Safety and efficacy of transcatheter embolization with Glubran®2 cyanoacrylate glue for acute arterial bleeding: a single-center experience with 104 patients

Enhancing Outcomes in Transarterial Embolization for Late Postpancreatectomy Hemorrhage: A Comparison of N-Butyl Cyanoacrylate with Mixed Embolic Agents Versus Mixed Embolic Agents Alone

BACKGROUND

This study aimed to retrospectively compare the efficacy of transarterial embolization (TAE) with N-butyl cyanoacrylate (NBCA) and conventional agents (microcoils, polyvinyl alcohol [PVA], or gelatin sponge) in the treatment of patients with late postpancreatectomy hemorrhage (late-PPH).

METHODS

From June 2012 to June 2022, this retrospective study enrolled 130 consecutive patients who underwent TAE treatment due to late-PPH at one institution. Of these patients, 56 were treated with NBCA-mixed conventional agents (NBCA-MA group), and 74 were treated with mixed conventional agents alone (MA group). The patients' clinical characteristics and TAE details were gathered. The clinical outcomes in the two groups were compared. Using univariate and multivariate logistic regression analyses, prognostic factors were evaluated for clinical success and 30-day mortality rates.

RESULTS

The clinical success in the NBCA-MA group was 80.4% higher than that in the MA group (60.8%). Rebleeding was significantly more common in the MA group (29.7% vs. 8.9%). The 30-day mortality rate of the NBCA-MA group was lower than that of the MA group (16.1% vs. 33.8%). NBCA use was a significant prognostic factor associated with clinical success, while age and NBCA use were significant factors associated with the 30-day mortality rate.

CONCLUSION

In conclusion, we found that TAE with NBCA is a safe and effective method for treating late-PPH.

[Imaging of the lymphatic vascular system-techniques]

CLINICAL/METHODICAL ISSUE

Imaging of the lymphatic vascular system is comparatively difficult and logistically demanding.

STANDARD RADIOLOGICAL METHODS

The field has developed significantly in recent decades. The longest established techniques are conventional X‑ray lymphangiography and lymphoscintigraphy.

METHODOLOGICAL INNOVATIONS

In recent years, magnetic resonance (MR) and computed tomography (CT) lymphangiography have been developed using different contrast medium (CM) techniques. For interstitial lymphangiography, CM is injected intracutaneously, and absorbed and drained by the lymphatic system. For direct techniques, CM is injected directly into a lymph node or a prepared lymph vessel.

PERFORMANCE

Lymphangiography procedures offer high anatomical and/or temporal resolution that have method-related differences. They allow better morphological assessment of the lymph vessels compared to lymphoscintigraphy. Furthermore, MR and CT lymphangiography are less invasive than conventional x‑ray lymphangiography.

EVALUATION

MR lymphangiography in particular allows dynamic assessment of lymph flow through repetitive imaging, which is particularly valuable in complex situations. While MR lymphangiography is now established in centers despite the off-label use of CM, data regarding CT lymphangiography is still very limited.

PRACTICAL RECOMMENDATIONS

A number of specific lymphatic imaging techniques are available at specialized centers.

Transcatheter arterial and venous embolisation with α-hexyl cyanoacrylate MagicGlue®: short-term safety and efficacy outcomes

PURPOSE

Our purpose was to assess the feasibility and the short-term safety and efficacy outcomes of a wide range of transcatheter arterial and venous embolisation procedures done using α-hexyl-cyanoacrylate (AHCA)-MagicGlue® in patients with bleeding and non-bleeding disorders.

METHODS

This single-centre retrospective study included consecutive patients who underwent emergent or planned AHCA-MagicGlue® transcatheter embolisation between February 2019 and September 2023. Technical success, clinical success, 30-day mortality, and complication rates were evaluated.

RESULTS

We included 101 patients with a mean age of 49.9 ± 20.5 years who underwent arterial (n = 43, 42.6%) or venous (n = 58, 57.4%) embolisation for bleeding (n = 16, 15.8%) or other reasons (n = 85, 84.2%). The technical success rate was 100%. After a mean follow-up of 2.2 months, the clinical success rate was 94% in patients with bleeding and 95% in other patients; 1 patient died of multi-organ failure unrelated to the procedure. In the 22 patients with prostatic artery embolisation, statistically significant improvements were recorded at 3 months versus baseline for the International Prostate Symptoms Score (IPSS) (10.0 ± 5.8 vs. 20.8 ± 7.3, p = 0.001), IPSS quality-of-life score (2.0 ± 1.4 vs. 5.0 ± 1.0; p = 0.001), and prostate volume (67.8 ± 38.0 mL vs. 96.7 ± 47.4 mL, p = 0.001). Adverse events occurred in 11 (10.9%) patients and were major in 4 and minor in 7 patients.

CONCLUSIONS

MagicGlue® transcatheter arterial and venous embolisation is feasible, effective, and safe for bleeding and non-bleeding conditions across a broad range of anatomic sites.

Ethylene-vinyl alcohol copolymer-based non-adhesive liquid embolic agent for transcatheter arterial embolization in patients with abdominal/pelvic arterial bleeding: A prospective, single-arm, multicenter cohort study

PURPOSE

The purpose of this study was to evaluate the safety and efficacy of a novel ethylene-vinyl alcohol copolymer-based non-adhesive liquid embolic agent for transcatheter arterial embolization (TAE) in patients with bleeding from abdominal and/or pelvic arteries MATERIALS AND METHODS: A prospective observational multicenter study (Clinicaltrials.gov Identifier: NCT04787120) included consecutive patients treated with TAE using a novel ethylene-vinyl alcohol copolymer-based non-adhesive liquid embolic agent (SQUIDPERI 18) at four university hospitals from 2021 to 2023. The indication for TAE included acute symptomatic bleeding or imminent risk of bleeding from visceral (n = 63), muscular (n = 23), or gastrointestinal (n = 29) abdominal/pelvic arteries combined with angiographic abnormalities. Patient characteristics, clinical success rates, and interventional-radiologist satisfaction with each TAE were assessed. Clinical success at 1- and 6 months was defined as survival without reintervention for rebleeding from the initially embolized site(s). Univariable and multivariable analyses were performed to identify variables associated with clinical failure of TAE.

