A prospective, randomized trial of butyl cyanoacrylate injection versus band ligation in the management of bleeding gastric varices

Gastric variceal bleeding is a catastrophic event. Both cyanoacrylate injection and banding ligation have been proven to be effective in the management of bleeding gastric varices. This study was performed to compare the efficacy and complications of both the modalities. Cirrhotic patients with a history of gastric variceal bleeding were randomized to 2 groups. The group receiving endoscopic obturation (group A) comprised 31 patients and the group receiving band ligation (group B) comprised 29 patients. Butyl cyanoacrylate and pneumatic-driven ligator were applied, respectively. Treatment was repeated regularly until obliteration of gastric varices. Active bleeding occurred in 15 patients in group A and 11 patients in group B. Initial hemostatic rate (defined as no bleeding for 72 hours after treatment) was 87% in group A and 45% in group B (P = .03). The sessions required to achieve variceal obliteration and obliteration rates were similar in both the groups. However, rebleeding rates were significantly higher in group B (54%) than group A (31%) (P = .0005). Treatment-induced ulcer bleeding occurred in 2 patients (7%) in group A and 8 patients (28%) in group B (P = .03). The amount of blood transfusions required were also higher in group B than group A (4.2 +/- 1.3 vs. 2.6 +/- 0.9 units, respectively) (P < .01). Nine patients of group A and 14 patients of group B died (P = .05). In conclusion, endoscopic obturation using cyanoacrylate proved more effective and safer than band ligation in the management of bleeding gastric varices.

A randomized controlled trial of cyanoacrylate versus alcohol injection in patients with isolated fundic varices

OBJECTIVE

Treatment of bleeding gastric varices (GVs) is still controversial, mainly because of anecdotal studies or inclusion of patients with GVs located at different sites that have variable incidences of bleeding. A prospective study was undertaken to compare the efficacy and safety of GV sclerotherapy using alcohol and GV obturation using cyanoacrylate glue.

METHODS

Thirty-seven consecutive patients with portal hypertension and endoscopic evidence of isolated GVs, 17 presenting with histories of active bleeding, were randomized to receive endoscopic intervention either with alcohol (n = 17) or with cyanoacrylate glue (n = 20) injection. Variceal obliteration, rebleeding, or death was the endpoint.

RESULTS

The glue was significantly more effective in achieving variceal obliteration than alcohol (100% vs 44%, p < 0.05). Furthermore, this could be achieved in a significantly shorter period (2.0 +/- 1.6 vs 4.7 +/- 3.2 wk, p < 0.05) and with a smaller volume of the agent. Cyanoacrylate glue injection could achieve arrest of acute GV bleeding more often than alcohol (89% vs 62%), and the need for rescue surgery was less; the difference was, however, not significant. Six patients died from uncontrolled GV bleeding, four being in the alcohol group. During a mean follow-up of 15.4 +/- 3.7 months there was no recurrence of GVs in either group.

CONCLUSIONS

Our results show that cyanoacrylate is more effective and achieves GV obliteration faster than injection sclerotherapy with alcohol. It also appears to be more useful in controlling acute GV bleeding, with less of a need for rescue surgery.

Low incidence of complications from endoscopic gastric variceal obturation with butyl cyanoacrylate

BACKGROUND & AIMS

Endoscopic variceal obturation with tissue adhesive is used to control gastric variceal bleeding. We investigated the prevalence of serious complications from this therapy.

METHODS

We performed a retrospective analysis of complications that occurred in 753 patients with gastric variceal hemorrhages who were hospitalized in 2 tertiary referral hospitals. All patients received N-butyl-2-cyanoacrylate as therapy for endoscopic variceal obturation.

RESULTS

Complications occurred in 51 patients. Thirty-three patients experienced rebleeding because of early-onset (within 3 months) extrusion of the N-butyl-2-cyanoacrylate glue cast (4.4%), 10 patients developed sepsis (1.3%), and 5 patients developed distant embolisms (0.7%; 1 pulmonary, 1 brain, and 3 splenic). One patient had major gastric variceal bleeding after endoscopic variceal obturation (0.1%), 1 developed a large gastric ulcer (0.1%), and 1 had mesentery hematoma, hemoperitoneum, and infection in the abdominal cavity (0.1%). The complication-related mortality was 0.53% (3 deaths from sepsis and 1 death from rebleeding after early-onset glue cast extrusion).

