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Penedos C, Pereira C, Lemos L, Pina P. Pulmonary biological glue embolism after endoscopic repair of gastric varices - A case report. Saudi J Anaesth 2023; 17:249-251. [PMID: 37260669 PMCID: PMC10228839 DOI: 10.4103/sja.sja_673_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 03/11/2023] Open
Abstract
Cyanoacrylate injection is widely used to treat hemorrhagic gastric varices. A pulmonary glue embolism is an unusual but potentially fatal complication. We present a case of a 51-year-old man with a history of alcoholic hepatic cirrhosis Child-Pugh B, who had an acute pulmonary embolism with sudden cardiorespiratory collapse due to biological glue injection used for the emergent repair of bleeding gastric varices. After the restoration of respiratory and hemodynamic parameters, he was admitted to the intensive care unit and the pulmonary biological glue emboli were documented with computed tomography scan. A high index of suspicion for this entity is essential in patients submitted to endoscopic sclerotherapy. Some might be asymptomatic or mildly symptomatic, while others might present with cardiorespiratory collapse.
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Affiliation(s)
- Constanca Penedos
- Serviço de Anestesiologia e Cuidados Intensivos, Centro Hospitalar e Universitário do Porto, Porto, Portugal
| | - Cristina Pereira
- Serviço de Anestesiologia e Cuidados Intensivos, Unidade Local de Saúde de Matosinhos, Porto, Portugal
| | - Leonor Lemos
- Serviço de Anestesiologia e Cuidados Intensivos, Centro Hospitalar e Universitário do Porto, Porto, Portugal
| | - Pedro Pina
- Serviço de Anestesiologia e Cuidados Intensivos, Centro Hospitalar e Universitário do Porto, Porto, Portugal
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Sabry F, Seif S, Eldesoky A, Hakim H, Altonbary AY. EUS-guided cyanoacrylate injection into the perforating vein versus direct endoscopic injection in the treatment of gastric varices. Endosc Int Open 2023; 11:E202-E210. [PMID: 36845270 PMCID: PMC9949986 DOI: 10.1055/a-1984-7070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
Background and study aims Endoscopic injection of gastric varices (GVs) using cyanoacrylate (CYA) is associated with significant adverse events (AEs). We aimed to compare the efficacy and safety of endoscopic ultrasound (EUS)-guided CYA injection into the perforating vein versus direct endoscopic injection (DEI) of CYA in treatment of high-risk GVs. Patients and methods This was a randomized controlled trial that included 52 patients with high-risk GVs. Group A underwent EUS-guided injection into the perforator vein and Group B underwent DEI of 1 mL CYA. Endoscopic examination and Doppler EUS were repeated after 3 months to confirm eradication. Obliteration by Doppler EUS was considered by absence of Doppler flow within the varix. Repeated injection was performed in the absence of obliteration. Doppler EUS examination was repeated at 3 and 6 months after each injection. Results Forty-three patients including 27 males and 16 females with mean age 57 years completed the study. Variceal obliteration was achieved during the index session after 3 months in eight of 21 (38.1 %) in group B compared to 17 of 22 (77.2 %) in group A ( P = 0.014). There was a significant difference in the amount of CYA needed to achieve obliteration in group B compared to group A (2 vs.1 mL, P = 0.027). There was no statistically significant difference in the overall AE rate between group A and group B (4.5 % vs. 14.3 %, P = 0.345). Conclusions EUS-guided CYA injection into the perforating veins achieved less amount of CYA, fewer number of sessions to obliteration, and similar overall AE rates in the treatment of high-risk GVs compared to DEI.
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Affiliation(s)
- Fady Sabry
- Mansoura University Faculty of Medicine, Department of Gastroenterology and Hepatology, Mansoura, Egypt
| | - Seham Seif
- Mansoura University Faculty of Medicine, Department of Gastroenterology and Hepatology, Mansoura, Egypt
| | - Ayman Eldesoky
- Mansoura University Faculty of Medicine, Department of Gastroenterology and Hepatology, Mansoura, Egypt
| | - Hazem Hakim
- Mansoura University Faculty of Medicine, Department of Gastroenterology and Hepatology, Mansoura, Egypt
| | - Ahmed Youssef Altonbary
- Mansoura University Faculty of Medicine, Department of Gastroenterology and Hepatology, Mansoura, Egypt
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Sirbu O, Sorodoc V, Floria M, Statescu C, Sascau R, Lionte C, Petris OR, Haliga RE, Morariu PC, Tirnoveanu A, Burduloi VM, Ursulescu C, Sorodoc L. Nontrombotic Pulmonary Embolism: Different Etiology, Same Significant Consequences. J Pers Med 2023; 13:jpm13020202. [PMID: 36836436 PMCID: PMC9963227 DOI: 10.3390/jpm13020202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/16/2023] [Accepted: 01/20/2023] [Indexed: 01/26/2023] Open
Abstract
Nontrombotic pulmonary embolism represents the embolization of different types of materials (cells, organisms, gas, foreign material) into pulmonary circulation. The disease is uncommon, and clinical presentation together with laboratory findings are nonspecific. Its pathology is usually misdiagnosed based on imaging findings as pulmonary thromboembolism, but the correct diagnosis is essential because different therapeutic approaches are required. In this context, knowledge of the risk factors associated with nontrombotic pulmonary embolism and specific clinical symptoms is fundamental. Our objective was to discuss the specific features of the most common etiologies of nontrombotic pulmonary embolism, gas, fat, amniotic fluid, sepsis and tumors, to provide assistance for a rapid and correct diagnosis. Because the most common etiologies are iatrogenic, knowledge of the risk factors could be an important tool for prevention or rapid treatment if the disease develops during different procedures. The diagnosis of nontrombotic pulmonary embolisms represent a laborious challenge, and endeavors should be made to prevent development and increase awareness of this disease.