RESULTS

Of the 110 patients enrolled, 104 had 1-month and 98 had 6-month data. Target vessel(s) were successfully occluded in 108 of the 110 patients, resulting in a technical success rate of 98.2 %. Clinical success rates at 1 and 6 months were 72.1 % (75/104 patients) and 64.3 % (63/98 patients), respectively. Mortality was 20/104 (19.2 %) at 1 month and 26/98 (26.5 %) at 6 months. One patient experienced an adverse event during TAE. The rates of adverse events and serious adverse events at 1 month were 31.4 % (32/102) and 22.5 % (23/102), respectively. Older age was the single variable associated with clinical failure of TAE at 1 month in both univariable and multivariable analysis. In more than 90 % of TAEs, the interventional radiologists were satisfied for five of the seven questionnaire items.

CONCLUSION

The novel ethylene-vinyl alcohol copolymer-based non-adhesive liquid embolic agent is safe and effective for TAE in patients presenting with acute symptomatic bleeding from abdominal/pelvic arteries.

Title: Is Celiac Trunk Revascularization Necessary After High-Flow Pancreaticoduodenal Arterial Arcades Aneurysm Retrograde Embolization?

Background and Objective: High-flow pancreaticoduodenal artery (PDA) aneurysms secondary to celiac trunk occlusion or stenosis have a high risk of rupture. Embolization offers a less invasive alternative to surgery. We evaluated the effectiveness and safety of retrograde embolization via the superior mesenteric artery of high-flow PDA aneurysms without celiac trunk revascularization. Methods: This retrospective bicentric study included patients who underwent embolization of high-flow PDA aneurysms due to significant celiac trunk stenosis or occlusion. All patients underwent pre-interventional dynamic contrast-enhanced computed tomography. Retrograde embolization was performed using microcoils and/or liquid agents without celiac trunk revascularization. Follow up involved clinical and radiological assessment at one month. Technical and clinical success were evaluated, and complications were categorized as minor or major. Results: Twenty-three patients (mean age 65 ± 14 years; 52% male) were included. Emergency embolization was required in 12 patients (52%). The technical success rate was 100%. Patients were monitored for a median of 16 months. Clinical success was 87%. No hemorrhagic recurrences were observed. Minor complications occurred in two cases. One major complication involved splenic infarction due to glue migration, requiring splenectomy and intensive unit care admission. Conclusions: Retrograde embolization of high-flow PDA aneurysms is effective and safe without needing celiac trunk revascularization.

Compare efficacy and safety of autologous blood clot injection with C-clamp vascular closure device in treatment of iatrogenic pseudoaneurysm after femoral artery puncture

INTRODUCTION

Iatrogenic femoral artery pseudoaneurysm (FAP) is a complication following femoral artery puncture, with an incidence rate of 0.2%-5.5% post-cardiac catheterization procedures. Management typically involves observation or interventional treatments such as ultrasound-guided compression (UGC) or ultrasound-guided thrombin injections. This study compares the efficacy and safety of ultrasound-guided autologous blood clot injection (UGCI) with C-clamp vascular closure device-assisted UGC in treating FAP.

MATERIALS AND METHODS

Conducted at a high-volume training and research center, this prospective study enrolled patients with iatrogenic FAP post-femoral artery puncture. Patients were randomized into two treatments: UGC with a C-clamp device or UGCI. Primary endpoints were thrombosis induction within 24 h, average procedure time, and length of hospital stay (LOS).

RESULTS

The study included 105 patients with 51 undergoing UGCI and 54 undergoing UGC. UGCI achieved a primary success rate of 96% versus 63% for UGC. The mean procedure duration for UGCI was significantly shorter (22 min) compared with UGC (49 min, p ⩽ 0.0001). LOS was also reduced in the UGCI group (1.5 days) compared to the UGC group (4.5 days). Complication rates were low for both procedures, with one deep vein thrombosis and one infection observed in the UGC group.

CONCLUSION

UGCI demonstrated to be a safe, efficient, and faster alternative for treating iatrogenic FAPs with a higher success rate, reduced LOS, and similar low complication rates compared to UGC. This study suggests that UGCI could be considered a preferred method for the management of FAP post-femoral artery catheterization.

Prostate artery embolization using n-butyl cyanoacrylate glue for symptomatic benign prostatic hyperplasia: A six-month outcome analysis in 103 patients

PURPOSE

The purpose of this study was to assess the feasibility, safety, and 6-month outcomes of prostate artery embolization (PAE) using N-butyl-cyanoacrylate (NBCA) glue as the only embolic agent in patients with benign prostatic hyperplasia (BPH)-related lower urinary tract symptoms.

MATERIALS AND METHODS

Patients with BPH-related lower urinary tract symptoms who were treated by PAE using methacryloxysulfolane-NBCA mixed with ethiodized oil (1:8 ratio) between September 2018 and January 2023 were retrospectively included. Vascular mapping was made using cone-beam computed tomography angiography. PAEs were performed as an outpatient procedure, under local anaesthesia. Outcomes were assessed at six months using the International Prostate Symptoms Score (IPSS) and associated quality-of-life score (IPSS-QoL), prostate-specific antigen (PSA) level, prostate volume, and International Index of Erectile Function form 5 (IIEF5).

RESULTS

A total of 103 men with a mean age of 68.4 ± 6 (standard deviation [SD]) years were included. Technical success rate was 100%. The mean fluoroscopy time was 26.4 ± 12.5 (SD) min and the median radiation dose was 23 980 mGy·cm (Q1, Q3: 16 770, 38 450). Compared to baseline, statistically significant improvements were observed at six months for the IPSS (8.9 ± 6.2 [SD] vs. 20.2 ± 6.5 [SD]; P = 0.01), IPSS-QoL (2.1 ± 1.4 [SD] vs. 5.1 ± 0.9 [SD]; P = 0.01), PSA level (3.6 ± 3.2 [SD] ng/mL vs. 4.8 ± 4.2 [SD] ng/mL; P = 0.0001), and prostate volume (78.6 ± 43.5 [SD] mL vs. 119.1 ± 65.7 [SD] mL; P = 0.01). Minor adverse events developed in 19/103 (18.4%) patients. No major complications occurred. Compared to baseline, the IIEF5 did not change significantly at six months (15.3 ± 6.8 [SD] vs. 15.8 ± 6.8 [SD]; P = 0.078).

CONCLUSION

PAE with NBCA is a feasible and safe method that provides good outcomes at six months in patients with BPH-related lower urinary tract symptoms. This method deserves further evaluation in randomized trials with longer follow-up.