CONCLUSIONS

The occurrence of complications after endoscopic variceal obturation with N-butyl-2-cyanoacrylate in gastric varices treatment is rare.

Clinical experience with N-butyl cyanoacrylate (Nexacryl) tissue adhesive

BACKGROUND

To investigate the indications, outcomes, and complications of N-butyl cyanoacrylate tissue adhesive for ocular clinical use. This tissue adhesive is under investigation by the Food and Drug Administration.

METHODS

N-butyl cyanoacrylate was used as an investigational device on 44 patients at the authors' institution over a 2-year period. The charts of these patients were reviewed.

RESULTS

The indications for glue application included corneal perforation (19 eyes), descemetoceles (9 eyes), leaking filtering blebs (6 eyes), stromal thinning (5 eyes), wound leaks (4 eyes), and exposure keratopathy (1 eye). A bandage contact lens was used over the dried tissue adhesive in 38 of the 44 eyes. Length of glue adherence ranged from 1 to 660 days (mean, 72 days). Outcome was penetrating keratoplasty (19 eyes), no further intervention (14 eyes), enucleation (4 eyes), surgical revision of a filter (2 eyes), scleral patch graft (1 eye), conjunctival transplant (1 eye), failed tarsorrhaphy (1 eye), suturing of wound (1 eye), and a lamellar graft (1 eye). Vision improved in 52% (23/44) of eyes.

CONCLUSION

This tissue adhesive may soon be available to all ophthalmologists, and the authors' experience demonstrates that it is an effective method of temporary or permanent closure of an impending or frank perforation.

Use of a wedged microcatheter for curative transarterial embolization of complex intracranial dural arteriovenous fistulas: indications, endovascular technique, and outcome in 21 patients

OBJECT

The aim of this study was to describe the application of a novel transarterial approach to curative embolization of complex intracranial dural arteriovenous fistulas (DAVFs). This technique is particularly useful in patients harboring high-grade DAVFs with direct cortical venous drainage or for whom transvenous coil embolization is not possible because of limited sinus venous access to the fistula site due to thrombosis or stenotic changes.

METHODS

Twenty-three DAVFs in 21 patients were treated using a transarterial N-butyl cyanoacrylate (NBCA) embolization technique with the aid of a wedged catheter. In all patients, definitive treatment involved two critical steps: 1) a microcatheter was wedged within a feeding artery, establishing flow-arrest conditions within the catheterized vessel distal to the microcatheter tip; and 2) NBCA was injected under these resultant flow-arrest conditions across the pathological arteriovenous connection and into the immediate draining venous apparatus, definitively occluding the fistula. Patient data were collected in a retrospective manner by reviewing office and inpatient charts and embolization reports, and by directly analyzing all procedural and diagnostic angiograms. Eight patients presented with the principal complaint of tinnitus/bruit, five with intracranial hemorrhage, four with cavrnous sinus syndrome, and one each with seizures, ataxia, visual field loss, and hiccups. The parent (recipient) venous structure of the DAVFs in this study included 11 leptomeningeal veins, eight transverse/sigmoid sinuses, three cavernous sinuses, and one sphenoparietal sinus. The NBCA permeated the arteriovenous shunt, perifistulous network, and proximal draining vein in all DAVFs. Occlusion was confirmed on postembolization angiography studies. No complication occurred in any patient in this series. There has been no recurrence during a mean follow up of 18.7 months (range 2-46 months).

CONCLUSIONS

Transarterial NBCA embolization with the aid of a wedged catheter in flow-arrest conditions is a safe and an effective treatment for intracranial DAVFs.

