze the safety and efficacy of N-butyl-2-cyanoacrylate for FV bleeding by using a standardized injection technique and regimen.

DESIGN

Retrospective.

SETTING

Two tertiary referral centers.

PATIENTS

A total of 131 patients (91 men/40 women) with FV underwent obliteration with N-butyl-2-cyanoacrylate by a standardized technique and regimen.

INTERVENTIONS

(1) Dilution of 0.5 mL of N-butyl-2-cyanoacrylate with 0.8 mL of Lipiodol, (2) limiting the volume of mixture to 1.0 mL per injection to minimize the risk of embolism, (3) repeating intravariceal injections of 1.0 mL each until hemostasis was achieved, (4) obliteration of all tributaries of the FV, (5) repeat endoscopy 4 days after the initial treatment to confirm complete obliteration of all visible varices and repeat N-butyl-2-cyanoacrylate injection if necessary to accomplish complete obliteration.

MAIN OUTCOME MEASUREMENTS

Immediate hemostasis rate, early rebleeding rate, bleeding-related mortality rate, procedure-related complications, long-term cumulative rebleeding-free rate, and cumulative survival rate.

RESULTS

Initial hemostasis and variceal obliteration were achieved in all patients. The mean number of sessions was 1 (range 1-3). The mean total volume of glue mixture used was 4.0 mL (range 1-13 mL). There was no occurrence of early FV rebleeding, procedure-related complications, or bleeding-related death. The cumulative rebleeding-free rate at 1, 3, and 5 years was 94.5%, 89.3%, and 82.9%, respectively.

CONCLUSION

Obliteration of bleeding FV with N-butyl-2-cyanoacrylate is safe and effective with use of a standardized injection technique and regimen.

Avoiding pitfalls: what an endoscopist should know in liver transplantation--part 1

Cirrhosis is associated with global homodynamic changes, but the majority of the complications are usually manifested through the gastrointestinal tract. Therefore, Gastrointestinal Endoscopy has become an important tool in the multidisciplinary approach in the management of these patients. With the ever growing number of cirrhotic patients requiring pre-transplant endoscopic management, it is imperative that the community endoscopists are well aware of the pathologies that can be potentially noted on Gastrointestinal Endoscopy. Their timely management is also considered to have the utmost importance in being able to stabilize the patient until their transfer to a Liver Transplant Center. The aim of this manuscript is to give a comprehensive update and review of various endoscopic findings that a non-transplant endoscopist will encounter in the pre-transplant setting.

Management of gastric fundal varices without gastro-renal shunt in 15 patients

AIM: To examine the portal hemodynamics of gastric fundal varices (GV) without gastro-renal shunt (GRS), and to retrospectively investigate the effects of various kinds of treatment on eradication.

METHODS: Ninety-four liver cirrhosis patients at high-risk of GV were treated in our hospital and enrolled in this study. We retrospectively examined their characteristics, liver function, and portal hemodynamics of GV. We performed balloon-occluded retrograde transvenous obliteration (BRTO) at first. If it was not technically possible to perform BRTO, endoscopic injection sclerotherapy using α-cyanoacrylate glue (CA) or percutaneous transhepatic obliteration (PTO) was performed.

RESULTS: Among the 94 patients, a GRS was present in 79 (84.0%), and absent in the remaining 15 (16.0%). The subphrenic vein was connected to the inferior vena cava as the drainage vein in 13 (86.7%) out of the 15 cases without GRS. We performed BRTO in 6 patients, CA in 4 patients and PTO in 5 patients. The eradication rate was 100% for each procedure, but the rate of early recurrence within 6 mo was 16.7% for BRTO, 50.0% for CA and 40.0% for PTO, respectively.

CONCLUSION: We should examine the hemodynamics before treatment of GV irrespective of the existence of GRS. If this hemodynamic examination reveals that the drainage vein connects directly to the inferior vena cava in GV without GRS, BRTO may be an effective treatment for GV with GRS.

Balloon-occluded retrograde transvenous obliteration of gastric varices: outcomes and complications in 49 patients

OBJECTIVE

Our aim was to evaluate the clinical outcomes, techniques, and complications of balloon-occluded retrograde transvenous obliteration for treating gastric varices with spontaneous gastrosystemic shunts.