Transcatheter arterial embolization with N-butyl cyanoacrylate for postoperative hemorrhage treatment following pancreatoduodenectomy

PURPOSE

Postoperative hemorrhage (PPH) is a severe complication of pancreatoduodenectomy (PD) with a mortality rate of 5-20.2% and mortality due to hemorrhage of 11-58%. Transcatheter arterial embolization (TAE) has been widely recommended for PPH, however, TAE with N-butyl cyanoacrylate (NBCA) for PPH treatment has been reported rarely. Therefore, this study aimed to evaluate the safety and efficacy of TAE with NBCA for PPH treatment following PD.

METHODS

This retrospective study included 14 male patients (mean age, 60.93 ± 10.97 years) with postoperative hemorrhage following PD treated with TAE using NBCA as the main embolic agent from October 2019 to February 2022. The clinical data, technical and success rate, and complications were analyzed.

RESULTS

Among the 14 patients who underwent TAE, the technical and clinical success rates were 100 and 85.71%, respectively. Angiography revealed contrast extravasation in 12 cases and a pseudoaneurysm in 3 cases. One patient developed a serious infection and died 2 days after the TAE.

CONCLUSION

TAE with NBCA for PPH treatment following PD, especially for massive hemorrhage caused by a pancreatic fistula, biliary fistula, or inflammatory corrosion, can result in rapid and effective hemostasis with high safety.

Endovascular Treatment of Visceral Artery Pseudoaneurysms with Ethylene-Vinyl Alcohol (EVOH) Copolymer-Based Non-Adhesive Liquid Embolic Agents (NALEAs)

Background and Objectives: Treatment of visceral artery pseudoaneurysms (VAPs) is always indicated regardless of their diameters, as their risk of rupture is significantly higher than that of visceral artery aneurysms. The invasiveness of surgery and its associated complications have led to a shift in favor of radiological interventions as the initial treatment of choice. However, there are still some unanswered questions on endovascular treatment of VAPs regarding the optimal endovascular technique and the efficacy and safety outcomes. The purpose of this multicenter study was to retrospectively evaluate the effectiveness and safety of endovascular treatment of visceral pseudoaneurysms using Ethylene-Vinyl Alcohol (EVOH) Copolymer-Based Non-Adhesive Liquid Embolic Agents (NALEAs). Materials and Methods: Consecutive patients who underwent endovascular embolization with EVOH-based NALEAs for visceral artery pseudoaneurysms between January 2018 and June 2023 were retrospectively evaluated. Results: 38 embolizations were performed. Technical success was achieved in all patients. The clinical success rate was high (92.1% overall), with no significant differences between ruptured and unruptured VAPs (p = 0.679). Seven patients (18.4%) experienced procedure-related complications, related to one case of non-target embolization, four splenic abscesses due to end-organ infarction, and two femoral pseudoaneurysms. The rates of procedure-related complications, end-organ infarction, and vascular access-site complications did not significantly differ between ruptured and unruptured VAPs (p > 0.05). Conclusions: Both ruptured and unruptured visceral pseudoaneurysms can be effectively and safely treated with NALEA-based endovascular embolization. We suggest considering the use of NALEAs, particularly in specific clinical cases that highlight their advantages, including patients with coagulopathy, fragile vessels, and embolization targets that are located at a considerable distance from the microcatheter tip and are otherwise difficult to reach.

Transcatheter Arterial Embolization for Bleeding Related to Pelvic Trauma: Comparison of Technical and Clinical Results between Hemodynamically Stable and Unstable Patients

BACKGROUND

Endovascular intervention is now the primary line of therapy for arterial injury brought on by pelvic trauma since it can significantly reduce considerable morbidity associated with surgery and can swiftly access and control bleeding sites. Despite international guidelines and widespread awareness of the role of angioembolization in clinical practice, robust evidence comparing the outcomes of angioembolization in hemodynamically stable and unstable patients is still lacking. This study aims to directly compare the outcomes of angioembolization for the treatment of pelvic traumatic arterial injury in patients with hemodynamic stability vs. hemodynamic instability.

METHODS

In our multicenter retrospective investigation, we analyzed data from consecutive patients who underwent, from January 2020 to May 2023, angioembolization for traumatic pelvic arterial injury.

RESULTS

In total, 116 angioembolizations were performed. Gelatin sponges (56.9%) and coils (25.9%) were the most widely used embolic agents. The technical and clinical success rates were 100% and 91.4%, respectively. No statistically significant differences were observed between the two groups in terms of technical success, clinical success, procedure-related complication rate, or 30-day bleeding-related mortality.

CONCLUSIONS

Angioembolization is an effective and safe option for the management of traumatic pelvic arterial lesions even in hemodynamically unstable patients, despite technical variations such as greater use of prophylactic angioembolization.

A Multicenter Retrospective Cohort Study Evaluating the Clinical Outcomes of Patients with Coagulopathy Undergoing Transcatheter Arterial Embolization (TAE) for Acute Non-Neurovascular Bleeding

Background and Objectives: Transcatheter arterial embolization (TAE) is the mainstay of treatment for acute major hemorrhage, even in patients with coagulopathy and spontaneous bleeding. Coagulopathy is associated with worsening bleeding severity and higher mortality and clinical failure rates. Furthermore, some unanswered questions remain, such as the definition of coagulopathy, the indication for TAE or conservative treatment, and the choice of embolic agent. This study aims to assess the efficacy and safety of TAE for spontaneous non-neurovascular acute bleeding in patients with coagulopathy. Materials and Methods: This study is a multicenter analysis of retrospectively collected data of consecutive patients with coagulopathy who had undergone, from January 2018 to May 2023, transcatheter arterial embolization for the management of spontaneous hemorrhages. Results: During the study interval (January 2018-May 2023), 120 patients with coagulopathy underwent TAE for spontaneous non-neurovascular acute bleeding. The abdominal wall was the most common bleeding site (72.5%). The most commonly used embolic agent was polyvinyl alcohol (PVA) particles or microspheres (25.0%), whereas coils and gelatin sponge together accounted for 32.5% of the embolic agents used. Technical success was achieved in all cases, with a 92.5% clinical success rate related to 9 cases of rebleeding. Complications were recorded in 12 (10%) patients. Clinical success was significantly better in the group of patients who underwent correction of the coagulopathy within 24 h of TAE. Conclusions: Transcatheter arterial embolization (TAE) is effective and safe for the management of acute non-neurovascular bleeding in patients with coagulopathy. Correction of coagulopathy should not delay TAE and vice versa, as better clinical outcomes were noted in the subgroup of patients undergoing correction of coagulopathy within 24 h of TAE.

