Cyanoacrylate glue embolisation for varicose veins - A novel complication

899 serious adverse events including 13 deaths, 7 strokes, 211 thromboembolic events, and 482 immune reactions: The untold story of cyanoacrylate adhesive closure

OBJECTIVE

The aim was to retrieve and analyse the serious adverse events of venous occlusion systems used in cyanoacrylate adhesive closure (CAC) submitted to regulatory agencies.

METHODS

The Total Product Life Cycle (TPLC) database of the US Food and Drug Administration (FDA), the Database of Adverse Event Notifications (DAEN) of the Australian Therapeutic Goods Administration (TGA), and the Yellow Card database of the UK Medicines and Healthcare Products Regulatory Agency (MHRA) were reviewed. Three Freedom of Information (FOI) requests had to be submitted to the MHRA to obtain data.

RESULTS

The TPLC contained 899 reports which included 13 cases of death, 7 strokes, 211 thromboembolic events, and 482 immune reactions. The DAEN recorded three reportable adverse events, and the MHRA recorded seven adverse incidents including one death.

CONCLUSION

CAC is associated with serious adverse events including death. These events are under-reported in the medical literature and only sub-optimally reported to the regulatory agencies.

Complications of cyanoacrylate adhesive closure therapy in chronic venous insufficiency: A single center, single-surgeon study

OBJECTIVES

In this study, we present the complication data of patients we treated for chronic venous insufficiency (CVI) with cyanoacrylate adhesive closure (CAC) therapy for 2 years.

METHODS

Complications of 382 CAC procedures performed by the same surgeon were reviewed retrospectively.

RESULTS

Independent of patients, depending on the payment system of the state; two hundred twenty-three (58.4%) of 382 procedures were performed using the Venex system, and the Variclose system was used in 159 (41.6%) patients. A phlebitis-like reaction occurred in 46 (12%) patients, induration in 18 (4.7%) patients, hyperpigmentation in five (1.3%) patients, abscesses in four (1%) patients, cellulitis in three (0.8%) patients, and granuloma in one (0.3%) patient. In addition, as serious complications, deep vein thrombosis (DVT) developed in three patients and pulmonary embolism in one of these patients. Interestingly, temporary blindness was also observed in one patient.

CONCLUSIONS

Although CAC therapy is a reliable method, its complications should not be ignored. Its use by experienced surgeons reduces the risk of complications.

Incidence and Clinical Impact of Endovenous Glue-Induced Hypersensitivity Among Patients Who Underwent Endovenous Cyanoacrylate Ablation Procedures: A Registry-Based Cohort Study

BACKGROUND

The characteristics of endovenous glue-induced hypersensitivity (EGIH) remain unclear.

OBJECTIVE

To assess the clinical impacts on patients with EGIH after endovenous cyanoacrylate-glue ablation (CA).

MATERIALS AND METHODS

A prospectively designed endovenous CA-specific registry was created, and a total of 335 limbs from 173 patients who underwent endovenous CA were enrolled for a cohort study.

RESULTS

Symptomatic EGIH was observed in 55 (31.8%) patients. Beyond the target vein area, systemic side effects were noted in 5.8% of the treated patients after CA. The median onset time was 13 postoperative days (range: 1-35 days). The median duration was 7 days, but about 10.9% of the affected patients experienced symptoms lasting longer than 4 weeks. In the EGIH and non-EGIH groups, significant improvements in venous clinical severity score and Chronic Venous Insufficiency Quality of Life Questionnaire-14 scores were observed 3 months postoperatively. The development of EGIH did not affect the postoperative patient-reported satisfaction scores ( p = .524).

CONCLUSION

EGIH is observed in a substantial proportion of patients. The side effects do not affect the clinical outcomes and patient-reported outcome measures. Further studies are required on the detailed pathogenesis and definition of EGIH.

Cyanoacrylate glue reactions: A systematic review, cases, and proposed mechanisms

OBJECTIVE

Cyanoacrylate glue closure was first used in humans 10 years ago to treat venous reflux of the axial veins. Studies have since shown its clinical efficacy in vein closure. However, great need exists to elucidate further the types of specific adverse reactions that cyanoacrylate glue can cause for better patient selection and to minimize these events. In the present study, we systematically reviewed the literature to identify the types of reported reactions. In addition, we explored the pathophysiology contributing to these reactions and proposed the mechanistic pathway with inclusion of actual cases.

