Tissue response to N-butyl-2-cyanoacrylate after percutaneous injection into cutaneous vascular lesions

Difficult removal after bronchial filling of an endobronchial Watanabe spigot with N‐butyl‐2‐cyanoacrylate for intractable pneumothorax: A case report

A 52‐year‐old man developed a right pneumothorax during treatment for COVID‐19. In a previous case report concerning this patient, his recovery was achieved through implanting four endobronchial Watanabe spigots (EWS) in the right B1 and B3 in two phases and spraying N‐butyl‐2‐cyanoacrylate (NBCA). One year later, EWS removal was planned. He was intubated under bronchoscopic guidance, and the right upper lobe was observed. The right B1 and B3 inlets were found to be covered with granuloma. Despite the presence of a nylon thread for easy retrieval and partial debridement of the granulation, removal of the implanted EWS in the right B1 and B3 using grasping forceps, basket forceps, and two types of balloons under fluoroscopic guidance was challenging. NBCA spraying is a possible cause of foreign body granuloma formation. Therefore, careful consideration of the indications for the combined EWS‐NBCA procedure is necessary.

Histopathological changes to the vascular wall after treatment of great saphenous veins using n-butyl-2-cyanoacrylate

Summary. Background: A histopathological examination was conducted on vein samples from six patients who had undergone great saphenous vein sealing with Histoacryl and Lipiodol to treat chronic venous insufficiency of the superficial venous system. Patients and methods: In each patient a sample of the complete vein including the surrounding tissue was obtained through a minor incision under perioperative sonographic monitoring. Each patient had signed an informed consent form. Samples were taken at the following intervals: six days, six weeks, six months, one year, two years, and three years after treatment. Results: N-butyl-2-cyanoacrylate with Lipiodol induces a thrombotic reaction in the acute phase and endothelium is destroyed but no significant inflammation or substantial vascular wall damage is present. In the subsequent period, a foreign body giant cell reaction emerges accompanied by only moderate chronic inflammation that does not extend to the vascular wall or the surrounding tissue. The thrombus is organized with minimal recanalization. The foreign material is gradually degraded, and it is no longer detectable after three years. The vessel wall showed slight sclerotization. Conclusions: N-butyl-2-cyanoacrylate that has been applied gradually degrades over the course of three years accompanied by a giant cell reaction, mild chronic inflammation and cicatrices, but there is minimal recanalization of the obturated section.

Embolization of palpebral and orbito-frontal fistulas: technical and anatomical considerations in treating high-flow superficial skin lesions with liquid embolics

The treatment of palpebral and periorbital fistulas may be challenging due to the presence of multiple anastomosis with eloquent ophthalmic and intracranial vascular territories. Moreover, cosmetic and functional characteristics of this area pose unique challenges to open surgical approaches and endovascular therapy. We review the advantages and disadvantages of different liquid embolics in treating palpebral and periorbital fistulas as we describe three successfully treated cases. Moreover, we describe important anatomical landmarks that should be considered at the time of treatment of these lesions.

Cyanoacrylate Associated Foreign Body Granulomatous Gastritis: A Report of Three Cases

Granulomas are rarely seen in gastric biopsies mostly as an involvement of granulomatous diseases like sarcoidosis, Crohn's disease, infections, neoplasms, and vasculitis. Here, we claim cyanoacrylate as a foreign body type granuloma-causing agent in the stomach after vascular embolisation. We present cyanoacrylate associated gastric changes of three cases: two endoscopic biopsies and one gastric resection. In two cases, cyanoacrylate associated ulcers and granulomatous inflammation were observed in gastric mucosal biopsies following endoscopic examination after 7 months and 6 years of the glue injections, respectively. In the third case, the cyanoacrylate injection was performed 2 months prior to the surgery. Then the patient underwent distal pancreatectomy for pancreatic adenocarcinoma and during the operation a gastric mass was resected with a suspicion of tumoral infiltration. These three cases demonstrated that glue exposure causes active chronic inflammation with foreign body type granulomas, mucosal ulceration, and bleeding in the gastric mucosa. Even further, it can induce mass formation in the injection sites.

