Transcatheter Arterial Embolization with N-Butyl-2-Cyanoacrylate in the Management of Spontaneous Hematomas

Spontaneous Soft Tissue Hematomas in Patients with Coagulation Impairment: Safety and Efficacy of Transarterial Embolization

The aim of this study is to report the authors' experience of percutaneous transarterial embolization (TAE) in patients with spontaneous soft tissue hematomas (SSTH) and active bleeding with anticoagulation impairment. The study retrospectively identified 78 patients who received a diagnosis of SSTH by CT scan and underwent TAE between 2010 and 2019 in a single trauma center. The patients were stratified using Popov classification into categories: 2A, 2B, 2C, and 3. The patient's 30-day survival after TAE was considered the primary outcome; immediate technical success, the need for additional TAE, and TAE-related complications were considered secondary outcomes. Immediate technical success, complication rate, and risk factors for death were analyzed. Follow-up stopped on day 30 from TAE. 27 patients (35%) fell into category 2A, 8 (10%) into category 2B, 4 (5%) into category 2C, and 39 (50%) into category 3. Immediate technical success was achieved in 77 patients (98.7%). Complications included damage at the arterial puncture site (2 patients, 2.5%) and acute kidney injury (24 patients, 31%). Only 2 patients (2.5%) had been discharged with a new diagnosis of chronic kidney disease. The 30-day overall mortality rate was 19% (15 patients). The mortality rate was higher in hemodynamically unstable patients, in Popov categories 2B, 2C, and 3, and in patients with an initial eGFR < 30 mL/min × 1.73 m². The study demonstrated a higher mortality risk for categories 2B, 2C, and 3 compared to category 2A. Nonetheless, TAE has proven effective and safe in type 2A patients. Even though it is unclear whether type 2A patients could benefit from conservative treatment rather than TAE, in the authors' opinion, a TAE endovascular approach should be promptly considered for all patients in ACT with active bleeding demonstrated on CT scans.

Clinical Outcomes of Transcatheter Arterial Embolization Using N-butyl-2-cyanoacrylate (NBCA) in Cirrhotic Patients

Purpose

To evaluate the clinical outcomes of transcatheter arterial embolization (TAE) with n-butyl-2-cyanoacrylate (NBCA) for treatment of bleeding in cirrhotic patients.

Materials and methods

A total of 35 cirrhotic patients (26 men, 9 women; mean age, 48.4 ± 11.1) who underwent TAE with NBCA for bleeding from January 2011 to December 2020 were retrospectively analysed. Only cirrhotic patients with active arterial bleeding confirmed on computed tomography (CT) were included. Fifteen patients were hemodynamically unstable before embolization procedure, and coagulopathy was observed in 32 patients. The mean MELD score and Child Pugh score were 24 ± 9.9 and 9.9 ± 2.2, respectively. The mean haemoglobin level and mean number of RBC units transfused before embolization were 7.4 ± 1.4 g/dL and 10.2 ± 4, respectively. The technical, clinical success rate and 30-day mortality rate were evaluated.

Results

Technical success and clinical success rates were achieved in 100% and 82.8% of patients, respectively. Overall 30-day mortality rate was 48%. No major complications related to the embolization procedure was seen. Only the greater number of RBC units transfused before the embolization procedure (OR = 1.81, 95% CI = 1.17-2.80, P = 0.007) was significantly associated with clinical failure. Greater number of RBC units transfused (OR = 1.53, 95% CI: 1.00-2.34, P = 0.004) and higher Child Pugh score (OR 2.44, 95% CI 1.26-4.71, P = 0.008) were significantly associated with higher 30-day mortality rate.

Conclusion

Transcatheter arterial embolization using NBCA can be used as the effective treatment option for bleeding in cirrhotic patients which has a high technical and clinical success despite the grave prognosis associated with cirrhosis.

A Proposed Algorithm on the Modern Management of Rectus Sheath Hematoma: A Literature Review

Rectus sheath hematoma (RSH) is a common entity with no clearly established protocol for management. Existing literature on RSH is outdated and does not incorporate modern technological advances in medicine and imaging. A total of 21 studies were included in this literature review based on PubMed and Google Scholar searches. Modern literature was selected from the last 10 years with the inclusion of three past pieces of literature. We performed a literature review to identify the latest research on RSH management and to consolidate an algorithm to help guide modern RSH treatment. Current RSH classification, scoring system, algorithm, and other predictors for treatment plan are discussed. The best RSH management requires early recognition of RSH followed by the appropriate implementation of conservative management and procedural intervention. The decision on picking the treatment of choice is assisted with the use of predictors, such as hematoma size, rate of hemoglobin drop, and the number of blood transfusions. Further studies are needed to clearly establish predictors among the different types of procedural intervention, and we hope the consolidated algorithm on current literature can help promote the standardization of protocol in the future.