METHODS

We searched the literature for reports of reactions following cyanoacrylate glue use in patients with venous diseases between 2012 and 2022. The search was performed using MeSH (medical subject headings) terms. The terms included cyanoacrylate, venous insufficiency, chronic venous disorder, varicose veins, vein varicosities, venous ulcer, venous wound, CEAP (clinical, etiologic, anatomic, pathophysiologic), vein, adverse events, phlebitis, hypersensitivity, foreign body granuloma, giant cell, endovenous glue-induced thrombosis, and allergy. The search was limited to the literature reported in English. These studies were evaluated for the type of product used and the reactions noted. A systematic review, in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) method, was performed. Covidence software (Melbourne, VC, Australia) was used for full-text screening and data extraction. Two reviewers reviewed the data, and the content expert served as the tiebreaker.

RESULTS

We identified 102, of which, 37 reported on cyanoacrylate use other than in the context of chronic venous diseases and were excluded. Fifty-five reports were determined appropriate for data extraction. The adverse reactions to cyanoacrylate glue were phlebitis, hypersensitivity, foreign body granuloma, and endovenous glue-induced thrombosis.

CONCLUSIONS

Although cyanoacrylate glue closure for venous reflux is generally a safe and clinically effective treatment choice for patients with symptomatic chronic venous disease and axial reflux, some adverse events could be specific to the properties of the cyanoacrylate product. We propose mechanisms for how such reactions can occur based on histologic changes, published reports, and case examples; however, further exploration is necessary to confirm these theories.

Efficiency of endovenous laser and glue ablation methods in comparison with conventional surgery for the treatment of venous ulcers

Introduction

In this study, we aimed to investigate the efficiency of endovenous laser and glue ablation techniques and compared the results with conventional surgical stripping.

Patients and Methods

Between January 2005 and January 2020, among 3133 consecutive patients with superficial venous reflux disease receiving treatment at our institution, there were 112 consecutive patients with active venous ulcers. Patients were divided into 3 groups as receiving conventional open surgical treatment (Group 1, n: 70), endovenous glue ablation (Group 2, n: 20), and endovenous laser ablation (Group 3, n: 22). Comorbidity factors, duration and size of the ulcers, deep, perforating, and small saphenous vein disease detected with detailed Doppler ultrasonography, and duration for healing and recurrence were investigated.

Results

The age, gender, comorbidities, smoking, history of previous treatment, diameter of the small saphenous vein, number of refluxing perforating veins, size of the ulcer, and ulcer recurrence ratio were not significantly different between groups. There were 7 patients with bilateral disease and in total 119 legs were intervened. Mean durations for complete ulcer healing were significantly lower in Group 1 (53.28 ± 22.1 days) than Group 2 (73.7 ± 39.6 days); however, it did not differ significantly between Group 1 and Group 3 (62.59 ± 19.65 days), and Group 2 and Group 3 ( p: 0.26). Ulcers recurred in 23 patients (33%) in stripping group at a mean follow up of 14.42 ± 4.6 months, in 7 patients (35%) in glue ablation group at a mean follow up of 11.97 ± 2.94 months, and in 5 patients (23%) in laser ablation group at a mean follow up of 12.66 ± 3.48 months ( p > 0.05 for all). Increased body mass index, co-existence of chronic venous insufficiency, active cigarette smoking, non-compliance with physician advises and exercise and compression stockings, and depth of the ulcers were correlated with recurrence.

Conclusion

The rationelle beyond treatment of the venous ulcers and prevention of recurrence relies on relief of the venous hypertension by interventional methods and/or compression therapy. None of the methods is superior over the others. Healing in short term without further recurrence may be achieved with successful intervention as well as good patient compliance.

Strategies and challenges in treatment of varicose veins and venous insufficiency

