Embolisation of proximal anastomotic pseudoaneurysm developing after surgical repair of abdominal aortic aneurysm with a bifurcated graft with n-butyl cyanoacrylate

We report a 60-year-old man who after undergoing surgical repair of an abdominal aortic aneurysm with a bifurcated graft subsequently developed a proximal anastomotic pseudoaneurysm, which was successfully treated by embolisation with n-butyl cyanoacrylate.

Endoscopic repair of bronchial dehiscence after lung transplantation

We report a case of bronchial dehiscence after right single lung transplantation and describe a novel means of management: bronchoscopic closure of the defect with alpha-cyanoacrylate glue.

Bucrylate treatment of bleeding gastric varices: 12 years' experience

BACKGROUND AND STUDY AIMS

For several years now there has been an increasingly widespread use of a tissue adhesive in the treatment of bleeding gastric varices to achieve rapid, safe control of hemostasis and prevent rebleeding. In this study we report on our experience with the use of Bucrylate (Hystoacryl) for the treatment of gastric varices over a period of more than a decade.

PATIENTS AND METHODS

Since 1988, 174 cirrhotic patients with actively bleeding gastric varices have been admitted to our department, where they received emergency treatment with injections of Bucrylate. Any associated nonbleeding esophageal varices were subjected to traditional sclerotherapy in combination with the Bucrylate treatment. The gastric varices were subdivided into four distinct groups according to the method advocated by Sarin in 1989. The patients underwent weekly sclerotherapy sessions until their varices were eradicated, and the follow-up with a mean of 36 months (range 9-90 months) consisted of endoscopy at 3, 6, and 12 months during the first year and then yearly checks to confirm obliteration of the varices.

RESULTS

The hemostasis (97.1%), early rebleeding (15.5%), and hospital mortality (19.5%) rates of the patients with bleeding gastric varices, treated with the tissue adhesive, were very similar to those of patients treated for esophageal varices over the same period (98.1%, 13.0%, and 16.4%, respectively). The most frequent cause of death at 30 days was liver failure (76% of cases), followed by hemorrhagic shock (8.8%), and other less frequent causes. Sclerotherapy achieved obliteration rate for gastric varices (70-75%) similar to that for esophageal varices in those patients with portal hypertension due to intrahepatic block (alcoholic and posthepatitis cirrhosis), but a rate of only 32% in the group of patients with prehepatic block (splenoportomesenteric thrombosis), where surgery proved more effective (69%). The medium- and long-term survival rates depended on the stability of the patients' liver conditions, on rapid, effective control of variceal hemostasis, and on complete, lasting obliteration of the gastric varices.

CONCLUSIONS

The use of Bucrylate in emergency sclerotherapy achieved results in bleeding gastric varices on a par with those obtained in esophageal varices in cases of alcoholic and posthepatitis cirrhosis. The group of patients with portal hypertension due to prehepatic block (splenoportal thrombosis) showed no benefit from sclerotherapy in terms of obliteration of gastric varices, but benefited from elective surgery. The choice of the obliterating treatment indicated may be facilitated by classifying gastric varices into distinct groups on the basis of anatomicotopographic criteria.

Physico-chemical characterization of insulin-loaded poly(isobutylcyanoacrylate) nanocapsules obtained by interfacial polymerization

Insulin could be encapsulated very efficiently in oily containing poly(isobutylcyanoacrylate) nanocapsules obtained by interfacial polymerization. In addition, these nanocapsules showed unexpected biological activity after intragastric administration. The hypoglycemic effect was characterized by a lag time period of 2 days and a prolonged effect over a period of 20 days. To explain, the high encapsulation rate of insulin achieved in these nanocapsules and the biological effect, this work was focused on the characterization of the nanocapsules and on the study of the mechanism of nanocapsule formation. Results showed that insulin was found unmodified during the nanoencapsulation process. This was due to the large amount of ethanol used in the preparation of the nanocapsules that initiated the polymerization of isobutylcyanoacrylate preserving the peptide from a reaction with the monomer. Results also showed that insulin was located inside the core of the nanocapsules and not simply adsorbed onto their surface.