Is It Possible to Eliminate Sutures in Open (Lichtenstein Technique) and Laparoscopic (Totally Extraperitoneal Endoscopic) Inguinal Hernia Repair? A Randomized Controlled Trial With Tissue Adhesive (n-Hexyl-α-Cyanoacrylate)

Background. The morbidity linked to the use of sutures in inguinal hernioplasty is well known. Tissue adhesives may be an alternative, so as to be able to improve levels of postoperative comfort, but clinical experience using them is limited. The aim of this study is to evaluate the efficiency of cyanoacrylate as a substitute for sutures in the treatment of inguinal hernias. Patients. Randomized clinical trial in abdominal wall unit. A total of 208 patients were operated upon for inguinal hernias of which 102 were unilateral hernias via open surgery using the Lichtenstein technique, randomized to receive prolene sutures (n = 52) or n-hexyl-α-cyanoacrylate glue (n = 50) and 106 were patients with bilateral inguinal hernias operated upon via totally extraperitoneal laparoscopy and randomized to receive either tackers (n = 54) or glue (n = 52). Main Outcome Measures. The primary endpoints were pain and recurrence. Secondary endpoints were operating time, postoperative morbidity, pain, and analgesic consumption. Results. No morbidity associated with the use of the glue existed. The use of glue significantly reduced the mean of surgical time (12 minutes in open surgery, 13 minutes in laparoscopic surgery), pain, and analgesics consumption, both via the open and laparoscopic approaches ( P < .001). After 1 year the adhesive did not change the recurrence rate in either of the approaches. The economic analysis shows potential yearly savings of 123 916.3 Euros. Conclusions. Substituting sutures with glue ( n-hexyl-α-cyanoacrylate) in open or laparoscopic inguinal hernioplasty is safe with less postoperative pain and the same possibilities of recurrence.

Combined radiological intervention and surgical excision of a periorbital arteriovenous fistula

OBJECTIVE

To describe a case of periorbital arteriovenous fistula (AVF) treated with a combined approach of endovascular intervention and surgical excision.

CASE REPORT

A 21-year-old lady presented with a vascular lump followed blunt trauma above the left medial brow area. Computed Tomography Angiogram (CTA) and Angiography of the internal and external carotid arteries showed presence of an AVF with main feeder vessel from a hypoplastic left ophthalmic artery. Pre-operative radiological embolization was performed but the patient defaulted planned surgery. She returned 4 months later complaining of pain and increased swelling of the lesion. Repeat CTA demonstrated residual shunt located below the supra-orbital rim medially supplied by the left supratrochlear artery. Excision was later performed without repeat embolization and was uncomplicated. Histological reported chronic inflammation with granulomatous foreign body giant cell reaction confirming pre-operative diagnosis of tissue reaction to glue cast.

CONCLUSION

Treatments of Orbital AVFs are challenging and require multidisciplinary team management involving interventional radiologists and orbital surgeons. A foreign body reaction can develop followed embolization with tissue glue alone. Prompt surgical excision is therefore recommended to minimize post operation morbidity.

Transcatheter arterial embolization of acute arterial bleeding in the upper and lower gastrointestinal tract with N-butyl-2-cyanoacrylate

PURPOSE

To assess the clinical utility and safety of transcatheter arterial embolization with N-butyl-2-cyanoacrylate (NBCA) for urgent control of acute arterial bleeding in the upper and lower gastrointestinal tract.

MATERIALS AND METHODS

Therapeutic NBCA embolization was performed in 37 patients (39 cases; mean age, 67.8 years) with acute upper (n = 16) or lower (n = 23) gastrointestinal tract bleeding after endoscopic management had failed. Transcatheter arterial embolization was performed using 1:1 to 1:5 mixtures of NBCA and iodized oil. The most common etiologies of bleeding were colonic diverticulosis (n = 13), malignancy (n = 11), and benign ulcer (n = 7). Coagulopathy was present in 11 patients, and 23 patients were hemodynamically unstable before NBCA embolization. Histologic examination for bowel ischemia was also performed in five patients who underwent excision of the lesion after NBCA embolization.