Percutaneous evacuation of anterior abdominal wall hematomas using catheter-based mechanical thrombectomy

Post-operative hematoma is a common surgical complication, often treated conservatively. However, persistent, recurrent or symptomatic hematomas may require percutaneous or surgical drainage. The authors present two cases of persistent post-surgical hematomas which were successfully evacuated in a single-setting using a percutaneous mechanical thrombectomy system.

Transarterial embolization with n-butyl cyanoacrylate for the treatment of abdominal wall hemorrhage

PURPOSE

We aimed to evaluate the effectiveness and safety of n-butyl cyanoacrylate (n-BCA) in the context of the transarterial embolization (TAE) of abdominal wall hemorrhage in an urgent scenario.

METHODS

A retrospective study of cases admitted from January 2008 to December 2017 in the emergency unit of our institution revealed 11 patients with abdominal wall hemorrhage who underwent digital subtraction angiography and TAE with n-BCA. We analyzed the sex, age, hemorrhagic risk factors, etiology, embolized vessel, technical success (no rebleeding in the embolized area), clinical success (hemoglobin level control and hemodynamic stability after the procedure), complications inherent to the procedure, and clinical outcome (mortality in 30 days).

RESULTS

The mean age was 63.4 years (52-83 years), with a predominance of the female sex (64%). The majority (91%) of patients presented hemorrhagic risk factors (chronic hepatopathy and anticoagulation drug usage). Spontaneous hemorrhage was present in 18% of patients, and the other 82% had an iatrogenic etiology. Technical success was achieved in 100% of the patients, which required the embolization of inferior epigastric artery in 10 patients (91%), circumflex iliac artery in 2 (18%), and superior epigastric artery in 1 (9%). Five patients were hemodynamically unstable, and despite achieving technical success, 4 (36%) died in less than 30 days due to decompensation of their clinical comorbidities caused by the acute phase. There were no complications inherent to the procedures.

CONCLUSION

The present study concludes that TAE with n-BCA is a safe and effective treatment for abdominal wall hemorrhage in an urgent scenario, with high rates of technical and clinical success.

Computed tomography-guided cyanoacrylate localization of small pulmonary nodules: feasibility and initial experience

OBJECTIVES

We report our initial technical experience with computed tomography (CT)-guided cyanoacrylate localization for resection of small pulmonary nodules (SPNs) and evaluate the feasibility of this technique.

METHODS

Between June 2016 and December 2017, the diagnostic results of 55 consecutive patients (69 SPNs) who underwent preoperative CT-guided cyanoacrylate localization and consequent video-assisted thoracoscopic surgery (VATS) resection were retrospectively evaluated. Localization-related outcomes and perioperative outcomes were assessed.

RESULTS

Preoperative CT-guided cyanoacrylate localization was successfully performed in all the cases. Simultaneous localization was achieved in 8 (14.5%) patients with 2 nodules and 3 (5.5%) patients with 3 nodules. The mean size of the nodules was 8.5 ± 3.2 mm (range 5-20 mm), and their mean depth from the nearest pleural surface was 10.9 ± 7.7 mm (range 2-36 mm). The overall mean localization procedural time was 13.7 ± 7.2 min (range 6-37 min). Two localization-related complications (intrapulmonary focal haemorrhage and pneumothorax) were observed in 7 (12.7%) and 12 (21.8%) patients, respectively. All patients with complications were asymptomatic and received conservative treatment only. All SPNs were resected under VATS without any conversion to minithoracotomy or thoracotomy.

CONCLUSIONS

CT-guided cyanoacrylate localization is a feasible procedure to localize SPNs. The advantages of this technique include flexibility between insertion and excision, the ability to be applied to the whole lung field, a high success rate, patient comfort after insertion and a fast learning curve. Further studies are warranted to confirm the efficacy of this technique.