Interventional Radiology for High-Flow Aneurysm of the Pancreaticoduodenal Arcades with Median Arcuate Ligament Syndrome: Review of 14 Patients

Transarterial embolization (TAE) for high-flow pancreaticoduodenal artery (PDA) aneurysms in patients with celiac-trunk stenosis by the median arcuate ligament (MAL) has been found effective both after rupturing and to prevent rupture. The objective was to describe the TAE techniques used and their effectiveness in excluding PDA aneurysms due to MAL syndrome. This single-center retrospective study done at the Dijon-Bourgogne University Hospital included all patients treated by TAE in 2010-2022 for ruptured or unruptured high-flow PDA aneurysms caused by MAL syndrome. We identified 14 patients (7 women and 7 men; mean age, 64 years). Packing and trapping techniques were used alone or together. Occlusion was with microcoils, co-polymer, or cyanoacrylate glue, used separately or combined. Technical success was achieved in 13 (93%) patients. Clinical success was achieved in 12 (86%) patients. One major and two minor complications were recorded within the first 30 days. No complications occurred after 30 days. Follow-up ranged from 1 to 84 months. No cases of aneurysm recanalization have been recorded to date. TAE had high technical and clinical success rates in our patients with unruptured or ruptured PDA aneurysms due to MAL syndrome.

Transcatheter Arterial Embolization (TAE) in the Management of Bleeding in the COVID-19 Patient

Background and Objectives: Increasing attention is being paid to the coagulation disorders associated with SARS-CoV-2 infection. Bleeding accounts for 3-6% of COVID-19 patient deaths, and is often a forgotten part of the disease. The bleeding risk is enhanced by several factors, including spontaneous heparin-induced thrombocytopenia, thrombocytopenia, the hyperfibrinolytic state, the consumption of coagulation factors, and thromboprophylaxis with anticoagulants. This study aims to assess the efficacy and safety of TAE in the management of bleeding in COVID-19 patients. Materials and Methods: This multicenter retrospective study analyzes data from COVID-19 patients subjected to transcatheter arterial embolization for the management of bleeding from February 2020 to January 2023. Results: Transcatheter arterial embolization was performed in 73 COVID-19 patients for acute non-neurovascular bleeding during the study interval (February 2020-January 2023). Coagulopathy was observed in forty-four (60.3%) patients. The primary cause of bleeding was spontaneous soft tissue hematoma (63%). A 100% technical success rate was recorded; six cases of rebleeding resulted in a 91.8% clinical success rate. No cases of non-target embolization were observed. Complications were recorded in 13 (17.8%) patients. The efficacy and safety endpoints did not differ significantly between the coagulopathy and non-coagulopathy groups. Conclusions: Transcatheter Arterial Embolization (TAE) is an effective, safe and potentially life-saving option for the management of acute non-neurovascular bleeding in COVID-19 patients. This approach is effective and safe even in the subgroup of COVID-19 patients with coagulopathy.

Efficacy and Safety of Ethylene-Vinyl Alcohol (EVOH) Copolymer-Based Non-Adhesive Liquid Embolic Agents (NALEAs) in Transcatheter Arterial Embolization (TAE) of Acute Non-Neurovascular Bleeding: A Multicenter Retrospective Cohort Study

Background and Objectives: Transcatheter arterial embolization (TAE) is part of the daily practice of most interventional radiologists worldwide. The ideal liquid embolic agent is far from being identified. Non-adhesive liquid embolic agents (NALEA) harden from the outside to the inside, resulting in deep penetration, known as "magma-like" progression, which permits a more distal embolization with good control of the embolic material. This multicenter retrospective cohort study aims to assess the efficacy, feasibility and safety of transcatheter arterial embolization (TAE) with ethylene-vinyl alcohol (EVOH)-based NALEAs (Onyx and Squid) in acute bleeding outside of the neurovascular area. Materials and Methods: This study is a multicenter analysis of retrospectively collected data of consecutive patients who had undergone, from January 2015 to December 2022, transcatheter arterial embolization with non-adhesive EVOH-based agents in the setting of acute non-neurovascular bleeding. Results: Fifty-three patients underwent transcatheter arterial embolization for acute non-neurovascular bleeding. Eight (15.1%) procedures were performed in patients with coagulopathy. The most used concentration of EVOH-based NALEAs was 34 (i.e., 8%), with a mean dose of 0.5 (±0.3) mL. The mean CT-to-groin time, the mean procedure time, the mean CT-to-embolization time and the mean fluoroscopy time were 22.9 (±12.4) min, 27.5 (±7) min, 50.3 (±13.1) min and 7.5 (±2.8) min, respectively. Technical success was achieved in all cases with a 96.2% clinical success rate. Complications were recorded in six (11.3%) patients. No statistically significant differences were observed between the group of patients with coagulopathy and the group of patients without coagulopathy in terms of efficacy and safety endpoints. Conclusions: Transcatheter arterial embolization (TAE) performed with non-adhesive EVOH-based embolic agents is an effective, feasible and safe strategy for the management of acute non-neurovascular bleeding, even in the subgroup of patients with coagulopathy.

Outcomes of transarterial embolization for large symptomatic focal nodular hyperplasia in 17 pediatric patients

BACKGROUND

To evaluate the safety and the long-term outcomes of transarterial embolization (TAE) with lipiodol-bleomycin emulsion (LBE) plus N-Butyl cyanoacrylate (NBCA) in the treatment of children with large symptomatic focal nodular hyperplasia (FNH).

METHODS

This is a retrospective case serial study. Children (aged <18 years) with FNH were treated. Indications for TAE were patients who were presenting with FNH related abdominal pain and the maximum diameter of FNH is more than 7 cm, and who were not candidates for surgical treatment. Technical success, adverse events, symptoms relief rate, and changes in the lesion size after TAE were evaluated.

RESULTS

Between January 2003 and February 2018, 17 pediatric patients were included. Technical success was achieved in all patients. Mean follow-up was 67.5 months. All patients had complete resolution of abdominal symptom. The mean largest diameter of the lesions decreased from 10.5 cm to 1.9 cm (P < 0.01). The mean volume reduction rate was 96.9%. The complete resolution of the FNH was observed in 16 patients. No further therapy was needed for all patients.