RESULTS

The technical success rate was 100%. Recurrent bleeding occurred in two patients. Complete hemostasis was achieved in all 11 patients with coagulopathy. Ulcers induced by transcatheter arterial embolization were noted in 6 of 20 patients who underwent endoscopic examination; the ulcers were successfully treated with conservative measures. Histologic examination revealed that despite inflammatory reactions in and around the vessels, no intestinal necrosis secondary to NBCA embolization was found. Hepatic abscess occurred in two cases, and ischemia of the lower limb occurred in one case; these complications were managed by percutaneous drainage and bypass surgery.

CONCLUSIONS

Transcatheter arterial embolization with NBCA is a good treatment option with a high rate of complete hemostasis and a low recurrent bleeding rate, even in patients with coagulopathy.

Single-Stage Excision of Localized Head and Neck Venous Malformations Using Preoperative Glue Embolization

Objective

Describe single-stage removal of head and neck venous malformations using percutaneous embolization with n–butyl cyanoacrylate ( n-BCA) glue prior to surgical resection.

Study Design

Case series with chart review.

Setting

Tertiary-care pediatric hospital.

Subjects and Results

A total of 169 venous malformations were identified between 2000 and 2012, and 102 (60.1%) were in the head and neck. Thirty-five of 102 (34.3%) were observed, 56 of 102 (54.9%) had invasive therapy, and 11 of 102 (10.8%) underwent n-BCA embolization and surgery (“GES procedure”). The median age of the glue embolization and surgery cohort was 14 years (range, 6-19), and 7 of 11 (63.6%) were female. Treated venous malformations involved the oral cavity/tongue (4/11; 36.4%) and parotid/face (7/11; 63.6%). During facial lesion excision, intraoperative facial nerve monitoring was used. All surgical sites (11/11) were closed primarily. No patient in this cohort had any posttreatment nerve deficits, dysarthria, and dysphagia or lesion persistence.

Conclusions

Localized venous malformations can be treated with preoperative percutaneous embolization with n-BCA glue followed by surgical excision. This technique, with selective motor nerve monitoring, appears safe and allows for complete venous malformation removal with limited nerve dissection, to allow maximal tissue and functional preservation.

Use of three-dimensional MRI-angiography in preoperative evaluation and postoperative management of hemangiomas of head and neck region

Hemangiomas (proliferating endothelial tumors) are the most common benign tumors of infancy. Most often hemangiomas are self-regressing lesions without any treatment. Approximately 10% of hemangiomas cause complications such as major ulceration/destruction, distortion of involved tissues, and obstruction of a vital structure. When the situation becomes complicated, there are different treatment alternatives, ranging from systemic or local corticosteroid use to surgery. Sclerotherapy using intralesional polidocanol (Aethoxysklerol) injection may be used before surgery to decrease blood loss or when a vital structure of the face is in danger because of sudden increase in size of a surrounding hemangioma. Before any kind of treatment for both hemangiomas and vascular malformations, preoperative diagnosis and anatomic position of the lesion must be documented thoroughly. With the help of magnetic resonance imaging, tridimensional vascular pattern of such lesions can be shown successfully. We used three-dimensional contrast-enhanced time-resolved magnetic resonance angiography to detect the changes of lesions for 2 children who have large hemangiomas on their faces, before and after sclerotherapy with polidocanol injection. The findings of three-dimensional magnetic resonance imaging studies help to better assess the success rate of treatment not only for us as the physicians but also for the parents of these children who cannot understand anything with standard two-dimensional radiologic imaging.