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Affiliation(s)
- Oana Sirbu
- Department of Internal Medicine, Clinical Emergency Hospital “Sfântul Spiridon”, 700111 Iasi, Romania
- Faculty of General Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 16 Universitatii Street, 700115 Iasi, Romania
| | - Victorita Sorodoc
- Department of Internal Medicine, Clinical Emergency Hospital “Sfântul Spiridon”, 700111 Iasi, Romania
- Faculty of General Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 16 Universitatii Street, 700115 Iasi, Romania
- Correspondence: (V.S.); (C.S.)
| | - Mariana Floria
- Department of Internal Medicine, Clinical Emergency Hospital “Sfântul Spiridon”, 700111 Iasi, Romania
- Faculty of General Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 16 Universitatii Street, 700115 Iasi, Romania
| | - Cristian Statescu
- Faculty of General Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 16 Universitatii Street, 700115 Iasi, Romania
- Department of Cardiology, Institute of Cardiovascular Diseases “Dr. George I.M. Georgescu”, 700503 Iasi, Romania
- Correspondence: (V.S.); (C.S.)
| | - Radu Sascau
- Faculty of General Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 16 Universitatii Street, 700115 Iasi, Romania
- Department of Cardiology, Institute of Cardiovascular Diseases “Dr. George I.M. Georgescu”, 700503 Iasi, Romania
| | - Catalina Lionte
- Department of Internal Medicine, Clinical Emergency Hospital “Sfântul Spiridon”, 700111 Iasi, Romania
- Faculty of General Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 16 Universitatii Street, 700115 Iasi, Romania
| | - Ovidiu Rusalim Petris
- Department of Internal Medicine, Clinical Emergency Hospital “Sfântul Spiridon”, 700111 Iasi, Romania
- Faculty of General Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 16 Universitatii Street, 700115 Iasi, Romania
| | - Raluca Ecaterina Haliga
- Department of Internal Medicine, Clinical Emergency Hospital “Sfântul Spiridon”, 700111 Iasi, Romania
- Faculty of General Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 16 Universitatii Street, 700115 Iasi, Romania
| | - Paula Cristina Morariu
- Department of Internal Medicine, Clinical Emergency Hospital “Sfântul Spiridon”, 700111 Iasi, Romania
- Faculty of General Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 16 Universitatii Street, 700115 Iasi, Romania
| | - Andreea Tirnoveanu
- Faculty of General Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 16 Universitatii Street, 700115 Iasi, Romania
| | - Vladut Mirel Burduloi
- Faculty of General Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 16 Universitatii Street, 700115 Iasi, Romania
| | - Corina Ursulescu
- Faculty of General Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 16 Universitatii Street, 700115 Iasi, Romania
- Department of Radiology, Clinical Emergency Hospital “Sfântul Spiridon”, 700111 Iasi, Romania
| | - Laurentiu Sorodoc
- Department of Internal Medicine, Clinical Emergency Hospital “Sfântul Spiridon”, 700111 Iasi, Romania
- Faculty of General Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 16 Universitatii Street, 700115 Iasi, Romania
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Tang L, Li X, Cui J, Huang LY. EUS-guided coil placement and cyanoacrylate glue injection for gastric variceal bleeding with obvious spontaneous portosystemic shunts. Endosc Ultrasound 2023; 12:84-89. [PMID: 36510864 PMCID: PMC10134932 DOI: 10.4103/eus-d-22-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background and Objective Ectopic embolism caused by cyanoacrylate glue for the treatment of gastric varices with obvious spontaneous portosystemic shunts is a serious complication of endoscopic therapy. This study was performed to investigate the safety and therapeutic effect of EUS-guided coil placement and cyanoacrylate glue injection for gastric varices with obvious spontaneous portosystemic shunts. Materials and Methods Six patients with gastric variceal bleeding and obvious spontaneous portosystemic shunts were included in this study. We evaluated the success rate of variceal occlusion after intraoperative embolization, the postoperative rebleeding rate at 48 h and 2 weeks posttreatment, and the incidence of ectopic embolism and other adverse events. Gastroscopy and computed tomography portal venography (CTPV) were performed 7 months later. Results All patients underwent successful coil placement and cyanoacrylate glue injection under EUS guidance. The blood flow was confirmed by Doppler examination, the target vessels were successfully blocked, and no rebleeding had occurred at 48 h or 2 weeks after endoscopic treatment. Gastroscopy was repeated 7 months after endoscopic treatment, revealing local ulcer formation. CTPV was also repeated 7 months after endoscopic treatment, showing that the coils were present in the target vessels with no displacement, the portosystemic shunt vessels were occluded, and no ectopic embolization had occurred. Conclusion The coil placement combined with cyanoacrylate glue embolism is a safe and effective method for patients with gastric variceal bleeding and obvious spontaneous portosystemic shunts.
