Cerebral embolism following N-butyl-2-cyanoacrylate injection for esophageal postbanding ulcer bleed: a case report. Hepatol Int. 2009;3:504-508. [PMID: 19669253 DOI: 10.1007/s12072-009-9130-5]

Polymerisation of cyanoacrylates: The effect of sclero-embolic and contrast agents

OBJECTIVES

The objective is to investigate the interaction of sclero-embolic and contrast agents with the polymerisation of medical grade n-butyl-cyanoacrylates.

METHODS

An in vitro spectrophotometric absorbance method was developed to detect changes in light transmission to measure n-BCA polymerisation. The initiation and the rate-of-polymerisation of mixtures of n-BCA with sclero-embolic and contrast agents were investigated.

RESULTS

Initiation of polymerisation: VENABLOCK™ and HISTOACRYL® were the fastest agents to polymerise, while VENASEAL™ was the slowest. Rate of polymerisation: Hypertonic saline inhibited the polymerisation of all n-BCAs, while hypertonic glucose prolonged the polymerisation rate. ETHANOL and detergent sclerosants had no effect. Contrast agents OMNIPAQUE™ and ULTRAVIST® initiated and prolonged the polymerisation of n-BCA, but in contrast, LIPIODOL® failed to initiate the process.

CONCLUSIONS

The commercially available medical cyanoacrylates differ in their polymerisation rates. These polymerisation rates are further affected when these products are used in conjunction with other compounds, such as sclero-embolic and contrast agents.

Endovascular management of incidentally discovered splenic arteriovenous fistula resulting from ruptured splenic aneurysm: Case report and review of the literature

Splenic arteriovenous fistulas (SAVFs) are rare vascular anomalies, which have a described association with splenic artery aneurysms. Treatment options include surgical fistula excision, splenectomy, or percutaneous embolization. Here we present a unique case of endovascular repair of a splenic arteriovenous fistula (SAVFs) associated with a splenic aneurysm. A patient with past medical history of early-stage invasive lobular carcinoma was referred to our interventional radiology practice to discuss an incidentally discovered splenic "vascular malformation" discovered during magnetic resonance imaging of the abdomen and pelvis. Arteriography demonstrated smooth dilatation of the splenic artery, with a fusiform aneurysm which had fistulized to the splenic vein. There were high flows and early filling of the portal venous system. The splenic artery, immediately proximal to the aneurysm sac, was catheterized using a microsystem and embolized using coils and N-butyl cyanoacrylate. Complete occlusion of the aneurysm and resolution of the fistulous connection was achieved. The patient was discharged home the following day, without complication. Associated splenic artery aneurysms and SAVFs are rare occurrences. Timely management is necessary to prevent adverse sequelae such as aneurysm rupture, further enlargement of the aneurysmal sac, or portal hypertension. Endovascular treatment, including n-Butyl Cyanoacrylate glue and coils, offers a minimally invasive treatment option, with facile recovery and low morbidity.

Targeted neonatal echocardiography-guided therapy pre-embolisation for congenital hepatic vascular malformation: inhaled nitric oxide to prevent paradoxical embolisation to the systemic circulation

Arteriovenous malformations may present with significant haemodynamic compromise in the neonatal period, typically with high output cardiac failure that may be accompanied by hypoxia and right ventricular dysfunction. Targeted neonatal echocardiography performed by trained neonatologists provides an enhanced physiology-based approach that can guide treatment and minimise complications. We present a case of a large hepatic vascular malformation whose therapy was guided by targeted neonatal echocardiography to prevent paradoxical embolisation of procedural glue to the systemic circulation.

Thromboembolic Events Secondary to Endoscopic Cyanoacrylate Injection: Can We Foresee Any Red Flags?

BACKGROUND

Gastric varices (GV) are associated with high morbidity and mortality in patients with portal hypertension. Endoscopic cyanoacrylate injection is the first-line recommended therapy for GV obliteration. This study aims to explore the reason behind related adverse events and better prevent its occurrence.

METHODS

A retrospective case series study was conducted from January 1, 2013, to December 31, 2016, to identify patients who experienced severe adverse events secondary to endoscopic cyanoacrylate injection. A literature review of similar cases was performed on two medical databases, Medline and Embase.

RESULTS

A total of 652 patients underwent cyanoacrylate injection at our center within the study duration. Five cases of severe adverse events related to the use of tissue adhesives were identified. Detailed clinical presentation, patient treatment, and outcomes were reviewed and analyzed. Twenty-seven similar cases were identified based on the literature review providing further insight into the study.