Current treatment of parotid hemangiomas

OBJECTIVES/HYPOTHESIS

Parotid hemangiomas are the most common salivary gland tumors in children. Their treatment has posed a challenge because of the lesions' expansive growth, resistance to treatment, and relationship with the facial nerve. Various treatment modalities have been attempted, and promising results have been achieved with surgical resection alone or in conjunction with endovascular sclerotherapy. Recently, bleomycin and oral propranolol have been introduced, and the results thus far are promising. Here we elucidate the treatment options and propose a treatment algorithm for parotid hemangiomas.

STUDY DESIGN

Retrospective chart review.

METHODS

We conducted a retrospective chart review of patients from 2004 to 2009 with hemangiomas involving the parotid gland. We included 56 patients and relevant parameters.

RESULTS

Seventy percent of patients were female. The female-to-male ratio was 2.3 to 1. Thirty-nine percent had unilateral parotid hemangiomas, 12.5% had cutaneous segmental hemangiomas. All 22 patients who underwent systemic steroid therapy responded initially, but 68% of these rebounded after cessation of therapy. Sixteen patients (29%) underwent surgery with excellent results (facial symmetry, restoration of contour, preserved facial nerve function). Seven (44%) patients received sclerotherapy 24 to 48 hours before surgery, and five (8%) received endovascular sclerotherapy alone. Ten patients were treated medically with oral propranolol. Eight of 10 had significant shrinkage of the lesion within the first month of treatment. There were no reported side effects.

CONCLUSIONS

Multiple treatment regimens have been used to successfully treat parotid hemangiomas. Although propranolol is a recent addition, it seems most promising. Further evaluation is warranted.

Ischemic effects of transcatheter arterial embolization with N-butyl cyanoacrylate-lipiodol on the colon in a Swine model

This study was designed to assess the safety of transcatheter arterial embolization (TAE) with n-butyl cyanoacrylate-lipiodol (NBCA-Lp) for the large bowel and to investigate the vital response to NBCA-Lp in a swine model. In nine swine, nine arteries nourishing the colon were embolized with NBCA-Lp (1 ml of NBCA mixed with 4 ml of lipiodol): sigmoid-rectal branch artery in six swine, right colic branch artery in two, and middle colic branch artery in one. The amount of NBCA-Lp was 0.1-0.4 ml. Sacrifice was conducted 3 days after TAE to identify histological infarction. Classification was conducted retrospectively: group A, vasa recta without NBCA-Lp embolization despite TAE; group B, three or fewer vasa recta with NBCA-Lp embolization; and group C, five or more vasa recta with NBCA-Lp embolization. In one swine in group A, no necrotic focus was observed. In group B, three of four swine experienced no ischemic damage. The remaining one swine experienced necrosis of mucosal and submucosal layers in one-fourth of the circumference. In group C, all four swine with marginal artery and five vasa recta or more embolized experienced total necrosis of mucosa, submucosa, and smooth muscle layers of the whole colonic circumference. Significant difference on the extent of ischemic damage was observed between groups B and C (P < 0.05). Microscopically, NBCA-Lp induced acute vasculitis. Embolization of three or fewer vasa recta with NBCA-Lp induced no ischemic damage or limited necrosis, whereas embolization of five or more vasa recta with NBCA-Lp induced extensive necrosis.

Initial experience using N-butyl cyanoacrylate for embolization of lower gastrointestinal hemorrhage

PURPOSE

To report initial experience using N-butyl cyanoacrylate (n-BCA) to control lower gastrointestinal hemorrhage (LGIH).

MATERIALS AND METHODS

From May 2005 to March 2009, 14 patients with LGIH underwent mesenteric angiography and transcatheter arterial embolization using n-BCA. Candidacy was primarily based on the patient's hemodynamic stability and the risk for future LGIH, determined by the presence of at least one of the following risk factors: more than one arterial feeder supplying the bleeding vessel, underlying coagulopathy, or need to resume anticoagulation after embolization. Outcome measures included technical success (immediate postembolic hemostasis confirmed with completion angiography showing no further extravasation of contrast medium), clinical success (postembolic hemostasis in the absence of complications 30 days after the procedure), and clinical failure (recurrence of LGIH necessitating repeat embolization or surgical treatment).