MATERIALS AND METHODS

From November 2002 through October 2005, 49 consecutive patients with gastric varices were treated by balloon-occluded retrograde transvenous obliteration. The sclerosant was injected through the outflow veins during balloon occlusion. Immediate postprocedural CT scans were obtained to evaluate the procedural details. Recurrence and rebleeding of gastric varices and worsening of esophageal varices were evaluated by endoscopic examination and CT. The survival rates and prognostic factors after the procedure were also assessed.

RESULTS

There were six procedural failures and two procedure-related deaths. Disappearance or marked shrinkage of the treated gastric varices with no recurrent gastric variceal bleeding was noted in 39 patients (79.6% clinical success rate). Approximately two thirds of our patients experienced worsening of esophageal varices during the median follow-up period of 457 days. The cumulative survival rates at 1 year and 3 years after balloon-occluded retrograde transvenous obliteration were 83.1% and 65.7%, respectively. The prognostic factors associated with survival were the preprocedural Child-Pugh classification and the total bilirubin level. The survival rates and procedural outcomes for the patients with severely compromised liver function were poor.

CONCLUSION

Balloon-occluded retrograde transvenous obliteration is an effective treatment for the obliteration of gastric varices. However, application of this procedure to severely compromised patients should be considered carefully.

Eosinophilic pleural effusion after gastric variceal obliteration with cyanoacrylate

Pleuropulmonary complications after endoscopic injection sclerotherapy for treatment of esophagogastric varices are not uncommon but are usually mild and self-limited. Herein we report a male patient with liver cirrhosis who underwent endoscopic injection sclerotherapy, using a mixture of n-butyl-2-cyanoacrylate and ethiodized oil for obliteration of gastric varices. After the procedure, he developed moderate amount of left pleural effusion that persisted for a period of time and required thoracentesis and medical treatment. We believed that the inadvertent retrograde reflux of the embolized glue and ethiodized oil via the portosystemic venous collateral into the left pleura might be the possible mechanism for the development of left pleural effusion as the droplets of ethiodized oil were seen along the left pleura on the imaging studies.

Case Report: Cystoscopic Use of Cyanoacrylate Glue for Bleeding during Transurethral Resection of Bladder Tumors

An 81-year-old woman with a history of nephroureterectomy and bladder cuff excision for grade 3 stage pT3N0M0 transitional-cell neoplasia presented with three bladder neoplasms. She also had symptomatic varicose veins in the lower extremities and received low-molecular-weight heparin. During transurethral resection of the tumors, deep ablation of the base of one lesion resulted in significant arterial bleeding that could not be controlled with normal endoscopic techniques. On the basis of previous positive experience, we endoscopically injected 3 mL of cyanoacrylate glue (Glubran 2) deeply (5 mm) into the tissue surrounding the bleeding site, making four injections with a device used for collagen injections. The area was irrigated with mannitol and sorbitol, and within a few seconds, there was complete remission of bleeding. We waited a further 90 seconds with the bladder distended to allow the substance to lose its adhesive properties so as to avoid having the bladder walls stick together. The catheter was removed on the third day, with resumption of micturition and clear urine. This appears to be the first case of cystoscopic use of cyanoacrylate glue to control bleeding.

Cyanoacrylate in the treatment of gastric varices complicated by multiple pulmonary emboli

Bleeding gastric varices are increasingly being obliterated with the aid of endoscopic injection of n-butyl-cyanoacrylate (histoacryl) diluted with lipiodol. This glue acts as a tissue adhesive that polymerizes on contact with blood in a gastric varix. Severe glue pulmonary embolism is a rare complication of injection therapy. This case involves a 52-year-old man with fundal gastric varices, who developed multiple pulmonary emboli following glue injection with profound hypoxia requiring hospital admission for 13 days, but with eventual recovery of normal lung function.