Haemoperitoneum due to spontaneous rupture of hepatic haemangiomatosis: treatment by superselective arterial embolization and partial hepatectomy

A case is reported of a 36-year-old woman with haemoperitoneum due to spontaneous rupture of hepatic haemangiomatosis. Computed tomography showed a subcapsular hepatic mass in the posterior segment of the right hemiliver (subsegment 7) containing a fluid-fluid level. Magnetic resonance imaging depicted a subcapsular hepatic mass displaying an internal fluid-fluid level suggestive of haematoma. Hepatic angiography showed an intense arterial blush in the area of the subsegment 7 and permitted a subsequent and temporarily effective superselective transcatheter embolization of the subsegmental arterial branch for subsegment 7. Because of a recurrence of intraperitoneal haemorrhage 15 days after the first embolization, a new selective hepatic artery embolization was performed. However, intraperitoneal haemorrhage recurred 10 days after the second embolization, and the patient underwent resection of the posterior segments of the right hemiliver (subsegments 6 and 7). This case suggests that superselective arterial embolization, when used alone, does not provide a permanent treatment of haemoperitoneum due to spontaneous rupture of hepatic haemangiomatosis. However, this technique seems to be useful in avoiding an emergency surgery, allowing a planned hepatic resection.

Symptomatic pulmonary complications from liquid acrylate embolization of brain arteriovenous malformations

PURPOSE

To describe symptomatic pulmonary emboli from brain arteriovenous malformation embolization with liquid acrylates and to analyze the reasons for these complications and describe preventive techniques.

METHODS

The clinical records of 182 patients embolized with acrylate glue since 1978 for treatment of brain AVMs were searched for evidence of symptomatic pulmonary complications. Originally iso-butyl-2-cyanoacrylate and more recently n-butyl-2-cyanoacrylate were used in all patients. Arteriovenous malformation morphology, amounts and techniques of glue injection, and clinical and radiologic investigations in the symptomatic patients were recorded.

RESULTS

Three patients had pulmonary symptoms within 48 hours of glue injection. One patient with a left frontal arteriovenous malformation had embolization with an isobutyl-2-cyanoacrylate/pantopaque/acetic acid mixture; severe pleuritic chest pain developed 2 days later. One patient with a left temporal and one with a left cerebellar arteriovenous malformation had embolization with n-butyl-2-cyanoacrylate/lipiodol mixtures; a cough, pleuritic chest pain, and bloody sputum developed in both within 24 hours. Two patients experienced a significant drop in PO2. No flow-arrest techniques were used for any of the injections in these three patients. All patients demonstrated significant changes on chest x-ray and CT chest examinations. All were treated conservatively and recovered spontaneously.

CONCLUSIONS

Symptomatic pulmonary complications can occur after acrylate glue injection, particularly when delivery systems without flow arrest are used in high-flow vascular brain lesions. Techniques using acetic acid to delay polymerization time and "sandwich" techniques in which glue is pushed with dextrose are also more susceptible to this complication.

A new technique for nonsurgical repair of peripheral pseudoaneurysm

Peripheral vascular lesions may be inaccessible to treatment using catheter techniques. Ultrasound imaging in combination with Doppler may identify such lesions and provide possibilities for image-guided compression, injection of embolizing material by direct puncture, or both.

[Complications of varicocele embolization: adhesion of the intravascular catheter during infusion of bucrylate]

The introduction of percutaneous occlusion techniques to manage a varicocele has made possible the control of the process with success rates similar to those obtained with conventional surgery. Its efficacy and minimal invasive nature, although not entirely risk-free, are responsible for its expansion. Contribution of one case of adhesion of the intravascular catheter to the underlying spermatic vein wall during infusion with isobutyl cyanoacrylate (bucrylate) as embolization material, an event which forced immediate surgical removal.

Scanning electron microscopic evaluation of the effects of intracameral injection of cyanoacrylate in the rabbit

We examined, using scanning electron microscopy, the effects of the injection of an isobutyl cyanoacrylate into the rabbit anterior chamber. Injection of the adhesive produced a rapidly polymerized mass that remained in the anterior chamber throughout the course of the study. Additionally, an active inflammatory response was noted in the anterior chamber, characterized by a progressively enlarging "cocoon" of fibrin and inflammatory cells surrounding the polymerized adhesive, as well as inflammatory cells in the trabecular meshwork. Following cyanoacrylate injection, the corneal endothelial cells were noted to be swollen for the first 14 days of the study.