Cure, morbidity, and mortality associated with embolization of brain arteriovenous malformations: a review of 1246 patients in 32 series over a 35-year period

Published reports of cure, morbidity, and mortality associated with the embolization of 1246 brain arteriovenous malformations during the last 35 years were reviewed. Embolization resulted in cure in 5% of arteriovenous malformations. The cure rates of embolization were 4% in reports of 708 patients published before 1990 and 5% in reports of 538 patients published since 1990 (P = not significant). Temporary morbidity from embolization was 10%, and permanent morbidity was 8%. Permanent morbidity was 9% before 1990 and 8% since 1990 (P = not significant). Death after embolization of brain arteriovenous malformations occurred in 1% of patients. Mortality associated with the embolization was 2% before 1990 and 1% since 1990 (P = not significant). Long-term morbidity associated with the use of neurotoxic embolization materials is worrisome but has never been proven.

N-butyl-2-cyanoacrylate pulmonary embolism after endoscopic injection sclerotherapy for gastric variceal bleeding

PURPOSE

The purpose of this work was to describe the radiologic and clinical manifestations of n-butyl-2-cyanoacrylate pulmonary embolism (PE) after endoscopic injection sclerotherapy (EIS) for gastric variceal bleeding.

METHOD

From 1992 to 1999, the medical records of 140 patients who had undergone EIS using n-butyl-2-cyanoacrylate were reviewed for identification of respiratory symptoms and amount of injection, and their pre- and postprocedure chest radiographs were reviewed to identify PE. In patients with PE, pre- and postprocedure chest radiographs (6/6), chest CT scans (3/6), lung perfusion scans (3/6), and follow-up chest radiographs (6/6) were analyzed retrospectively.

RESULTS

Radiographically evident PE was observed in 6 (4.3%) of 140 patients. In comparison with patients without emboli, these patients received a higher mean volume of injection (4.2 vs. 1.8 ml) (p = 0.0011). Four of the six patients with pulmonary emboli had respiratory symptoms. Chest radiographs and CT scans showed unusual tubular or nodular, radiopaque pulmonary emboli along the pulmonary vessels. Multiple peripheral, wedge-shaped, subsegmental perfusion defects were seen on perfusion lung scans. In five of six patients, the radiographic abnormalities showed complete or partial resolution. There were no fatalities directly associated with PE.

CONCLUSION

Radiographically evident PEs are uncommonly observed following EIS and appear to be more common in patients receiving a higher volume of liquid acrylate. Affected patients were either mildly symptomatic or asymptomatic, and there were no direct fatalities of this complication.

Histoacryl. Its use in aesthetic facial plastic surgery

Since their discovery in 1949, cyanoacrylates have evoked interest as being a possible ideal "tissue glue." Several different forms of these compounds have been developed in order to try to reduce or eliminate tissue toxicity. Butyl-2-cyanoacrylate (Histoacryl) appears to be the closest ideal material as it induces low tissue reactivity and toxicity. It has been used extensively for middle ear surgery with little or no adverse effects. A historical review of tissue adhesives and a discussion of technical considerations is outlined. A clinical trial of 100 patients treated with Histoacryl on various surgical wounds revealed no significant adverse effects with wound healing, graft rejection, or infection over a six-month period. Histoacryl appears to offer many advantages and few disadvantages over conventional suture techniques.

Use of cyanoacrylate tissue adhesive for closing facial lacerations in children

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Endoscopic hemostasis of esophageal and gastric variceal bleeding with Histoacryl

Endoscopic injection of the tissue adhesive n-butyl-2-cyano-acrylate (Histoacryl) has been tried for esophageal or fundic variceal bleeding in 23 patients. Definitive hemostasis was achieved in 22 with a single injection of Histoacryl. Throughout the entire hospitalization period, which was completed with at least two weekly sessions of conventional sclerotherapy, only one recurrent bleeding was recorded. Four patients died of hepatic decompensation. It is suggested that Cyanoacrylate could overcome some of the shortcomings of conventional sclerotherapy such as early recurrent hemorrhage and bleeding from fundic varices.