Surface Modification of Poly(lactic-co-glycolic acid) Microspheres with Enhanced Hydrophilicity and Dispersibility for Arterial Embolization

In this study, a series of poly(lactic-co-glycolic acid) (PLGA) microspheres with different particle sizes for arterial embolization surgery were prepared. The polydopamine (PDA) and polydopamine/polyethyleneimine (PDA/PEI) were respectively coated on the PLGA microspheres as shells, in order to improve the hydrophilicity and dispersibility of PLGA embolization microspheres. After modification, with the introduction of PDA and PEI, many hydrophilic hydroxyl and amine groups appeared on the surface of the PLGA@PDA and PLGA@PDA/PEI microspheres. SEM images showed the morphologies, sizes, and changes of the as-prepared microspheres. Meanwhile, the XPS and FT-IR spectra demonstrated the successful modification of the PDA and PEI. Water contact angles (WCAs) of the PLGA@PDA and PLGA@PDA/PEI microspheres became smaller, indicating a certain improvement in surface hydrophilicity. In addition, the results of in vitro cytotoxicity showed that modification had little effect on the biosafety of the microspheres. The modified PLGA microspheres suggest a promising prospective application in biomedical field, as the modified microspheres can reduce difficulties in embolization surgery.

Pain perception following epithelialized gingival graft harvesting: a randomized clinical trial

OBJECTIVES

The aim of this study was to compare the effects of a hemostatic collagen sponge and a collagen sponge sealed with a bio-adhesive material on the palatal donor sites with the purpose of minimizing postoperative pain after epithelialized gingival graft (EGG) harvesting.

MATERIAL AND METHODS

The present study consisted of 44 EGGs harvested in 44 patients. In the control group, a hemostatic collagen sponge was applied over the palatal wound, while the test group was treated with additional cyanoacrylate. Patients were observed for 14 days, evaluating the pain level by using the visual analogic scale. The consumption of analgesic during the postoperative period, the willingness for retreatment and the characteristic of the graft were also analyzed.

RESULTS

Statistically significant differences in pain perception were found between test and control groups in each of the studied days (p < 0.01). Analgesic consumption was lower in the test group (p < 0.01). Graft width < 14 mm was found to be associated with lower discomfort (p < 0.01).

CONCLUSIONS

Adding an additional layer of cyanoacrylate over a hemostatic collagen sponge on the palatal wound following EGG harvesting was found to be successful in minimizing the postoperative discomfort and the need for analgesics.

CLINICAL RELEVANCE

Postoperative pain after palatal tissue harvesting can be successfully minimized if the donor site open wound is protected with an external layer of cyanoacrylate over a collagen sponge.

Safety and efficacy of transcatheter embolization with Glubran®2 cyanoacrylate glue for acute arterial bleeding: a single-center experience with 104 patients

PURPOSE

To assess the efficacy and the safety of Glubran^®2 n-butyl cyanoacrylate metacryloxysulfolane (NBCA-MS) transcatheter arterial embolization (TAE) for acute arterial bleeding from varied anatomic sites and to evaluate the predictive factors associated with clinical success and 30-day mortality.

METHODS

A retrospective review of consecutive patients who underwent emergent NBCA-MS Glubran^®2 TAE between July 2014 and August 2016 was conducted. Variables including age, sex, underlying malignancy, cardiovascular comorbidities, coagulation data, systolic blood pressure, and number of red blood cells units (RBC) transfused before TAE were collected. Clinical success, 30-day mortality, and complication rates were evaluated. Prognostic factors were evaluated by uni- and multivariate logistic regression analyses for clinical success, and by uni- and bivariate analyses after adjustment by bleeding sites for 30-day mortality.

RESULTS

104 patients underwent technically successful embolization with bleeding located in muscles (n = 34, 32.7%), digestive tract (n = 28, 26.9%), and viscera (n = 42, 40.4%). Clinical success rate was 76% (n = 79) and 30-day mortality rate was 21.2% (n = 22). Clinical failure was significantly associated with mortality (p < 0.0001). A number of RBC units transfused greater than or equal to 3 were associated with poorer clinical success (p = 0.025) and higher mortality (p = 0.03). Complications (n = 4, 3.8%) requiring surgery occurred only at puncture site. No ischemic complications requiring further invasive treatment occurred. Mean TAE treatment time was 4.55 min.

CONCLUSIONS

NBCA-MS Glubran^®2 TAE is a fast, effective, and safe treatment for acute arterial bleeding whatever the bleeding site.

Safety and effectiveness of transcatheter embolization in the treatment of internal mammary artery injuries

PURPOSE

Demonstrate the role of endovascular management in the treatment of internal mammary artery (IMA) injuries using transcatheter embolization reviewing our 7-year experience.

MATERIALS AND METHODS

Our retrospective analysis of cases consists of a total of 12 patients (8 M and 4 F; mean age 52 years) who underwent angiographic studies and transcatheter embolization for IMA injuries. Causes of vascular injury were divided in high-energy trauma (n = 6), iatrogenic (n = 3) and penetrating injuries (n = 3). Type of trauma, associated injury, imaging findings, treatments and complications were assessed. Imaging findings included active haemorrhage, pseudoaneurysm and focal dissection.