CONCLUSIONS

TAE with LBE plus NBCA appears to be a safe and effective treatment in pediatric patients with large symptomatic FNH. It could be considered as the first-line treatment for symptomatic large FNH.

Medical Adhesives and Their Role in Laparoscopic Surgery—A Review of Literature

Laparoscopic surgery is undergoing rapid development. Replacing the traditional method of joining cut tissues with sutures or staples could greatly simplify and speed up laparoscopic procedures. This alternative could undoubtedly be adhesives. For decades, scientists have been working on a material to bond tissues together to create the best possible conditions for tissue regeneration. The results of research on tissue adhesives achieved over the past years show comparable treatment effects to traditional methods. Tissue adhesives are a good alternative to surgical sutures in wound closure. This article is a review of the most important groups of tissue adhesives including their properties and possible applications. Recent reports on the development of biological adhesives are also discussed.

Transcatheter arterial embolization for massive hemobilia with N-butyl cyanoacrylate (NBCA) Glubran 2

BACKGROUND

Massive hemobilia is a life-threatening condition and therapeutic challenge. Few studies have demonstrated the use of N-butyl cyanoacrylate (NBCA) for massive hemobilia.

PURPOSE

To investigate the efficacy and safety of transcatheter arterial embolization (TAE) using NBCA Glubran 2 for massive hemobilia.

MATERIAL AND METHODS

Between January 2012 and December 2019, the data of 26 patients (mean age 63.4 ± 12.6 years) with massive hemobilia were retrospectively evaluated for TAE using NBCA. The patients' baseline characteristics, severities of hemobilia, and imaging findings were collected. Emergent TAE was performed using 1:2-1:4 mixtures of NBCA and ethiodized oil. Technical success, clinical success, procedure-related complications, and follow-up outcomes were assessed.

RESULTS

Pre-procedure arteriography demonstrated injuries to the right hepatic artery (n = 24) and cystic artery (n = 2). Initial coil embolization distal to the lesions was required in 5 (19.2%) patients to control high blood flow and prevent end-organ damage. After a mean treatment time of 11.2 ± 5.3 min, technical success was achieved in 100% of the patients without non-target embolization and catheter adhesion. Clinical success was achieved in 25 (96.2%) patients. Major complications were noted in 1 (3.8%) patient with gallbladder necrosis. During a median follow-up time of 16.5 months (range 3-24 months), two patients died due to carcinomas, whereas none of the patients experienced recurrent hemobilia, embolic material migration, or post-embolization complications.

CONCLUSION

NBCA embolization for massive hemobilia is associated with rapid and effective hemostasis, as well as few major complications. This treatment modality may be a promising alternative to coil embolization.

Clinical Outcomes of Transcatheter Arterial Embolization Using N-butyl-2-cyanoacrylate (NBCA) in Cirrhotic Patients

Purpose

To evaluate the clinical outcomes of transcatheter arterial embolization (TAE) with n-butyl-2-cyanoacrylate (NBCA) for treatment of bleeding in cirrhotic patients.

Materials and methods

A total of 35 cirrhotic patients (26 men, 9 women; mean age, 48.4 ± 11.1) who underwent TAE with NBCA for bleeding from January 2011 to December 2020 were retrospectively analysed. Only cirrhotic patients with active arterial bleeding confirmed on computed tomography (CT) were included. Fifteen patients were hemodynamically unstable before embolization procedure, and coagulopathy was observed in 32 patients. The mean MELD score and Child Pugh score were 24 ± 9.9 and 9.9 ± 2.2, respectively. The mean haemoglobin level and mean number of RBC units transfused before embolization were 7.4 ± 1.4 g/dL and 10.2 ± 4, respectively. The technical, clinical success rate and 30-day mortality rate were evaluated.

Results

Technical success and clinical success rates were achieved in 100% and 82.8% of patients, respectively. Overall 30-day mortality rate was 48%. No major complications related to the embolization procedure was seen. Only the greater number of RBC units transfused before the embolization procedure (OR = 1.81, 95% CI = 1.17-2.80, P = 0.007) was significantly associated with clinical failure. Greater number of RBC units transfused (OR = 1.53, 95% CI: 1.00-2.34, P = 0.004) and higher Child Pugh score (OR 2.44, 95% CI 1.26-4.71, P = 0.008) were significantly associated with higher 30-day mortality rate.

Conclusion

Transcatheter arterial embolization using NBCA can be used as the effective treatment option for bleeding in cirrhotic patients which has a high technical and clinical success despite the grave prognosis associated with cirrhosis.

Selective Arterial Embolization with N-Butyl Cyanoacrylate Prior to CT-Guided Percutaneous Cryoablation of Kidney Malignancies: A Single-Center Experience

The study’s purpose was to assess the safety, feasibility and efficiency of selective arterial embolization (SAE) using N-butyl cyanoacrylate (NBCA) glue before percutaneous cryoablation (PCA) of renal malignancies in patients whose tumor characteristics and/or comorbidities resulted in an unacceptable risk of bleeding. In this single-center retrospective study of 19 consecutive high-risk patients (median age, 74 years) with renal malignancies managed in 2017–2020 by SAE with NBCA followed by PCA, data about patients, tumor and procedures characteristics, complications, renal function and hemoglobin concentration before and after treatment, as well as recurrence were collected. Charlson comorbidity index was ≥4 in 89.5% of patients. Ten patients were treated by antiplatelet and/or anticoagulant therapy. Median tumor largest diameter was 3.75 cm (range, 1–6.5 cm) and R.E.N.A.L. nephrometry score was ≥7 in 80%, indicating substantial tumor complexity. No major complications were recorded and minor complications occurred in 7 patients. No residual tumor was found at 6-week imaging follow-up in 18/19 patients. Tumor recurrence was visible in 1/16 patients at 6-month imaging follow-up. No significant difference was found for renal function after treatment (p = 0.07), whereas significant decrease in hemoglobin concentration was noted (p = 0.00004), although it was relevant for only one patient who required only blood transfusion and no further intervention. SAE prior to PCA is safe and effective for managing renal malignancies in high-risk patients.