CONCLUSION

Although rare in incidence, systemic embolism associated with cyanoacrylate injection is often fatal or debilitating. This report may raise awareness in treatment protocol, including the necessity of preoperative angiographic studies, to avoid similar adverse events in clinical practice.

Use of self-expanding metal stents for difficult variceal bleed

BACKGROUND/AIM

Patients with variceal band ligation (VBL)-induced ulcer bleeding and those with persisting bleeding in spite of VBL carry a high mortality. Balloon tamponade and transjugular intrahepatic portosystemic shunt have limitations in terms of complications, cost, and availability. The aim was to evaluate the efficacy of Sx-Ella Danis stent in persistent or complicated variceal bleeding.

METHODS

Twelve patients with either persistent variceal bleeding or VBL-induced ulcer bleeding were treated with the placement of Sx-Ella Danis stents. The patients were followed up for mortality, complications, and efficacy to control bleeding.

RESULTS

Stents were inserted successfully in all 12 patients (with immediate hemostasis). There was an immediate cessation of bleeding in all 12 patients with no stent-related complication. Five out of 12 patients died during 30 days post-procedure due to worsening encephalopathy or sepsis. Enteral feeding could be started in all 12 patients 6 h after stent placement. One patient had bleeding 10 days after stent removal and was re-stented but expired 7 days later. Stents were removed in eight patients at a mean duration of 17.5 days. (range 7 to 30 days).

CONCLUSIONS

Sx-Ella Danis stent is a useful modality to control persistent variceal bleeding as well VBL-related ulcer bleeding.

New Endoscopic Technologies and Procedural Advances for Endoscopic Hemostasis

Endoscopic interventions are first-line therapy for upper and lower gastrointestinal bleeding. Injection therapy in combination with a second endoscopic modality has reduced re-bleeding, need for surgery and mortality in non-variceal bleeding. For variceal bleeding endoscopic banding or cyanoacrylate injection techniques are recommended interventions. However, despite ease of application and general acceptance of these techniques, there is an ongoing re-bleeding rate associated with significant in-hospital mortality. We discuss current literature on new advances in endoscopic technologies and procedural techniques that have emerged to improve patient outcomes.

Cyanoacrylate glue for gastrointestinal bleeding

PURPOSE OF REVIEW

Cyanoacrylate (CYA) therapy has become an important component of the therapeutic toolbox of the interventional endoscopists with direct endoscopic injection accepted as first-line therapy of gastric varices. However, its generalized use has been cautioned by its serious adverse event profile.

RECENT FINDINGS

Endoscopic ultrasound guided therapy has several conceptual advantages over free-hand injection, particularly as it ensures intravascular delivery of therapy. This has allowed innovation with the use of vascular coils with or without CYA therapy, and very encouraging long-term results are now published showing reduced serious adverse events and low rebleeding rates.

SUMMARY

Direct endoscopic ultrasound guided intravascular injection of CYA is gaining widespread acceptance and offers reduced complication rates and significantly lower rebleeding rates. Data are supportive of CYA use both for primary and secondary prophylaxis of gastric varices.

Endoscopic management of gastric variceal bleeding

Expert knowledge of endoscopic management of gastric varices is essential, as these occur in 20% of patients with portal hypertension. Bleeding is relatively uncommon, but carries significant mortality when this occurs. Inability to directly target intravascular injections and the potential complication related to glue embolization has resulted in the development of novel techniques. Direct visualization of the varix lumen using endoscopic ultrasound (EUS) allows targeted therapy of feeder vessels with real-time imaging. EUS-guided combination therapy with endovascular coiling and cyanoacrylate injections promise to provide reduced complication rates, increased obliteration of varices, and reduced long-term rebleeding rates.

Cerebral and splenic infarctions after injection of N-butyl-2-cyanoacrylate in esophageal variceal bleeding

Variceal bleeding is the most serious complication of portal hypertension, and it accounts for approximately one fifth to one third of all deaths in liver cirrhosis patients. Currently, endoscopic treatment remains the predominant method for the prevention and treatment of variceal bleeding. Endoscopic treatments include band ligation and injection sclerotherapy. Injection sclerotherapy with N-butyl-2-cyanoacrylate has been successfully used to treat variceal bleeding. Although injection sclerotherapy with N-butyl-2-cyanoacrylate provides effective treatment for variceal bleeding, injection of N-butyl-2-cyanoacrylate is associated with a variety of complications, including systemic embolization. Herein, we report a case of cerebral and splenic infarctions after the injection of N-butyl-2-cyanoacrylate to treat esophageal variceal bleeding.