RESULTS

Embolization was performed with microcoils in all patients; complete thrombosis was obtained in four patients by additional injection of Spongostan pledgets and in two patients with 300-500 μm particles. The technical success rate was 100%. No patient died as a direct result of vascular injury; one died of myocardial contusion and one for severe multiorgan failure related to high-energy trauma. No major and minor complications were registered. No patient required emergency surgery or subsequent surgical treatment.

CONCLUSION

Transcatheter embolization offers an effective, efficient and safe alternative to conventional surgical management of IMA injuries.

Outcomes of Transcatheter Arterial Embolization with a Modified N-Butyl Cyanoacrylate Glue for Spontaneous Iliopsoas and Rectus Sheath Hematomas in Anticoagulated Patients

PURPOSE

To assess the efficacy and safety of n-butyl cyanoacrylate methacryloxy sulfolane (NBCA-MS) transcatheter arterial embolization for anticoagulation-related soft-tissue bleeding and to evaluate predictive factors of clinical success and 30-day mortality.

MATERIALS AND METHODS

A retrospective review of 50 anticoagulated patients (25 male; mean age, 71.7 y ± 14.2; range, 19-87 y) who underwent emergent Glubran 2 NBCA-MS embolization for iliopsoas hematomas (IPHs; n = 38), rectus sheath hematomas (n = 11), or both (n = 1) between 2011 and 2016 was performed. Inclusion criteria were active bleeding on computed tomography (CT) and anticoagulation. The mean number of red blood cell (RBC) units transfused was 4.8 ± 3.2 (range, 0-14), median hemoglobin level before embolization was 9.7 g/dL (range, 6.2-18 g/dL), and median "mean blood pressure" (MBP) was 62.5 mm Hg (range, 58.3-75 mm Hg). Mean International Normalized Ratio before intervention was 2.5 ± 1.5 (range, 1.0-6.9). Angiograms revealed extravasation in 44 of 50 patients (88%). Mean hematoma volume was 1,119.2 cm³ ± 863.5 (range, 134.0-3,589.0 cm³).

RESULTS

Technical success was achieved in 100% of patients, and 30-day clinical success was achieved in 66% of patients. Recurrent bleeding and mortality rates within 30 days of embolization were 34% and 44%, respectively. No complications related to the embolization procedure occurred. Lower MBP (P = .003), greater number of RBC units transfused (P = .003), greater volume of hematoma (P = .04), and IPH location (P = .02) were associated with decreased clinical success. Clinical failure (P = .00002), lower MBP (P = .004), greater number of RBC units transfused (P = .002), and IPH location (P = .01) were significantly associated with higher 30-day mortality rates.

CONCLUSIONS

Transcatheter arterial embolization with NBCA-MS is safe and effective in treating refractory soft-tissue bleeding in anticoagulated patients despite the high mortality rates associated with this patient population.

Spontaneous Intramuscular Hematomas of the Abdomen and Pelvis: A New Multilevel Algorithm to Direct Transarterial Embolization and Patient Management

PURPOSE

To report our experience using a multilevel patient management algorithm to direct transarterial embolization (TAE) in managing spontaneous intramuscular hematoma (SIMH).

MATERIALS AND METHODS

From May 2006 to January 2014, twenty-seven patients with SIMH had been referred for TAE to our Radiology department. Clinical status and coagulation characteristics of the patients are analyzed. An algorithm integrating CT findings is suggested to manage SIMH. Patients were classified into three groups: Type I, SIMH with no active bleeding (AB); Type II, SIMH with AB and no muscular fascia rupture (MFR); and Type III, SIMH with MFR and AB. Type II is furthermore subcategorized as IIa, IIb and IIc. Types IIb, IIc and III were considered for TAE. The method of embolization as well as the material been used are described. Continuous variables are presented as mean ± SD. Categorical variables are reported as percentages. Technical success, clinical success, complications and 30-day mortality (d30 M) were analyzed.

RESULTS

Two patients (7.5%) had Type IIb, four (15%) Type IIc and 21 (77.5%) presented Type III. The detailed CT and CTA findings, embolization procedure and materials used are described. Technical success was 96% with a complication rate of 4%. Clinical success was 88%. The bleeding-related thirty-day mortality was 15% (all with Type III).

CONCLUSION

TAE is a safe and efficient technique to control bleeding that should be considered in selected SIMH as soon as possible. The proposed algorithm integrating CT features provides a comprehensive chart to select patients for TAE.

LEVEL OF EVIDENCE

4.