Swan-Ganz catheter-induced rupture of the pulmonary artery: successful early management by transcatheter embolization

An 84-year-old patient with severe aortic valve stenosis suffered Swan-Ganz catheter-induced massive pulmonary hemorrhage. Immediate therapeutic embolism of the segmental artery by using a liquid, tissue-adhesive, occlusive agent (isobutyl-2-cyanoacrylate) controlled bleeding.

Embolization of cerebral arteriovenous malformations with bucrylate. Experience in a first series of 29 patients

The experience with embolization of intracerebral arteriovenous malformations (AVMs) with bucrylate (isobutyl-2-cyanoacrylate) in 29 patients is reported. In 9 cases (31%) less than 1/3 of the AVM nidus was occluded, in 12 (41%) 1/3 to 2/3, in 4 (14%) more than 2/3, and total occlusion was only seen in 3 cases (10%). One patient was never embolized, owing to procedure complications. At follow-up angiography in 20 patients, partial revascularization was found in 11 AVMs and further occlusion in 2. Complications occurred in 11 cases (38%). Five patients (17%) suffered from hemorrhage: 2 died, one deteriorated severely and 2 recovered. Unintentional embolization or edema resulted in neurologic deficits in 6 patients (21%), permanent in 3 and reversible in 3. Symptomatic improvement was initially found in 13 patients (45%) but was stable only in 9. In 9 patients (38%) embolization was followed by elective surgery or irradiation. The best results were obtained in small and medium-sized AVMs (less than 6 cm) while there was a high risk of complications and an uncertain palliative effect in large AVMs.

Transcatheter thoracic duct embolization in the dog. An experimental study

Thoracic duct embolization was created by injecting an isobutyl 2-cyanoacrylate/iophendylate (IBCA) mixture through a cannulated mesenteric lymphatic vessel in eight normal dogs. Aqueous contrast lymphangiography was repeated at minute 10 and week 6. Six dogs were euthanatized at week 6 and two dogs at month 6. Embolization with 1.5 to 3.9 ml of the mixture resulted in complete obstruction of the thoracic duct in all eight dogs. Results of lymphangiography in six dogs at week 6 showed a persistent, complete obstruction of the thoracic duct in six dogs and alternate lymphaticovenous anastomoses in four dogs. Histologically, there were a sclerosing granulomatous response surrounding the lymphatic embolus, mild congestive changes in the mesenteric lymph nodes, and mild lacteal dilatation in the jejunum. The procedure was well tolerated with only a few complications. One dog suffered partial thrombosis of the cranial vena cava by the injected material with later dislodgement and embolization of a pulmonary artery branch. Modifications have been made in the injection procedure to avoid this complication. This technique for occlusion of the thoracic duct shows potential for clinical use in the management of canine chylothorax. The obstruction appears to be complete and permanent, and surgical/anesthetic time is decreased greatly from previously described procedures.

Surgical repair of rabbit tibia osteotomy using isobutyl-2-cyanoacrylate

Isobutyl-2-cyanoacrylate was employed in the surgical repair of the osteotomized rabbit tibia in vivo. Union occurred at 24.3 +/- 3.1 days postoperatively when the adhesive had been used, compared with 35.5 +/- 3.6 days when no intervention was implemented. Healing of the osteotomy was not aided by external fixation or immobilization in either case. The results indicate the feasibility of using isobutyl-2-cyanoacrylate in the repair of load-bearing bones.

Splenic arteriogastric fistula from plication of a gastric ulcer. Therapeutic embolization

Massive upper gastrointestinal hemorrhage occurred in a 66-year-old man 18 days after suture plication of a giant gastric ulcer. Arteriography revealed a splenic arteriogastric fistula. Therapeutic embolization with tissue adhesive (bucrylate) successfully controlled hemorrhage after failure of attempted particulate embolization.

Histologic analysis of tissue response to bucrylate-pantopaque mixture

A toxicologic-pathologic study of isobutyl-2-cyanoacrylate (Bucrylate) was carried out first in dogs and then in humans whose arteriovenous malformations were infused with this embolic agent. The canine specimens obtained at 7, 18, 28, and 147 days after embolization showed the development of a mild histiocytic giant cell reaction, which evolved to end-state sclerotic arteritis. The response was confined to the vessels and did not involve contiguous parenchymal tissues. Ten human specimens, obtained from 1 hr to 7 years after treatment, showed a similar bland reaction with no evidence of suppuration or premalignant changes.