Endovascular Use of Cyanoacrylate-Lipiodol Mixture for Peripheral Embolization: Properties, Techniques, Pitfalls, and Applications

Endovascular embolization agents are particles and fluids that can be released into the bloodstream through a catheter to mechanically and/or biologically occlude a target vessel, either temporarily or permanently. Vascular embolization agents are available as solids, liquids, and suspensions. Although liquid adhesives (glues) have been used as embolic agents for decades, experience with them for peripheral applications is generally limited. Cyanoacrylates are the main liquid adhesives used for endovascular interventions and have a major role in managing vascular abnormalities, bleeding, and many vascular diseases. They can only be injected as a mixture with ethiodized oil, which provides radiopacity and modulates the polymerization rate. This review describes the characteristics, properties, mechanisms of action, modalities of use, and indications of the cyanoacrylate-Lipiodol® combination for peripheral embolization.

In Vivo Experimental Endovascular Uses of Cyanoacrylate in Non-Modified Arteries: A Systematic Review

Cyanoacrylates were first used for medical purposes during World War II to close skin wounds. Over time, medical applications were developed, specifically in the vascular field. Uses now range from extravascular instillation in vascular grafting to intravascular injection for embolization. These applications were made possible by the conduct of numerous preclinical studies involving a variety of tests and outcome measures, including angiographic and histological criteria. Cyanoacrylates were first harshly criticized by vascular surgeons, chiefly due to their fast and irreversible polymerization. Over the past five years, however, cyanoacrylates have earned an established place in endovascular interventional radiology. Given the irreversible effects of cyanoacrylates, studies in animal models are ethically acceptable only if supported by reliable preliminary data. Many animal studies of cyanoacrylates involved the experimental creation of aneurysms or arteriovenous fistulas, whose treatment by endovascular embolization was then assessed. In clinical practice, however, injection into non-modified arteries may be desirable, for instance, to deprive a tumor of its vascular supply. To help investigators in this field select the animal models and procedures that are most appropriate for their objectives, we have reviewed all published in vivo animal studies that involved the injection of cyanoacrylates into non-modified arteries to discuss their main characteristics and endpoints.

Prostate Artery Embolization Using N-Butyl Cyanoacrylate Glue for Urinary Tract Symptoms Due to Benign Prostatic Hyperplasia: A Valid Alternative to Microparticles?

Our goal was to evaluate the feasibility, safety, and short-term outcomes of prostate artery embolization (PAE) with N-butyl cyanoacrylate (NBCA) glue as the only embolic agent in patients with benign prostatic hyperplasia (BPH)-related lower urinary tract symptoms (LUTSs). A two-center retrospective study of 50 patients (mean age, 67.6 ± 7.4 years; range, 54-85 years) treated with NBCA between 2017 and 2020 was conducted. PAE was performed using a mixture of Glubran 2 glue and Lipiodol in a 1:8 ratio, under local anesthesia, on an outpatient basis, after cone-beam computed tomography vascular mapping. Mean total injected NBCA/Lipiodol volume was 0.9 ± 0.3 mL, total injection time was 21.9 ± 7.8 s, and total radiation dose was 18,458 ± 16,397 mGy·cm. Statistically significant improvements over time occurred for the International Prostate Symptoms Score (9.9 ± 6.8 versus 20.5 ± 6.7, p = 0.0001), quality-of-life score (2.2 ± 1.5 versus 4.9 ± 1.0, p = 0.0001), prostate-specific antigen level (4.6 ± 3.0 versus 6.4 ± 3.7, p = 0.0001), and prostate volume (77.3 ± 30.5 versus 98.3 ± 40.2, p = 0.0001) at a median of 3 months versus baseline. Minor adverse events developed in 11/50 (22%) patients, but no major complications occurred. The International Index of Erectile Function did not change significantly. PAE with NBCA is feasible, safe, fast, and effective for patients with BPH-related LUTSs. Prospective comparative studies with longer follow-ups are warranted.

Efficacy, safety and outcomes of transcatheter arterial embolization with N-butyl cyanoacrylate glue for non-variceal gastrointestinal bleeding: A systematic review and meta-analysis

PURPOSE

To perform a systematic review and meta-analysis to determine the safety, efficacy, and outcomes of transcatheter arterial embolization (TAE) with N-butyl cyanoacrylate (NBCA) as the single embolic agent for the management of non-variceal upper and lower gastrointestinal bleeding (GIB).

MATERIALS AND METHODS

A literature search using MEDLINE/PubMed, EMBASE, and SCOPUS databases was performed for studies published from January 1980 to December 2019. Data from eligible studies were extracted and evaluated by two independent reviewers. Exclusion criteria were sample size <5, article reporting the use of NBCA with other embolic agents, no extractable data, and duplicate reports. Technical success, clinical success, 30-day rebleeding, 30-day overall and major complications, and 30-day mortality were evaluated. The estimated overall rates were calculated with their 95% confidence intervals, based on each study rate, weighted by the number of patients involved in each study. Heterogeneity across studies was assessed using the Q test and I² statistic.

RESULTS

Fifteen studies with 574 patients were included. For upper GIB (331 patients), the technical and clinical success rates, and 30-day rebleeding and mortality rates, were 98.8% (328 of 331 patients) and 88.0% (237 of 300 patients), and 12.5% (69 of 314 patients) and 15.9% (68 of 331 patients), respectively. Thirty-day overall and major complications occurred in 14.3% (28 of 331 patients) and 2.7% (7 of 331 patients) of patients, respectively. For lower GIB (243 patients), the technical and clinical success rates, and 30-day rebleeding and mortality rates, were 98.8% (78 of 78 patients) and 78.0% (145 of 189 patients), and 15.7% (33 of 218 patients) and 12.7% (14 of 78 patients), respectively. Thirty-day overall and major complications occurred in 13.0% (25 of 228 patients) and 8.6% (19 of 228 patients) of patients, respectively.

CONCLUSION

TAE with NBCA is safe and effective for treating non-variceal GIB, with high clinical success and very low major complication rates.

The safety and efficacy of Glubran 2 as biliostatic agent in liver resection

Background

Biloma, an encapsulated collection of bile outside the biliary tree, supported by a predominantly iatrogenic biliary fistula, and bile likeage are two of the most important surgical complications after liver resection. We, hypothesized to conduct a project aimed to prevent, or reduce, the formation of biloma or biliary fistula applying on the hepatic resection area the cyanoacrylate glue (Glubran2).