Distal embolization and local vessel wall ulceration after gastric variceal obliteration with N-butyl-2-cyanoacrylate: a case report and review of the literature

Repeated endoscopic injections of N-butyl-2-cyanoacrylate mixtures into large gastric varices in a single patient led to two complications: initially, pulmonary embolism, and later local ulceration of the wall of a varix. The latter resulted in massive uncontrollable hemorrhage that ultimately led to a fatal outcome. This case report also analyzes complications reported in the literature during similar endoscopic procedures for gastric varices.

Cyanoacrylate in the treatment of gastric varices complicated by multiple pulmonary emboli

Bleeding gastric varices are increasingly being obliterated with the aid of endoscopic injection of n-butyl-cyanoacrylate (histoacryl) diluted with lipiodol. This glue acts as a tissue adhesive that polymerizes on contact with blood in a gastric varix. Severe glue pulmonary embolism is a rare complication of injection therapy. This case involves a 52-year-old man with fundal gastric varices, who developed multiple pulmonary emboli following glue injection with profound hypoxia requiring hospital admission for 13 days, but with eventual recovery of normal lung function.

Effects of a mixture of a low concentration of n-butylcyanoacrylate and ethiodol on tissue reactions and the permanence of arterial occlusion after embolization

OBJECTIVE

Cyanoacrylates are the most commonly used liquid embolic agents. For embolization of arteriovenous malformations, a mixture of a low concentration of n-butylcyanoacrylate (NBCA) and Ethiodol (Savage Laboratories, Melville, NY) has been recommended for deeper penetration of the nidus. Dilution of NBCA, however, might result in different degrees of tissue reaction and might influence the permanence of vessel occlusion, with an increased risk of vessel recanalization. We compared tissue reactions induced by different NBCA/Ethiodol mixtures and analyzed the permanence of their embolic effects.

METHODS

NBCA was diluted with Ethiodol to prepare the following standard solutions: Mixture A, low concentration (NBCA/Ethiodol ratio of 20:80); Mixture B, high concentration (50:50). The study was designed in two parts, because tissue reactions after embolization are considered to be a combination of foreign body reactions to solidified material and reactions to the injured blood vessel. Foreign body reactions were studied by intramuscularly injecting both glue mixtures into the backs of 18 rats. Specimens were obtained at various times after implantation. Immunohistochemical analysis and esterase staining were used to detect macrophages and neutrophils, respectively. The densities of these inflammatory cells were calculated and statistically compared. To study the degree of vascular wall injury and the permanence of embolic effects, the renal arteries in 48 rabbits were embolized with NBCA Mixture A or B. Six specimens for each group were obtained at various times after embolization.

RESULTS

There was no significant difference in foreign body reactions between groups treated with Mixtures A and B, at any time. However, the macrophage density was larger for both groups at 3 months versus 3 days and for the group treated with Mixture B at 3 months versus 2 weeks. There was no difference in the degree of vessel wall injury. None of the embolized vessels demonstrated evidence of recanalization.

CONCLUSION

The low concentration of NBCA induced a tissue response similar to that of the high-concentration form. Embolized vessels exhibited no greater incidence of recanalization. Therefore, embolization of arteriovenous malformations with diluted NBCA may be safe.

Randomized trial of N-butyl-2-cyanoacrylate compared with injection of hypertonic saline-epinephrine in the endoscopic treatment of bleeding peptic ulcers

BACKGROUND AND STUDY AIMS

Theoretically, the injection of cyanoacrylate may be effective for peptic ulcer bleeding, but randomized clinical trials are rare. The aim of this study was to compare the efficacy of N-butyl-2-cyanoacrylate (Histoacryl) and hypertonic saline-epinephrine (HSE) in the endoscopic treatment of major peptic ulcer hemorrhage.

PATIENTS AND METHODS

A total of 126 patients with major peptic ulcer hemorrhage and active bleeding or a nonbleeding visible vessel were randomly allocated to endoscopic injection with HSE (63 patients; group 1) or to injection with Histoacryl (63 patients; group 2). The two groups were well matched for age, sex, initial hemoglobin values, ulcer size and location, and bleeding stigmata.