Intraoperative embolization of cerebral arteriovenous malformations

Nineteen patients with large cortical or deep seated cerebral arteriovenous malformation (AVM) were treated with intraoperative embolization using bucrylate (isobutyl-2-cyanoacrylate, IBC). In three cases of medium-sized AVM, the procedure was followed by a total excision of the lesion during the same operation. The results were excellent. In one case a hematoma and brain swelling following embolization necessitated total removal immediately afterwards. In eight patients embolization was carried out in two or three stages, to achieve a gradual obliteration of the shunt and to diminish the risk of postoperative brain swelling. Nevertheless, in three of these patients, postoperative hemiplegia was seen, which, however, improved considerably over a 1-2 year period. Complete occlusion of the shunt was obtained in only two patients. Seven patients underwent single-stage embolization, which resulted in partial obliteration of the AVM in six of them. In two of these, this treatment had been proposed for the accompanying symptoms of seizures and ischemic attacks. In all but one case the epileptic seizures decreased or disappeared completely after embolization. One patient suffered intracerebral bleeding three months after partial obliteration. Mortality was zero. It is argued that an alteration of the cerebral circulation with subsequent hyperemia is the most important sequela of rapid obliteration of large AVMs. Some details concerning the structure of cerebral AVMs are discussed.

Embolization of small vessels with a double-lumen microballoon catheter. Part II: Laboratory, animal, and histological studies. Work in progress

A double-lumen microballoon catheter system measuring 0.5-0.85 mm in outer diameter (1.3-2.8 F) was fabricated for passage through standard 4.1 and 5 F catheters. By arresting circulation with the balloon, embolization with low-viscosity silicone rubber, ethanol, or isobutyl-2-cyanoacrylate can proceed in a methodical, unhurried manner, permitting precise control of tissue penetration and preventing paradoxical embolization of other vessels. Problems such as gluing the catheter in situ with cyanoacrylate did not occur. The catheter may also be inserted during surgery to control embolization at a remote site, which did result in the catheter being glued in situ in one case.

Treatment of cerebral arteriovenous malformations: combined neurosurgical and neuroradiologic approach

Experience with 31 intraoperative embolizations performed on 23 patients is reported. The procedure involves the direct injection of embolic material into the main arterial feeders during craniotomy. The combined effort involves the exposure of the lesion at craniotomy, standard arteriotomy, and fluoroscopically monitored intravascular infusion of contrast material followed by the injection of bucrylate (IBCA, Ethicon, Somerville, NJ) mixed with tantalum or Pantopaque into the feeding vessels and into the interstices of the malformation. It was concluded that the procedure significantly diminishes operating time and blood loss for the lesions that were subsequently resected. Fluoroscopy coupled with high-quality stop-frame videotape recording allows a detailed study of the flow characteristics of the malformation so that polymerization time can be regulated appropriately. Follow-up varied from 3 months to 4 1/2 years. There were two deaths related to the procedure and one additional complication of cortical blindness that partially resolved. None of the survivors rebled. Most of the survivors improved.

[Visceral arterial embolization (VAE). Note I. VAE in renal cancer. Experimental study and preliminary clinical results]

After a short history of the VAE, a new method in the intervention radiology, the authors present the technique and results of the experimental renal VAE performed on dogs, with autologous clot, Gelaspon and Isobutyl-2-cyanoacrylat. The favourable results of the experimental investigations permitted for the first time in our country the use of VAE in inoperable renal cancers. The paper presents the clinico-therapeutical results of VAE as well as the control angiographic and echotomographic aspects after embolization. The conclusions support the need of using VAE both preoperatively and in the inoperable cases of renal cancer, suggesting the possibility of extending the use of this method to other visceral cancers with selective arterial catheterizations approach.

Two different calibrated-leak balloons: experimental work and application in humans

Two different types of latex calibrated-leak balloon catheters have been developed. One consists of a Teflon catheter with a detachable latex balloon and is used to embolize branches of the external carotid artery. The other consists of a Silastic catheter with a nondetachable latex balloon and is used to embolize brain arteriovenous malformations. An experimental model and animal experiments have determined the best conditions for safe and reproducible embolization with isobutyl-2 cyanoacrylate (IBC-2). Selective catheterization of branches of external carotid, middle cerebral, anterior cerebral, and posterior cerebral arteries in humans is facilitated, and embolization with IBC-2 has been achieved with these balloon catheters.