Methods

We searched in our surgical database all patients underwent liver resection for mCRC from January 2013 to December 2018 and we found a total of 510 patients. 205 patients for Group A (study population: included patients in which we have used Glubran2 during surgical procedure) and 113 patients for Group B (control group), were enrolled.

Results

In both Groups no patients died during hospitalization and the 30-day mortality was 0 %. During follow-up in Group A, a biliary fistula was found in 2 patients (1 %) versus 3 patients in the Group B (2,6 %). In patients enrolled in Group A no adverse event were reported relate to the use of Glubran2.

Conclusions

It is possible to affirm that the use of Glubran2 as biliostatic agent after liver resection is useful to prevent bile leakage complication and biloma formation and its use demonstrated to be safe and feasible during liver surgery.

Recurrent massive hemoptysis in a patient with cystic fibrosis: balloon assisted Onyx embolization after bronchial artery coil recanalization

Background

Although not standard of care, Cystic Fibrosis patients with recurrent hemoptysis occasionally have coil embolization of bronchial arteries. In the event of recanalization of these arteries in this specific subset of patients, the presence of indwelling coils makes the prospect of conventional particle embolization more difficult, preventing both adequate catheterization of the coiled segment and reflux of the particles.

Case presentation

In this report, we describe a case of bronchial artery embolization of a complex Cystic Fibrosis patient with massive hemoptysis from recanalized coiled bronchial arteries utilizing a Scepter Balloon Catheter® (Microvention Terumo, USA) in administration of the liquid embolic agent Onyx® (Medtronic, USA).

Conclusions

The Scepter occlusion balloon catheter allowed for careful placement of the tip within the interstices of the pre-existing coils, allowing for Onyx injection directly into the coil mass without reflux, reconfirming the benefits of Onyx embolization in bronchial artery embolization and providing evidence that the Scepter occlusion balloon catheter should be added to the armamentarium of devices used in complex bronchial artery embolization for Cystic Fibrosis patients with massive hemoptysis.

Ten-year experience with arterial embolization for peptic ulcer bleeding: N-butyl cyanoacrylate glue versus other embolic agents

OBJECTIVES

To compare our experience with N-butyl cyanoacrylate glue as the primary embolic agent versus other embolic agents for transcatheter arterial embolization (TAE) in refractory peptic ulcer bleeding and to identify factors associated with early rebleeding and 30-day mortality.

METHODS

Retrospective study of 148 consecutive patients comparing the clinical success rate in 78 patients managed with Glubran®2 N-butyl cyanoacrylate metacryloxysulfolane (NBCA-MS) alone or with other agents and 70 with other embolic agents only (coils, microspheres, ethylene-vinyl alcohol copolymer, or gelatin sponge) at a university center in 2008-2019. Univariate and multivariate logistic regression analyses were done to identify prognostic factors.

RESULTS

The technical success rate was 95.3% and the primary clinical success was 64.5%. The early rebleeding and day-30 mortality rates were 35.4% and 21.3%, respectively. Rebleeding was significantly less common with than without Glubran®2 (OR, 0.47; 95% CI, 0.22-0.99; p = .047) and significantly more common with coils used alone (OR, 20.4; 95% CI, 10.13-50.14; p = .024). The only other factor independently associated with early rebleeding was having two or more comorbidities (OR, 20.14; 95% CI, 10.01-40.52; p = .047). Day-30 mortality was similar in the two treatment groups. A lower initial hemoglobin level was significantly associated with higher day-30 mortality (OR, 10.38; 95% CI, 10.10-10.74; p = .006). Fluoroscopy time was significantly shorter with Glubran®2 (20.8 ± 11.5 min vs. 35.5 ± 23.4 min, p = .002). Both groups (Glubran®2 vs. other agents) had similar rates of overall complications (10.7% vs. 9.1%, respectively, p = .786).

CONCLUSIONS

Glubran®2 NBCA-MS as the primary agent allowed for faster and better clinical success compared to other embolic agents when used for TAE to safely stop refractory peptic ulcer bleeding.

KEY POINTS

• Choice of embolic agent for arterial embolization of refractory peptic ulcer bleeding is still debated. We compared our experience with N-butyl cyanoacrylate (NBCA) glue vs. other embolic agents. • The use of Glubran®2 NBCA glue in the endovascular management of refractory peptic ulcer bleeding was significantly faster and more effective, and at least as safe compared to other embolic agents. • NBCA glue offers several advantages compared to other embolic agents and provides rapid hemostasis when used for arterial embolization to treat refractory peptic ulcer bleeding. It should be the first-line therapy.

Current role of cyanoacrylate glue transcatheter embolization in the treatment of acute nonvariceal gastrointestinal bleeding

INTRODUCTION

Over the past three decades, transcatheter arterial embolization (TAE) has become the first-line therapy for the management of acute nonvariceal gastrointestinal bleeding (NVGIB) that is refractory to endoscopic hemostasis. Advances in catheter-based techniques and newer liquid embolic agents, as well as recognition of the effectiveness of minimally invasive treatment options, have expanded the role of interventional radiology in the treatment of acute NVGIB. Many embolic agents have been used successfully. However, no guidelines exist about the choice of the best embolic agent which is still controversial. Cyanoacrylate glue has gained acceptance over time. This article aims to address the current role of TAE using cyanoacrylate glue for the treatment of acute NVGIB.

AREAS COVERED

The authors undertook a literature review of the current evidence on the use of cyanoacrylate glue in treating patients with acute NVGIB.

EXPERT OPINION

The evidence shows that cyanoacrylate glue is the most clinically useful embolic agent in treating patients with acute NVGIB, despite the need for learning curve, especially in case of coagulopathy. At present, research is ongoing to assess liquid embolic agents in the treatment of patients presenting with acute NVGIB. More research is needed but cyanoacrylate glue show promise for the future.