RESULTS

Initial hemostasis was achieved in 58 cases (92.1%) in group 1 and in 60 cases (95.2%) in group 2 (P=0.717). Rebleeding rates were 16 of 58 in group 1 and seven of 60 in group 2 (P=0.051). There were no significant differences regarding the rates of permanent hemostasis (51 of 63 in group 1 vs. 57 of 63 in group 2, P=0.203), emergency surgery (seven of 58 in group 1 vs. three of 60 in group 2, P=0.200), or hospital mortality due to bleeding (0 in group 1 and 0 in group 2). With regard to the rebleeding rate, there was a significant difference between group 1 and group 2 in the subgroup with active arterial bleeding (11 of 26 in group 1 and four of 29 in group 2, P=0.039) but not in the subgroup with a nonbleeding visible vessel (five of 32 in group 1 and three of 31 in group 2, P=0.708). There were no statistically significant differences in hemostatic results between the two treatment groups in the subgroups with gastric ulcers or duodenal ulcers. Although no complications followed HSE therapy, arterial embolization with infarction occurred in two patients in the Histoacryl group, of whom one died.

CONCLUSIONS

Compared with HSE injection, Histoacryl injection showed no statistically significant differences in hemostatic results, except for decreasing the rebleeding rate in the patients with active arterial bleeding. However, the use of Histoacryl to control peptic ulcer bleeding should be reserved as a last resort before surgery, because of possible embolic complication.

Safety and Risk of Superselective Transcatheter Arterial Embolization for Acute Lower Gastrointestinal Hemorrhage with N-Butyl Cyanoacrylate: Angiographic and Colonoscopic Evaluation

PURPOSE

To retrospectively evaluate the safety and risk of transcatheter arterial embolization (TAE) with N-butyl cyanoacrylate (NBCA) for urgent acute arterial bleeding control in the lower gastrointestinal tract by angiography and colonoscopy.

MATERIALS AND METHODS

NBCA TAE was performed in 16 patients (mean age, 63.7 y) with lower gastrointestinal bleeding (diverticular hemorrhage, tumor bleeding, and intestinal tuberculosis). Angiographic evaluation was performed by counting the vasa recta filled with casts of NBCA and ethiodized oil (Lipiodol) after TAE. Patients were classified as follows: group Ia, with a single vas rectum with embolization of 1 branch (n = 6); group Ib, with a single vas rectum with embolization of ≥ 2 branches (n = 8); group II, with embolization of multiple vasa recta (n = 2). All patients underwent colonoscopy within 1 month, and ischemic complications (ulcer, scar, mucosal swelling, fibrinopurulent debris, and necrosis) were evaluated.

RESULTS

The procedure was successful in all patients. No ischemic change was observed in any patients in group Ia and in two patients in group Ib. Ischemic changes were observed in six group Ib patients and both group II patients. Group Ib patients experienced ischemic complications that improved without treatment. One patient in group II underwent resection for intestinal perforation after embolization of three vasa recta. One patient in group II with sigmoid stricture with embolization of six vasa recta required prolonged hospitalization.

CONCLUSIONS

NBCA embolization of ≥ 3 vasa recta can induce ischemic bowel damage requiring treatment. NBCA TAE of one vas rectum with ≥ 2 branches could also induce ischemic complications. However, these were silent and self-limited.

Procedure-related complications in gastric variceal obturation with tissue glue

AIM

To focus on procedure-related complications, evaluate their incidence, analyze the reasons and discuss the solutions.

METHODS

Overall, 628 endoscopic gastric variceal obturation (EGVO) procedures (case-times) with NBC were performed in 519 patients in the Department of Endoscopy of the Third Affiliated Hospital of Sun Yat-Sen University from January 2011 to December 2016. The clinical data of patients and procedure-related complications of EGVO were retrospectively analyzed.