Review article: recent advances in the management of bleeding gastric varices

Gastric variceal bleeding can be challenging to the clinician. Tissue adhesives can control acute bleeding in over 80%, with rebleeding rates of 20-30%, and should be first-line therapy where available. Endoscopic ultrasound can assist in better eradication of varices. The potential risks of damage to equipment and embolic phenomena can be minimized with careful attention to technique. Variceal band ligation is an alternative to tissue adhesives for the management of acute bleeding, but not for secondary prevention due to a higher rate of rebleeding. Endoscopic therapy with human thrombin appears promising, with initial haemostasis rates typically over 90%. The lack of controlled studies for thrombin prevents universal recommendation outside of clinical trials. Balloon occluded retrograde transvenous obliteration is a recent technique for patients with gastrorenal shunts, although its use is limited to clinical trials. Transjugular intrahepatic portosystemic stent shunt is an option for refractory bleeding and secondary prophylaxis, with uncontrolled studies demonstrating initial haemostasis obtained in over 90%, and rebleeding rates of 15-30%. Non-cardioselective beta-blockers are an alternative to transjugular intrahepatic portosystemic stent shunt for secondary prophylaxis, although the evidence is limited. Shunt surgery should be considered in well-compensated patients. Splenectomy or embolization is an option in patients with segmental portal hypertension.

Pulmonary thromboembolism in children

Pulmonary thromboembolism (PTE) is uncommonly diagnosed in the pediatric patient, and indeed often only discovered on autopsy. The incidence of pediatric PTE depends upon the associated underlying disease, diagnostic tests used, and index of suspicion. Multiple risk factors can be found including: peripartum asphyxia, dyspnea, haemoptysis, chest pain, dehydration, septicemia, central venous lines (CVLs), trauma, surgery, ongoing hemolysis, vascular lesions, malignancy, renal disease, foreign bodies or, uncommonly, intracranial venous sinus thrombosis, burns, or nonbacterial thrombotic endocarditis. Other types of embolism can occur uncommonly in childhood and need to be recognized, as the required treatment will vary. These include pulmonary cytolytic thrombi, foreign bodies, tumor and septic emboli, and post-traumatic fat emboli. No single noninvasive test for pulmonary embolism is both sensitive and specific. A combination of diagnostic procedures must be used to identify suspect or confirmed cases of PTE. This article reviews the risk factors, clinical presentation and treatment of pulmonary embolism in children. It also highlights the current diagnostic tools and protocols used to evaluate pulmonary embolism in pediatric patients.

Radiopaque pulmonary arteries on chest radiography

We report a case of a 58-year-old male with cirrhosis and upper gastrointestinal bleeding who developed multiple lipiodol pulmonary emboli after endoscopic injection sclerotherapy for gastric variceal bleeding. The patient did not have any respiratory symptoms after the sclerotherapy. A chest radiograph, obtained 1 day after the procedure for the evaluation of fever, demonstrated multiple tubular radiopacities in both hilar regions. CT confirmed the existence of multiple radiopaque emboli within the main pulmonary arteries, a small pleural effusion, and no evidence of associated pulmonary parenchymal changes. The patient had no further symptoms, and the radiologic opacities persisted on radiographs obtained 3 months later.

Pulmonary embolization of 2-octyl cyanoacrylate after endoscopic injection therapy for gastric variceal bleeding

N-butyl-2-cyanoacrylate, a tissue adhesive that polymerizes on contact with weak bases such as blood, is being used widely outside the United States to obliterate gastric varices. Embolization of this material can occur via portosystemic shunts. We report a case of pulmonary embolization of 2-octyl cyanoacrylate (an analogue of N-butyl-2-cyanoacrylate) that occurred after endoscopic injection therapy for gastric variceal bleeding. Cyanoacrylate embolism is difficult to diagnose with computed tomographic angiography because radiopaque emboli are masked by the contrast material. It is important to distinguish these emboli from conventional thromboemboli because "glue emboli" require only symptomatic treatment. Clinicians should have a high index of suspicion for embolism in the setting of tachycardia, chest pain, or hypoxia after a patient undergoes endoscopic injection therapy with cyanoacrylate glue for gastric variceal bleeding. The radiologist should be alerted so that the appropriate radiographic settings are used to make the diagnosis.