[Capillary embolization. Part II. Occlusion of the entire arterial system of experimentally induced renal tumors ]

221 renal rat tumors (induced by Dimethylnitrosamine) are embolized by gelfoam powder, IBC/Lipiodol and Ethibloc/Glucose. The effect of those embolization media is compared to ligation and glucose perfusion. Recurrencies and rate of surviving tumor tissue are dependent on the stage of the neoplasm, sufficient capillary propagation of the medium, and exact volume-dependent embolization. It could be proven that large areas of renal rat tumors are equally supplied by the main artery and parasitary collaterals. Only homogeneous distribution and complete downstream propagation of the embolization medium from the main artery to the capillaries will achieve breakdown of this parasitary supply. Glucose governed Ethibloc embolization achieves in 80% of tumors with a 6 fold renal volume and in 50% of larger tumors complete necrosis. It has the lowest complication rate of all tested materials.

Treatment of intracerebral arteriovenous malformations with isobutyl 2-cyanoacrylate: initial clinical experience

From November 1976 to September 1979, 46 patients with intracranial arteriovenous malformations or fistulas participated in a clinical study using isobutyl 2-cyanoacrylate (IBCA), with tantalum, for palliative or preoperative occlusion of the blood supply to the abnormalities. Although failure to obtain satisfactory position of a functioning microcatheter precluded deposition of IBCA 10 times, a total of 51 of a possible 62 feeding vessels were occluded with the tantalum-impregnated glue. The technique, results, and complications are discussed in light of the clinical follow-up, which varied from 12 to 48 months.

[Percutaneous embolization of renal cancer. Clinical evaluation (author's transl)]

The authors deal with 17 cases of renal adenocarcinoma treated with preventive embolization, widened nephrectomy and total parenteral nutrition, as well as one case of palliative definitive embolization in a patient who could not be operated. The most remarkable clinical aspects turned out to be in the easier and safer maneuverability under surgery, a decrease in mortality during and after the operation, reduced consumption of blood units, and a better which were treated only with purely surgical therapy.

[Therapeutic occlusion of the hypogastric arteries with isobutyl-2-cyanoacrylate in vesical and prostatic cancer (author's transl)]

The authors refer their clinical experience of the use of embolization of the hypogastric arteries in cases of serious haemorrhage of the bladder and prostate. The immediate results in the 14 cases observed are decidedly positive, especially considering the serious conditions of certain neoplastic patients, which ruled out alternative surgical treatment. Nevertheless, even when the embolization technique has been correctly used, the possibility exists that bleeding may start up again after some time, and this is always caused by the revascularization of the neoplasia.

Bucrylate embolization of abdominal aortic aneurysms: an adjunct to nonresective therapy

Abdominal aneurysmectomy in a patient with an abdominal aortic aneurysm who has cardiac, renal, or pulmonary disease is associated with a high surgical mortality. Fifteen such patients underwent nonresective therapy of an abdominal aortic aneurysm consisting of an axillobifemoral bypass graft which maintains blood flow to the lower extremities. At the time of the graft the iliac vessels were ligated, occluding the outflow tract from the aneurysm, and resulting in retrograde thrombosis. In three of the 15 patients, however, the aneurysm remained patent because of patency of the hypogastric arteries. The outflow tract in these three patients was occluded by a transcatheter injection of Bucrylate, a tissue adhesive, into the distal abdominal aorta and iliac vessels. Bucrylate embolization is a potentially useful adjunct to nonresective treatment of abdominal aortic aneurysms.

[New techniques for embolisation of the internal spermatic vein: intravenous tissue adhesive (author's transl)]

The diagnostic venography of the internal spermatic vein evaluating varicocele induced sterility in men, has become a standard procedure. It can now immediately be followed by a non-surgical treatment of this disease by means of a transcutaneous catheter embolisation. In this new technique use is made of isobutyl-2-cyanoacrylate (Bucrylate, Ethicon), a tissue adhesive. The method is relatively simple, safe and successful. Up to now 35 patients were cured according to this technique, once even bilaterally, on an out patient basis. The occlusion was complete in all cases as objectivated by a control venography directly after the embolisation, as well as by the normalisation of the clinical, thermographic, Doppler, hormonal and sperm findings.