RESULTS

In the 628 EGVO procedures, sticking of the needle to the varix occurred in 9 cases (1.43%), including 1 case that used lipiodol-diluted NBC and 8 cases that used undiluted NBC (P = 0.000). The needle was successfully withdrawn in 8 cases. Large spurt bleeding occurred in one case, and hemostasis was achieved by two other injections of undiluted glue. The injection catheter became blocked in 17 cases (2.71%) just during the injection, and 4 cases were complicated with the needle sticking to the varix. Large glue adhesion to the endoscope resulted in difficulty withdrawing the endoscope in 1 case. Bleeding from multiple sites was observed in the esophagus and gastric cardia after the endoscope was withdrawn. Hemostasis was achieved by 1% aethoxysklerol injection and intravenous somatostatin. The ligation device stuck to the varices in two cases during the subsequent endoscopic variceal ligation. In one case, the ligation device was successfully separated from the esophageal varix after all bands were released. In another case, a laceration of the vein and massive bleeding were observed. The bleeding ceased after 1% aethoxysklerol injection.

CONCLUSION

Although EGVO with tissue glue is usually safe and effective, a series of complications can occur during the procedure that may puzzle endoscopists. There is no standard operating procedure for addressing these complications. The cases described in the current study can provide some reference for others.

Life-threatening intraabdominal arterial embolization after histoacryl injection for bleeding gastric ulcer

N-butyl-cyanoacrylate (Histoacryl) injection has become the treatment of choice for acutely bleeding esophagogastric varices, and is the only effective option for endoscopic treatment of gastric varices. Recent reports confirm the ability of Histoacryl injection therapy to achieve immediate hemostasis in cases of gastric ulcer bleeding or Dieulafoy ulcer, where conventional endoscopic hemostatic treatment had failed. Although the overall safety record of Histoacryl injection has been relatively good, there have been scattered cases of serious complications. Here, we present two patients showing life-threatening intraabdominal arterial embolization after Histoacryl injection. They had chronic gastric ulcers with active arterial bleeding. In spite of attempts at hemostatic treatment, complete hemostasis was not achieved. We injected Histoacryl, diluted with Lipiodol, into bleeding gastric ulcers, resulting in successful hemostasis. Soon after the procedure, intraabdominal arterial embolization developed in both patients. One patient survived and the other died. Based on these experiences, we would like to warn gastrointestinal endoscopists to be alert to these fatal complications, and we propose that less diluted Histoacryl seems to be preferable in cases of bleeding peptic ulcers.

The Efficacy of Lymph Node Embolization Using N-Butyl Cyanoacrylate Compared to Ethanol Sclerotherapy in the Management of Symptomatic Lymphorrhea after Pelvic Surgery

PURPOSE

To compare the efficacy of lymph node (LN) embolization using N-butyl cyanoacrylate versus ethanol sclerotherapy in the management of symptomatic postoperative pelvic lymphorrhea.

MATERIALS AND METHODS

Thirty-three patients with 40 instances of symptomatic postoperative lymphorrhea were treated with either LN embolization or sclerotherapy at Seoul National University Hospital from January 2009 to July 2017 and were retrospectively included (LN embolization group: 24 lymphoceles of 19 patients, mean age of 59.29 years; sclerotherapy group: 16 lymphoceles of 14 patients, mean age of 60.95 years). The types of operations were hysterectomy and bilateral oophorectomy with pelvic lymph node dissection (n = 9), radical prostatectomy (n = 3), and renal transplantation (n = 2) for the sclerotherapy group and radical prostatectomy (n = 10) and hysterectomy and bilateral oophorectomy with pelvic lymph node dissection (n = 9) for the LN embolization group. The 3 most common indications of treatment were lower extremity edema (n = 11), pain (n = 11), and fever (n = 8). The amount of leak before treatment (initial daily drainage) and clinical outcomes, including the clinical success rate in 3 weeks, treatment period, and complication rate were compared between both groups.

RESULTS

LN embolization showed a higher 3-week clinical success rate than sclerotherapy in a univariate analysis (83.3% and 43.8%, P = .026). There was no statistically significant difference in the treatment period and the complication rate (7.1 days and 12.3 days, P = .098; 8.3% and 25.0%, P = .184).

CONCLUSIONS

LN embolization is more effective for treating postoperative pelvic lymphorrhea than sclerotherapy with similar safety.