RESULTS

Fourteen patients with active LGIH were treated with n-BCA, with 100% technical success. Two patients had rebleeds resulting in bowel resection. One patient experienced a minor rebleed that spontaneously resolved. One patient died secondary to multiorgan failure in the setting of multiple medical problems. The remaining 10 patients had complete clinical success, experiencing no signs of rebleeding or infarction.

CONCLUSIONS

The results suggest that n-BCA can be a useful alternative embolic agent for the treatment of hemodynamically unstable patients with LGIH when standard microcoiling techniques fail or are not feasible and in patients with coagulopathy.

Embolization of cyanoacrylate glue in systemic circulation in a case of hepatocellular carcinoma: an autopsy report

We report a case of embolism of the sclerosant dye with subsequent formation of foreign-body giant cell reaction within the veins of pulmonary and portal circulation in an autopsy case of hepatocellular carcinoma developing over an underlying primary biliary cirrhosis.

Volumetric assessment of results of treatment of vascular malformations of the head and neck regions treated with a minimally invasive surgical technique after embolization procedure

Treatment of large soft tissue vascular lesions, one of the greatest challenges facing plastic surgeons, is patient specific in almost all cases, and preoperative angiographic evaluation and embolization of these lesions are standards of care. The aim of this study was to evaluate the usefulness of 3-dimensional demonstration and volumetric assessment of soft tissue vascular lesions both in the treatment of these lesions with curettage and in the participation of the patients to the decision-making process of the disease. Five patients with vascular malformation of the head and neck regions were included to this prospective trial. All patients were evaluated with preoperative angiography, and selective embolizations of the soft tissue vascular lesions were done in the same session by the same interventional radiologists. The amount of embolic agent injected was determined according to the size and vascularization of the lesions. Surgery was done by curettage of the embolized lesions 7 to 10 days after the embolization procedure. The raw data obtained from preoperative and postoperative high-resolution computed tomographic scans of the patients were processed with a Mimics 9.22 Software (Materialise's Interactive Medical Image Control System, Leuven, Belgium). Volume and surface area of the injected embolic agent were assessed. Statistical analysis was performed using the software package SPSS 10.0 for Windows (SPSS Inc, Chicago, IL). Wilcoxon signed rank test was used to compare the measurements of the volume and the surface area of injected sclerosing agent preoperatively and postoperatively. There were no complications related to either the preoperative angiography or embolization procedure. All the patients emphasized (assessed) that the 3-dimensional demonstration of the lesions and their relation with other anatomic structures helped them to understand the extent of their pathology and aim of the proposed treatment. The difference between the volumetric measurements before and after the treatment was found statistically significant. Treatment of large soft tissue vascular lesions with curettage after embolization has acceptable cosmetic results. Although it is not possible to remove all of the sclerosing agent from its injection site with this technique, a significant amount of it can be removed, and the 3-dimensional vascular architecture of the lesion is disturbed. Reactive chronic inflammation against the remaining sclerosing agent and the intralesional scarring caused by curettage lead to further improvement. Using 3-dimensional imaging modalities helps patients and/or their relatives to understand their disease and participate in the decision-making process.

Recanalization of splenic artery aneurysm after transcatheter arterial embolization using N-butyl cyanoacrylate

A 65-year-old woman who had been diagnosed as having microscopic polyangiitis developed sudden abdominal pain and entered a state of shock. Abdominal CT showed massive hemoperitoneum, and emergent angiography revealed a ruptured splenic artery aneurysm. After direct catheterization attempts failed due to tortuous vessels and angiospasm, transcatheter arterial embolization using an n-butyl cyanoacrylate (NBCA)-lipiodol mixture was successfully performed. Fifty days later, the patient developed sudden abdominal pain again. Repeated angiography demonstrated recanalization of the splenic artery and splenic artery aneurysm. This time, the recanalized aneurysm was embolized using metallic coils with the isolation method. Physicians should keep in mind that recanalization can occur after transcatheter arterial embolization using N-butyl cyanoacrylate, which has been used as a permanent embolic agent.