Tissue adhesive arrests stromal melting in the human cornea

The direct early application of cyanoacrylate adhesive to a prepared ulcer bed and adjacent basement membrane, followed by placement of a bandage lens, gave good results in ten patients with corneal ulceration. The patients had ulceration with keratitis sicca, herpes keratitis, and other surface diseases. Progressive melting was arrested in all cases, and concurrent adjunctive therapies were used as indicated. The technique is quick and simple.

[Intracranial saccular aneurysms: experimental evaluation of intravascular therapeutic procedures]

Studies were performed on adult mongrel dogs to evaluate the possibility of occluding saccular aneurysms with an intravascular injection of the tissue adhesive Bucrylat (isobutyl-2-cyanoacrylate). Fourteen surgically constructed carotid aneurysms were occluded by the injection of Bucrylat through a fluoroscopically positioned intra-arterial catheter. Angiography performed immediately before and after injection and up to 1 month following treatment revealed progressive and persistent occlusion of the aneurysms. The specimens examined histologically 1 month after the injection showed an endothelialized fibrous tissue bridge crossing the neck of the aneurysm what appear to indicate a permanent occlusion of the structures treated. A similar approach to treat intracranial aneurysms will depend on advances in the field of selective intracranial catheterization that will permit safe and accurate catheterization of the aneurysm sac.

Obliteration of esophageal varices by PTP: a follow-up of 43 patients

The percutaneous transhepatic portal vein catheterization (PTP) with selective obliteration of the coronary vein and/or the short gastric veins in treating bleeding esophageal varices was introduced in 1974. In order to prevent recanalization of the vessels Bucrylate (isobutyl-2-cyano-acrylate) has been used in 43 patients 55 times during a period of 34 months (October 1975 to July 1978). The obliterative treatment was followed by rebleeding in 35% of the cases and continued bleeding occurred in two patients. Fourteen patients were treated on 16 occasions during acute bleedings, and five of these (36%) died within two months from a portal vein thrombosis caused by the obliterative procedure. Because of these findings PTP with obliteration of the veins feeding the esophageal varices is not recommended as an elective way of treatment. It should only be used in the acute bleeding patient when transesophageal sclerosering therapy, continuous vasopressin infusion and balloon tamponade have failed. Fifty-six per cent of the patients acutely treated stopped bleeding for more than one week, thus avoiding an emergency shunt or devascularization operation which are associated with a high mortality rate.

Modification of cyanoacrylate for therapeutic embolization: preliminary experience

Cyanoacrylate is a satisfactory material for therapeutic embolization, but it has the disadvantage of not being radiopaque and polymerizing within 1 sec after contact with ionic materials. Its behavior was modified with varying concentrations of iophendylate and were able to satisfactorily control its polymerization from 1 to 30 sec. This control should allow penetration of arteriovenous malformations, which is necessary if cure is to result. The iophendylate adds radiopacity and seems to enhance the suspension of tentalum, another opacifying agent. Preliminary experience in dogs is encouraging, but too few humans have been treated with this method to recommend it as more than an experimental procedure at this time.

Transcatheter vascular occlusion therapy with isobutyl 2-cyanoacrylate (bucrylate) for control of massive upper-gastrointestinal bleeding

Transcatheter embolization with bucrylate, a tissue adhesive, was performed in 16 patients with massive upper-gastrointestinal bleeding. Control of arterial bleeding from the stomach was achieved in 6 of 8 patients, and from the duodenum in 3 of 4. Embolization of gastric veins resulted in temporary control of esophageal variceal bleeding in 3 of 4 patients. Histological study showed no evidence of bucrylate causing histotoxicity in 2 patients. Because bucrylate polymerizes rapidly, a localized vascular occlusion mimicking a surgical ligation is produced. Because collateral vessels are not occluded. localized tissue ischemia is unlikely. Tissue adhesives are, however, difficult to use.

Isobutyl 2-cyanoacrylate (bucrylate) in obliteration of gastric coronary vein and esophageal varices

Percutaneous transhepatic portography was performed in 22 patients with liver cirrhosis and portal hypertension. All patients had bled or were bleeding from presumed esophageal varices. One or more veins feeding esophageal varices were occluded with bucrylate. Follow-up examination in eight patients 1-12 months later showed recanalization of previously obliterated veins in six; however, these veins were markedly smaller than before the procedure. In patients where veins were still occluded, new veins had opened up and carried blood to the esophageal varices, which were filled to a lesser degree than before. In our experience, bucrylate is superior to Gelfoam, thrombin, and Etolein in producing venous occlusion.