Patients with varicose veins can be treated with conservative or surgical approaches based on the clinical conditions and patient preferences. In the recent decade, the recommendations for managing symptomatic varicose veins have changed dramatically due to the rise of minimally invasive endovascular techniques. The literature was systematically searched on Medline without language restrictions. All papers on the treatment of varicose veins and venous insufficiency with different procedures were included and reviewed. Endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) both are same safe and effective in terms of occlusion rate, and time to return to normal activity. In comparison with RFA or EVLT, Cure conservatrice et Hemodynamique de l'Insufficience Veineuse en Ambulatoire (CHIVA) may cause more bruising and make little or no difference to rates of limb infection, superficial vein thrombosis, nerve injury, or hematoma. In terms of recurrence of varicose veins, there is little or no difference between CHIVA and stripping, RFA, or EVLT. Great saphenous vein recanalization is highest in the ultrasound-guided foam sclerotherapy (FS) group (51%) during 1 year of follow-up. The 2013 National Institute for Health and Care Excellence clinical guidelines recommend surgery as a third-line therapeutic option after EVLA or RFA and sclerotherapy. Although the mechanochemical endovenous ablation (MOCA) is a non-thermal, non-tumescent option and appears to be of similar efficacy to stab avulsion with no potential risk of nerve damage, the overall success rate of MOCA is lower than those of other procedures such as EVLA, RFA, or high ligation and stripping. EVLA is the most cost-effective therapeutic option, with RFA being a close second for the treatment of patients with varicose veins. Endovenous thermal ablation (EVLA or RFA) is recommended as a first-line treatment for varicose veins and has substituted the high ligation of saphenofemoral junctional reflux and stripping of varicose veins. Ultrasound-guided FS is associated with a high recurrence rate and can be used in conjunction with other procedures. MOCA and cyanoacrylate embolization appear promising, but evidence of their effectiveness is required.

Current Best Practice in the Management of Varicose Veins

This article outlines the current best practice in the management of varicose veins. “Varicose veins” traditionally means bulging veins, usually seen on the legs, when standing. It is now a general term used to describe these bulging veins, and also underlying incompetent veins that reflux and cause the surface varicose veins. Importantly, “varicose veins” is often used for superficial venous reflux even in the absence of visible bulging veins. These can be simply called “hidden varicose veins”. Varicose veins usually deteriorate, progressing to discomfort, swollen ankles, skin damage, leg ulcers, superficial venous thrombosis and venous bleeds. Patients with varicose veins and symptoms or signs have a significant advantage in having treatment over conservative treatment with compression stockings or venotropic drugs. Small varicose veins or telangiectasia without symptoms or signs can be treated for cosmetic reasons. However, most have underlying venous reflux from saphenous, perforator or local “feeding veins” and so investigation with venous duplex should be mandatory before treatment. Best practice for investigating leg varicose veins is venous duplex ultrasound in the erect position, performed by a specialist trained in ultrasonography optimally not the doctor who performs the treatment. Pelvic vein reflux is best investigated with transvaginal duplex ultrasound (TVS), performed using the Holdstock-Harrison protocol. In men or women unable to have TVS, venography or cross-sectional imaging is needed. Best practice for treating truncal vein incompetence is endovenous thermal ablation. Increasing evidence suggests that significant incompetent perforating veins should be found and treated by thermal ablation using the transluminal occlusion of perforator (TRLOP) approach, and that incompetent pelvic veins refluxing into symptomatic varicose veins in the genital region or leg should be treated by coil embolisation. Bulging varicosities should be treated by phlebectomy at the time of truncal vein ablation. Monitoring and reporting outcomes is essential for doctors and patients; hence, participation in a venous registry should probably be mandatory.

Successful Postoperative Nephrocutaneous Fistula Treatment With Omental Flap Grafting: A Case Report

Nephrocutaneous fistula (NCF) is a rare and severe complication of renal disease and surgical procedures. Treatments for NCF are based on the renal function, and can include nephrectomy, heminephrectomy, nephroureterectomy, endourological maneuvers or antibiotic therapy alone. Here we report a case of a chronic NCF which occurred 5 years after partial nephrectomy. In this report, we describe a new surgical approach for the management of a patient with postoperative NCF. In the present case, in addition to removing the fistulous tract, we also performed an omental flap grafting to tightly cover the kidney. In addition to limiting and controlling the local inflammation, the omental flap prevents contact between the kidney and the flank muscle on its posterior rim. No recurrence or complications occurred throughout 10 months of follow-up. The NCF was successfully treated with completely removal of the sinus tract and omental flap grafting, without nephrectomy. This case adds new aspects to the treatment of NCF.

Varicose Veins and Chronic Venous Disease

Chronic venous disease is a worldwide problem associated with significant morbidity and is expected to increase in prevalence as the current population ages. This is a comprehensive review of the anatomy, pathophysiology, genomics, clinical classification, and treatment modalities of chronic venous disease.

Cyanoacrylate Granuloma After Cyanoacrylate Closure of Incompetent Saphenous Veins

BACKGROUND

Cyanoacrylate closure (CAC) is a minimally invasive surgery to treat incompetent saphenous veins.

OBJECTIVE

To evaluate the incidence, the risk factors for, and the management of cyanoacrylate granuloma (CAG) after CAC of incompetent saphenous veins in patients with chronic venous disease.