In vitro and in vivo studies on the use of Histoacryl(®) as a soft tissue glue

The skin adhesive Histoacryl(®) consists of n-butyl-2-cyanoacrylate which polymerises in contact with moisture. It is not fully biodegradable, produces heat during polymerisation and releases products which are toxic and inhibit cell growth. Clinical application is exclusively approved to glue skin. However, there are also clinical studies and case reports in the scientific literature, which discuss the application of Histoacryl(®) as a soft tissue adhesive. In parallel to an analysis of the literature which discusses the usage of Histoacryl(®) in head and neck surgery, we performed in vitro and in vivo investigations with this adhesive. In vitro, the vitality of cultured cell lines which where treated with extracts of Histoacryl(®) was determined with a viability assay. In addition, Histoacryl(®) was examined by fixing defined mucous membrane of the nasal septum in an animal study in rabbits. The analysis of the literature shows both positive and negative results for the application of Histoacryl(®) as a soft tissue adhesive depending on the manner and place of the application as well as the applied amount of glue. Our own results confirm a negative influence of Histoacryl(®) on the viability of cultured cells and soft tissue. The histological examination showed that a better biocompatibility is achieved if the glue is used in small amounts. Both the literature study as well as the in vitro and in vivo examinations showed that the usage of Histoacryl(®) as a soft tissue glue may be arguable. Critical factors are the moisture at the application area and the applied amount of glue.

Development of an acute obstructive hydrocephalus model in rats using N-butyl cyanoacrylate

PURPOSE

Previous animal models of obstructive hydrocephalus that was frequently combined with subarachnoid inflammation are not suitable for investigating cerebrospinal fluid (CSF) flow between ventricles and cisterns in obstructive hydrocephalus. In this study, we attempted to develop a new animal model for obstructive hydrocephalus in rats sparing subarachnoid space using N-butyl cyanoacrylate (NBCA).

METHODS

Hydrocephalus was induced in adult male Sprague-Dawley rats with NBCA (n=15) or with kaolin (n=10). For the NBCA model, a silicone tube was inserted through the foramen of Magendie into the fourth ventricle, into which 20 μL of a mixture of NBCA and ethiodized oil was injected. For the kaolin model, 100 μL of 20% kaolin solution was injected into the cistern magna. The rats in the NBCA and kaolin groups were sacrificed 3 and 21 days after surgery, respectively.

RESULTS

Eleven rats in the NBCA group developed hydrocephalus (73.3%), with a 13.3% mortality rate. The kaolin group showed hydrocephalus in eight rats (80%), with a 20% mortality rate. The mean Evans' indices were 0.37 ± 0.02, 0.45 ± 0.04, and 0.53 ± 0.09 in the control, NBCA, and kaolin groups, respectively (p < 0.05). There was no remarkable arachnoid adhesion or inflammatory change of the ventricular wall in the NBCA group.

CONCLUSIONS

The NBCA model seems to be a useful animal model for acute obstructive hydrocephalus with preserved subarachnoid CSF pathway. This model can be useful for studying CSF flow between ventricles and cisterns.

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.

Implantation of self-expanding metal stent in the treatment of severe bleeding from esophageal ulcer after endoscopic band ligation

Endoscopic variceal ligation is superior to sclerotherapy because of its lower rebleeding and complication rates. However, ligation may be associated with life-threatening bleeding from postbanding esophageal ulcer. We report a case of a 49-year-old male with massive hemorrhage from esophageal ulcer on 8th day after successful band ligation of bleeding esophageal varices caused by postviral liver cirrhosis (Child-Pugh class C). A removable polyurethane membrane-covered self-expanding metal stent (SX-ELLA stent Danis, 135 mm × 25 mm, ELLA-CS, Hradec-Kralove, Czech Republic) was inserted in ICU for preventing fatal hemorrhage. Complete hemostasis was achieved and stent was removed after 8 days without rebleeding or any complications. To the best of our knowledge, this is the first report in English literature regarding life-threatening hemorrhage from postbanding esophageal ulcer successfully treated by self-expanding metal stent in a patient with portal hypertension.