Transportal intravariceal sclerotherapy with N-butyl-2-cyanoacrylate for gastric varices

Four patients with gastric varices without catheterizable draining veins through a systemic vein were treated with transportal intravariceal sclerotherapy with n-butyl-2-cyanoacrylate (NBCA). In all patients, the gastric varices were successfully obliterated with 2-5 mL of NBCA-lipiodol mixture injected via a microcatheter introduced into the varices with transhepatic or transileocolic portal venous access. No complications related to the procedure were encountered. Follow-up gastroendoscopy showed disappearance (n = 3) or marked decrease (n = 1) of the varices. Neither recurrent gastric varices nor variceal bleeding were observed during the follow-up period (6-46 months). Transportal intravariceal sclerotherapy is useful for obliteration of gastric varices in selected cases.

A pilot study of 2-octyl cyanoacrylate injection for treatment of gastric fundal varices in humans

BACKGROUND

N-butyl cyanoacrylate injection has been shown to be effective and safe for the endoscopic treatment of gastric varices. N-butyl cyanoacrylate is not available in the United States, but use of a similar agent, 2-octyl cyanoacrylate, recently was approved for skin closure. This pilot study prospectively evaluated the efficacy and safety of 2-octyl cyanoacrylate injection for treatment of gastric fundal varices.

METHODS

Twenty-five patients with large gastric fundal varices with either stigmata of recent hemorrhage, a history of bleeding, or high-risk varices underwent intravariceal injection of undiluted 2-octyl cyanoacrylate. The end points for this study were cessation of active bleeding, successful obliteration of visible varices, and prevention of bleeding.

RESULTS

Within 2 weeks of treatment, 52% of patients had a history of significant variceal bleeding, and 12% had active gastric variceal bleeding at the time of injection. The rate of immediate hemostasis was 100%. Gastric variceal bleeding recurred in 4% of patients (mean follow-up 11 months). The overall mortality rate was 12%; the bleeding-related mortality rate was 4%.

CONCLUSIONS

Injection of 2-octyl cyanoacrylate appears to be efficacious and safe for both prevention and control of gastric variceal hemorrhage. Larger studies are required to further establish the use of 2-octyl cyanoacrylate for treatment of gastric fundal varices.

Transcatheter obliteration of gastric varices: Part 2. Strategy and techniques based on hemodynamic features

Balloon-occluded retrograde transvenous obliteration (BRTO) has become the treatment of choice for gastric varices at many institutions in Japan. However, in some cases that involve complex types of afferent or draining veins, the use of standard BRTO for the treatment of gastric varices may be associated with several difficulties that can lead to unfavorable results. In such cases, additional techniques are required for successful treatment. These techniques include stepwise injection of the sclerosing agent, selective injection of the agent via a microcatheter, coil embolization of the afferent gastric veins, double-balloon catheterization, and BRTO performed with percutaneous transhepatic portal venous access or transileocolic venous access. The majority of gastric varices can be treated successfully with a combination of these techniques. However, accurate assessment of the variceal hemodynamic pattern is the most important factor in ensuring successful treatment.

2-Octyl-cyanoacrylate (Dermabond), a new glue for variceal injection therapy: results of a preliminary animal study

BACKGROUND

Endotherapy of bleeding gastric varices is problematic. The aim of this descriptive study in an animal model was to compare 2-octyl-cyanoacrylate (Dermabond), a Food and Drug Administration-approved agent for superficial wound closure, to N-butyl-2-cyanoacrylate (Histoacryl), an agent available outside of the United States for the endoscopic treatment of bleeding gastric varices.

METHODS

Eight New Zealand white rabbits were randomly assigned to either the study agent Dermabond or the control agent, Histoacryl. Both active agents were equally mixed with ethiodized poppy seed oil (Ethiodol) and injected into the auricular vein. The animals were euthanized at various time intervals after injection. A 2 cm strip of tissue on either side of the injection site along with the adjacent perivascular tissues were resected for histologic evaluation.

RESULTS

The use of 0.5 mL of Dermabond effectively induced vascular occlusion compared with 0.2 mL of Histoacryl. The histologic changes acutely and at 1 week were similar with each mixture.

CONCLUSION

Dermabond may be useful in the treatment of gastric variceal bleeding, but further studies are necessary to determine dose response rates in animals and humans.