MATERIALS AND METHODS

Data specific to incompetent saphenous veins, including great saphenous veins, anterior accessory saphenous veins, and small saphenous veins, that were treated with CAC were retrospectively evaluated.

RESULTS

A total of 126 saphenous veins from 101 patients were included. Recapture of the delivery catheter before withdrawal was not performed in all patients. Cyanoacrylate granuloma occurred in 3 of 101 (2.9%) patients, and in 3 of 126 (2.3%) treated saphenous veins. All patients with CAG presented with granuloma and abscess at the puncture site 3 to 5 months after CAC. All patients were treated with incision, drainage, and removal of the glue foreign body. No recurrent granuloma was observed during the study period. No patient or procedural predictive factor for CAG was identified.

CONCLUSION

Cyanoacrylate granuloma is not a rare complication after CAC when recapture of the delivery catheter is not performed. Patients should be advised of the possibility of CAG after CAC.

Comparative analysis of the results of cyanoacrylate ablation and radiofrequency ablation in the treatment of venous insufficiency

BACKGROUND

Varicose vein treatment has shifted to less invasive techniques owing to the complications associated with traditional treatment. The present study was designed to compare the effectiveness of cyanoacrylate ablation (CAA) with radiofrequency ablation (RFA).

METHODS

Patients who had undergone RFA vs CAA (634 vs 246 patients) to treat great saphenous vein (GSV) insufficiency during a 5-year period were included in the present study. The preoperative and postoperative CEAP (clinical, etiologic, anatomic, pathophysiologic) class, symptoms, recurrence, and Doppler ultrasound findings were compared.

RESULTS

All the veins in both groups were occluded at day 5. The 1-month closure rates were 97.3% and 98.7% for RFA and CAA, respectively. The overall postoperative closure rates at 5 years were 93.1% and 91.1% for RFA and CAA, respectively. The postoperative symptoms, CEAP class, and Doppler ultrasound findings were similar in both groups. The 5-year symptom-free survival rates were 73.5% and 72.0% in the RFA and CAA groups, respectively. The venous clinical severity scores had decreased from 5.9 ± 1.2 to 0.9 ± 0.8 and 5.8 ± 0.9 to 0.8 ± 0.6 in the RFA and CAA groups, respectively. The Aberdeen varicose vein questionnaire scores had decreased from 19.7 ± 5.5 to 4.8 ± 1.5 in the RFA group and from 18.9 ± 5.8 to 4.9 ± 1.4 in the CAA group.

CONCLUSIONS

CAA seems to be the ideal treatment for GSV insufficiency because it is suitable for most patients and is nonthermal and nontumescent, with satisfactory results comparable to those with RFA. Long-term outcomes and cost analyses from larger series are required to confirm our findings.

Symptom improvement after cyanoacrylate glue adhesion and endovenous laser ablation in low-grade CEAP clinical classes

OBJECTIVE

Low-grade primary superficial venous reflux (C₀ - C₃EpAsPr) is a common feature of chronic venous disease. However, the procedural efficacy focusing on symptom characteristics and improvement patterns in this population has not been fully explored.

METHODS

From 2018 to 2019, 325 limbs from 279 patients with C₀ - C₃EpAsPr (including 66.1% with C0-1) who underwent cyanoacrylate ablation (CA) with ultrasonography-guided foam sclerotherapy (UGFS) or endovenous laser ablation (EVLA) with UGFS were included in this study. Venous symptoms were classified into five categories: leg heaviness, calf cramping, itching sensation, pain, and numbness. A retrospective propensity score-matched analysis of a prospectively designed case report form (CRF) was performed to identify the improvement magnitude of each symptom. As secondary outcomes, postoperative changes in symptom severity (0 - 5 points), the Venous Reflux Originated Severity Score (VROSS), the Venous Clinical Severity Score (VCSS), and the ChronIc Venous Insufficiency Quality of Life Questionnaire (CIVIQ-14) were evaluated by performing a three-month postoperative data analysis.