Back to the Future: Lipiodol in Lymphography-From Diagnostics to Theranostics

Lipiodol is an iodinated poppy seed oil first synthesized in 1901. Originally developed for therapeutic purposes, it has mainly become a diagnostic contrast medium since the 1920s. At the end of the 20th century, Lipiodol underwent a transition back to a therapeutic agent, as exemplified by its increasing use in lymphangiography and lymphatic interventions. Nowadays, indications for lymphangiography include chylothorax, chylous ascites, chyluria, and peripheral lymphatic fistula or lymphoceles. In these indications, Lipiodol alone has a therapeutic effect with clinical success in 51% to 100% of cases. The 2 main access sites to the lymphatic system for lymphangiography are cannulation of lymphatic vessels in the foot (transpedal) and direct puncture of (mainly inguinal) lymph nodes (transnodal). In case of failure of lymphangiography alone to occlude the leaking lymphatic vessel as well as in indications such as protein-losing enteropathy, postoperative hepatic lymphorrhea, or plastic bronchitis, lymphatic vessels can also be embolized directly by injecting a mixture of Lipiodol and surgical glues (most commonly in thoracic duct embolization). The aim of this article is to review the historical role of Lipiodol and the evolution of its clinical application in lymphangiography over time until the current state-of-the-art lymphatic imaging techniques and interventions.

Partial splenic embolization with Glubran®2/Lipiodol® mixture for oncological patients with hypersplenism-related thrombocytopenia requiring systemic chemotherapy

Background

Partial splenic embolization (PSE) has been used to improve thrombocytopenia related to hypersplenism. The optimal embolic agent is still debated. The purpose of this study was to evaluate the safety, hematologic response and outcomes of PSE with cyanoacrylate glue for oncological patients with hypersplenism-related thrombocytopenia requiring systemic chemotherapy (SC).

Methods

Retrospective single-center observational report of cancer patients with thrombocytopenia related to hypersplenism and requiring SC who underwent PSE with N-butyl cyanoacrylate-methacryloxy sulfolane (NBCA-MS) Glubran^®2 glue between February 2015 and September 2017. All patients were treated under local anesthesia with a Glubran^®2/Lipiodol^® mixture of 1:5 ratio. They all received empiric antibiotic coverage. Splenic volume and parenchyma infarction rate were evaluated by CT scan within 1 month of PSE. Primary and secondary endpoints of the current study included a platelet count increase >150×10⁹/L and the initiation of SC, respectively. Periprocedural laboratory values and adverse events were recorded.

Results

PSE was performed in eight patients (6 males, 2 females; median age, 59 years; range, 33-75 years) for a technical success of 100%. For procedures with adequate follow-up, primary and secondary endpoints were achieved in 100% (7 of 7 patients) and 100% (7 of 7 patients) of patients, respectively. One patient died before follow-up, unrelated to the procedure. Mean splenic infarction post-PSE was 55% (range, 21-70%) on CT scan. For 7 patients with laboratory follow-up, the mean platelet count significantly increased from 74×10⁹/L [range, (62-83) ×10⁹/L] immediately before PSE to a peak level of 272×10⁹/L [range, (161-417) ×10⁹/L] 10 days after PSE (P<0.05). All patients could receive SC after PSE. No non-target glue embolization occurred. All patients experienced a transient and moderate postembolization syndrome. No severe postembolization syndrome occurred. No major complication was reported. The mean overall survival was 7.9 months (range, 0.6-10.4 months) among the 8 patients after PSE.

Conclusions

PSE with cyanoacrylate glue is safe and effective in the management of thrombocytopenia related to hypersplenism in cancer patients. It allows sufficient platelet count improvement for administration of SC.

Percutaneous ultrasound-guided balloon-assisted embolization of iatrogenic femoral artery pseudoaneurysms with Glubran®2 cyanoacrylate glue: safety, efficacy and outcomes

Background

Femoral pseudoaneurysm (PA) is a frequent complication of arterial access for endovascular procedures. Surgery has traditionally been considered as the gold standard of therapy. We aimed to report our experience of percutaneous ultrasound (US)-guided balloon-assisted embolization with cyanoacrylate glue for the treatment of iatrogenic femoral PAs.

Methods

Retrospective two-center study of patients with femoral iatrogenic PAs treated by N-butyl cyanoacrylate-methacryloxy sulfolane (NBCA-MS) Glubran^®2 glue embolization between July 2013 and November 2017. All patients underwent contralateral arterial access with balloon placement of an appropriate size in front of the PA neck before glue/lipiodol embolization in a 1:1 ratio by percutaneous US-guided puncture of the aneurysmal sac under fluoroscopy control.

Results

Twenty-three patients (12 females, 11 males; median age, 79 years; range, 18-93 years) were included. Median PA size was 34 mm (range, 17-60 mm). The median time to treatment was 5 days (range, 1-30 days). Twenty patients (86.9%) were successfully treated by glue injection alone. The three remaining patients (13.1%) with persistent PA or associated arterial-venous fistula were immediately treated during the same procedure by additional stent-graft. Then, overall immediate and 1-month clinical success rates were 100%. No surgical conversion was necessary. No recurrence was reported during the median follow-up of 11 months (range, 2-73 months). Two (8.7%) puncture-related complications occurred at the contralateral arterial access site, which spontaneously resolved. No non-target glue embolization occurred.

Conclusions

US-guided balloon-assisted glue embolization is safe and effective to treat iatrogenic femoral PAs in most cases, offering complete exclusion of the PA and avoiding the morbidity of open surgery.

Trans Arterial Embolization of Non-variceal Upper Gastrointestinal Bleeding: Is the Use of Ethylene-Vinyl Alcohol Copolymer as Safe as Coils?

PURPOSE

The safety of liquid embolics over the conventional coils for the treatment of non-variceal upper gastrointestinal bleeding (UGIB) approach is still unclear. Purpose of this study is to assess the safety of ethylene-vinyl alcohol copolymer (EVOH 6%) over coils in the treatment of UGIB.

MATERIALS AND METHODS

All the upper gastrointestinal tract embolization procedures performed in a single center in a 6-year period were reviewed. Patients embolised with coils (Group A) versus those embolised with EVOH 6% (Group B) were compared. Technical/clinical success, bleeding recurrence, complication and mortality rates were analyzed.

RESULTS

A total 71 patients were included in the study (41 Group A and 30 Group B). Coagulopathy was present in 21% of Group A and 46% of Group B patients (p < 0.05). Technical and clinical success was 97.6 and 92.7% for Group A, and 100 and 93.3% for Group B respectively, (p > 0.05). Ten patients (17% Group A; 10% Group B) re-bled within the first 36 h and all of them were re-treated successfully with a second embolization. In Group A one major complication (bowel ischemia) occurred. No complication occurred in Group B. The survival rate in the first 30 days was 90.3% for group A and 90% for group B (p > 0.05).

CONCLUSION

This study demonstrated EVOH 6% appears to be as safe and effective as coils in the treatment of non-variceal UGIB.