Acute lymphoblastic leukemia in a patient with chronic cyanoacrylate exposure

Environmental agents have long been thought to be linked to the development of malignancies. Due to the difficulty in identifying and verifying exposures to such agents, only a few chemical compounds are clearly linked to malignancies. We report here the case of a 36-year-old man with pre-B cell acute lymphoblastic leukemia. This patient was using industrial strength glue to reattach a chipped tooth for approximately 1 year, and such use was associated with chronic exposure of his oral mucosa to this glue. This case raises the possibility that chronic exposure to cyanoacrylates, the adhesive agents in industrial strength glue, may be associated with the development of acute lymphoblastic leukemia in humans.

Histopathological study of vascular changes after intra-arterial and intravenous injection of N-butyl-2-cyanoacrylate

OBJECTIVE

To assess the histopathological vascular changes after injection of N-butyl-2-cyanoacrylate into the vessels of adult rabbits.

METHODS

The animals used were 42 pure-blood New Zealand white rabbits weighing 2-3 kg. 0.2 mL cyanoacrylate with lipiodol was injected into the external jugular vein and femoral artery of each rabbit. Tissue specimens were obtained for histopathological study at 3 days, 7 days, 2 weeks, 3 weeks, 4 weeks, 2 months and 3 months after injection.

RESULTS

The vessels were obliterated immediately after the injection. The main manifestation of histopathology at 3 days to 2 weeks was an acute inflammatory reaction; this progressed to subacute vasculitis at 3 weeks and a chronic granulomatous foreign body reaction developed at 4 weeks. The glue mass essentially disappeared in 2-3 months, replaced by fibrotic tissue with partial vascular recanalization. At 3 weeks after injection, the elastic fibrils of the arterial wall proliferated distinctly, resulting in narrowing of the lumen with subsequent obliteration, whereas the venous wall still showed inflammation and necrosis without hyperplasia of elastic fibrils. Extrusion of glue was observed over 1-3 months in both arteries and veins and was obvious in the latter.

CONCLUSIONS

The histopathological changes after injection of N-butyl-2-cyanoacrylate were similar in the arteries and the veins with the exception of hyperplasia of elastic fibrils in the arterial wall and inflammation and necrosis in the venous wall at 2-3 weeks. Glue extrusion was seen in both arteries and veins.

Fiducial markers for MR histological correlation in ex vivo or short-term in vivo animal experiments: a screening study

PURPOSE

To test injectable fiducial markers for magnetic resonance (MR) histological correlation in ex vivo or in vivo animal experiments.

MATERIALS AND METHODS

A total of 35 potential markers were tested ex vivo in pork muscle. The end-points were: 1) visibility, size, and shape on MR images and at macroscopic examination; 2) 24-hour stability; and 3) microscopic appearance. Selected markers were injected in vivo (rabbit's muscle and breast tumor tissue) to test their three-hour in vivo stability and their potential toxicity. Finally, different dilutions of the two best markers were assessed again through the same screening tests to determine whether their size on MR images could be customized by dilution.

RESULTS

Two fluid acrylic paints containing inorganic pigments were found to be potentially interesting markers. On MR images, they created well-defined susceptibility artifacts. The markers made with iridescent bronze paint (iron oxide coated mica particles) were readily visible on microscopy and their size on MR images could be customized by dilution. The iridescent stainless steel paint (iron, chromium, nickel) created ex vivo the smallest markers in tissue but needed colloidal iron staining to be visible on microscopy and could not be easily diluted.

CONCLUSION

Fluid acrylic paints are potentially interesting markers for MR histological correlation. Further studies are needed to assess their long-term properties.