RESULTS

After adjusting the data, 174 limbs (87 CA with UGFS and 87 EVLA with UGFS) were matched. Symptoms that showed the greatest improvement after treatment were night cramping (94.7%) and itching (93.8%), followed by heaviness (85.2%), numbness (77.8%), and pain (60.9%). All symptom improvement scores after each endovenous procedure showed similar patterns in both groups. Advantages of CA with UGFS over EVLA with UGFS were observed in procedure time (20.1± 10.6 min vs. 28.4± 10.9 min, p = .001) and perioperative visual analogue pain scores (2.99± 2.34 vs. 3.74 ± 2.49, p = .03). Compared to preoperative values, VROSS, VCSS, CIVIQ-14, and symptom severity scores were significantly improved in both groups (all p < .001). Improvements in all five symptoms (p = .085 to 1.0), VCSS (p = .435), CIVIQ-14 (p = .788) and satisfaction scores (p = .392) three months postoperatively were comparable between the two groups. There were two cases of endovenous glue-induced thrombosis and 24 (27.6%) cases of type IV hypersensitivity reactions in the CA group.

CONCLUSIONS

Minimally invasive endovenous surgery with CA and EVLA provides significant symptom improvement for patients with low-grade CEAP classes.

Registry to investigate the efficacy and safety of the VenaBlock© VeIn SEaling system for VaRicose veins in SingApore - Six months results of the RIVIERA trial

BACKGROUND

The Venablock^© Venous Closure System (Invamed, Ankara, Turkey) is a novel cyanoacrylate-based non-thermal non-tumescent embolization device to block refluxing truncal veins for chronic venous insufficiency and varicose veins. The aim was to prospectively evaluate the safety and 6 months efficacy of Venablock^© for the treatment of primary great saphenous vein (GSV) and small saphenous vein (SSV) incompetency in a multi-ethnic cohort from Singapore.

METHODS

This was a single arm, single investigator prospective study of 29 patients (39 limbs, 39 truncal veins) recruited over a 5-month period (August 2019 to February 2020), who were treated with the Venablock^© device at a tertiary vascular unit in Singapore. Patients with symptomatic varicose veins (C2-6) and had truncal reflux > 0.5 second on venous Duplex ultrasound were included. Follow-up occurred at 2 weeks, 3 and 6 months with dedicated quality of life questionnaires and a targeted Duplex ultrasound performed to check for continued venous occlusion.

RESULT

Mean age was 61.4 (±11.0) years and mean BMI was 26.2 (±5.7) kg/m². 11/29 (37.9%) were males. Most common CEAP class treated was 2 (12/29, 41.3%). Mean diameter of treated GSV was 5.7 (±2.0) mm, 4.8 (±1.7) mm and 4.2 (±1.3) mm for the proximal, mid and distal above knee segments respectively. Mean time from access puncture to sheath removal was 23.4 (±10.0) mins. Vein occlusion at 2 weeks, 3 and 6 months was 39/39 (100%), 39/39 (100%) and 36/37 (97.2%) respectively. 5/29 (17.2%) developed puncture site infections, of which 3/29 (7.7%) required formal surgical drainage. 3/29 (7.7%) developed phlebitis. At 6 months, revised Venous Clinical Severity Score improved from 5.2 (±3.5) to 2.1 (±2.9; p < .001); EuroQol-5 Dimension score, from 7.4 (±2.1) to 5.7 (±1.4; p < .001); Aberdeen Varicose Vein Questionnaire score, from 18.1 (±15.5) to 7.9 (±8.9; p = .007); and Chronic Venous Insufficiency Questionnaire, from 18.6 (±16.2) to 4.5 (±6.3; p < .001).

CONCLUSION

Venablock^© is a safe and efficacious option of treating truncal venous insufficiency in a multi-ethnic Asian cohort from Singapore in the short term. There is a significant improvement in QoL. Longer follow-up is required to assess the durability of this technique, in particular the higher puncture site infection rates observed compared to other glue-based therapies.

NTNT Methods – Efficacy and Safety Issue

The management of elimination of the pathological reflux in the saphenous vein has been developed recently by introducing the endovenous thermal techniques (EVTA), which have become the first line treatment. However, thermal techniques require tumescent infiltration, what may be the cause of discomfort. Furthermore, the use of EVTA has a potential risk of thermal damage of superficial nerves and requires to wear stocking after the procedure.

Non-thermal non-tumescent techniques (NTNT) were proposed as a valid, safe and effective alternative to EVTA with significant clinical improvement, high complete occlusion rate and high posttreatment patient satisfaction. The most common novel NTNT are catheter-directed cyanoacrylate adhesive closure (CAC) and mechanochemical ablation.

In the paper an overview of the currently available data regarding the NTNT efficacy and safety are presented.

Based on the literature, NTNT has a high efficacy, comparable with the EVTA techniques, with an acceptable risk increase. However further studies with long-term results are needed also with regard to safety aspects.