Intraarterial cyanoacrylate: an adjunct in the treatment of spinal/paraspinal arteriovenous malformations

Arteriovenous malformations are difficult lesions to treat whether surgical or catheter occlusive therapy is used. If the major feeders are ligated or blocked, other arteries open quickly to supply the malformation. Isobutyl 2-cyanoacrylate, deposited with a calibrated leak balloon microcatheter, has given satisfactory short term improvement in both the signs and symptoms of two patients with spinal arteriovenous malformations. Superselective placement of the catheter system, a provocative test perfusion of the arteriovenous malformation and its supplying vessels before the acutal occlusion, and high quality fluoroscopy and angiographic equipment added to the safety of the procedure. No long term results are available, but this system may prove itself another tool in the catheter therapist's armamentarium.

The treatment of intracranial aneurysms by injection with a tissue adhesive

The authors have developed a technique of occluding intracranial aneurysms by the direct injection of a tissue adhesive. Previous work in our laboratory had revealed the unusual intravascular characteristics and physiological properties of isobutyl-2-cyanoacrylate (IBC). These findings had indicated the feasibility of utilizing IBC in the treatment of intracranial aneurysms by its direct injection. We have now treated twenty patients by this method. Eighteen aneurysms were injected during open craniotomy and two were treated by closed stereotactic injection utilizing electronic radiography. Follow-up data, ranging from 1 to 6 years after operation, are available on these patients. Sixteen patients (80% of the series) have had good to excellent results. Our experience and the application of this technique as a potential tool in the treatment of intracranial aneurysms are discussed.

Therapeutic renal arterial occlusion for elimination of proteinuria: 'medical nephrectomy'

A patient with severe nephrotic syndrome who was too debilitated to undergo surgical nephrectomies, underwent therapeutic bilateral renal artery occlusion by the selective injection of isobutyl 2-cyanoacrylate into the renal arteries. The therapy resulted in dramatic cessation of urine flow and elimination of proteinuria.

Studies concerning the hsitotoxicity of isobutyl-2-cyanoacrylate tissue adhesive when employed as an oral hemostat

An experimental study was implemented to determine the effectiveness of isobutyl-2-cyanoacrylate (bucrylate) as an oral hemostat, its influence on sequential wound healing, and its potential as a carcinogen. Segregated groups of equal numbers of male and female Long-Evans Hooded Rats underwent deep (socket) and superficial (surface) aerosol placement of bucrylate to maxillary molar extraction sites. Bucrylate proved to be an effective oral hemostat, rapidly retarding postextraction hemorrhage. Deep placement of the adhesive resulted in retarding of healing and lingering macrohistiocytic aggregates in wounds. Superficial placement of the material resulted in very little long-term macrohistiocytic response, and would healing showed little retardation. A neoplastic potential was not demonstrated for bucrylate.

Experimental catheter obstruction of the gastric coronary vein. Possible technique for percutaneous intravascular tamponade of the gastroesophageal varices

Experimental catheter obstruction of the left gastric (coronary) vein was explored in 10 dogs. Using a transjugular approach, the liver was punctured and the portal vein catheterized. Coaxially introduced catheters were then used to catheterize selectively and produce an intravascular obstruction (tamponade) of the gastric coronary vein. Ballon catheters were used for a temporary occlusion. Injection of a tissue adhesive, isobutyl 2-cyanoacrylate, was used for a definitive obliteration. The achieved results show the anatomical feasibility of this approach and give good perspective for development of a clinical method for percutaneous intravascular tamponade of the bleeding gastroesophageal varices in cirrhotics.

Experimental arteriovenous fistula. Creation and percutaneous catherter obstruction with cyanoacrylate

Arteriovenous fistula models were created of plastic and in dogs, allowing exploration of the intraarterial use of tissue adhesive, isobutyl cyanoacrylate. A delivery system utilizing superselective coaxial catheterization was developed on the model. Carotid artery to external jugular vein shunts constructed in 19 dogs provided a suitable in vivo model. Using varied injection techniques, the shunts were occluded in 17 of 17 treated animals. Three dogs subsequently died because of embolization to the lungs and one carotid artery was occluded. Techniques to avoid these complications were devised. Refinement of the intraarterial use of these adhesives will offer us another mode of treatment of vascular abnormalities.