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Affiliation(s)
- Li Tang
- Department of Gastroenterology, Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong Province, China
| | - Xu Li
- Department of Gastroenterology, Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong Province, China
| | - Jun Cui
- Department of Gastroenterology, Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong Province, China
| | - Liu-Ye Huang
- Department of Gastroenterology, Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong Province, China
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Guber K, Zilinyi RS, Driggin E, Soroush A, Welinsky S, Nathanson J, Sethi A, Rubin D. Rare Complication of Endoscopic Variceal Therapy: Wide-Complex Tachycardia Associated With Embolization of Glue and Coil. JACC Case Rep 2022; 4:433-437. [PMID: 35693901 PMCID: PMC9175143 DOI: 10.1016/j.jaccas.2021.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/09/2021] [Accepted: 11/15/2021] [Indexed: 06/15/2023]
Abstract
We present the case of a woman with upper gastrointestinal bleeding secondary to gastric varices requiring endoscopic cyanoacrylate glue and coil embolization. The procedure was complicated by regular, wide-complex tachycardia, with further investigation revealing cardiopulmonary migration of the glue and coil. (Level of Difficulty: Advanced.).
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Affiliation(s)
- Kenneth Guber
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Robert S. Zilinyi
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Elissa Driggin
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Ali Soroush
- Division of Gastroenterology, Columbia University Irving Medical Center, New York, New York, USA
| | - Sara Welinsky
- Division of Gastroenterology, Columbia University Irving Medical Center, New York, New York, USA
| | - John Nathanson
- Division of Gastroenterology, Columbia University Irving Medical Center, New York, New York, USA
| | - Amrita Sethi
- Division of Gastroenterology, Columbia University Irving Medical Center, New York, New York, USA
| | - David Rubin
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
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Frassei JDS, Franco CS, Brambilla VR, Loureiro BMC, Kiebert CDS, Fonseca EKUN, Ando SDM, Sawamura MVY. Cyanoacrylate pulmonary embolism after endoscopic sclerotherapy of gastric varices. EINSTEIN-SAO PAULO 2021; 19:eAI5778. [PMID: 33503148 PMCID: PMC7821951 DOI: 10.31744/einstein_journal/2021ai5778] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 10/23/2020] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - Camila Soares Franco
- Hospital das Clínicas , Faculdade de Medicina , Universidade de São Paulo , São Paulo , SP , Brazil
| | | | | | | | | | - Sabrina de Mello Ando
- Hospital das Clínicas , Faculdade de Medicina , Universidade de São Paulo , São Paulo , SP , Brazil
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Thiruvengadam SS, Sedarat A. The Role of Endoscopic Ultrasound (EUS) in the Management of Gastric Varices. Curr Gastroenterol Rep 2021; 23:1. [PMID: 33389241 PMCID: PMC7778619 DOI: 10.1007/s11894-020-00801-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Gastric varices (GV) are an important complication of portal hypertension, and the current recommendation for management is beta-blocker therapy for primary prophylaxis and transjugular intrahepatic portosystemic shunt (TIPS) for active bleeding or secondary prophylaxis. Direct endoscopic injection of cyanoacrylate (CYA) glue has been investigated but has drawbacks including limited endoscopic characterization of GV and possible distal glue embolism. To this end, endoscopic ultrasound (EUS) has been pursued to help in characterization of GV, visualization of treatment in real time, and confirmation of obliteration with Doppler. RECENT FINDINGS In this paper, we review treatments for GV involving EUS, including EUS-guided injection of CYA and coils, either alone or in combination. We also discuss less common methods, including EUS-guided injection of thrombin and absorbable gelatin sponge. We then review literature comparing EUS-guided methods with direct endoscopic therapy and comparing individual EUS-guided methods with one another. We conclude by highlighting drawbacks of EUS in this field, including the unproven benefit over conventional therapy, lack of a standardized approach, and limited availability of expertise and necessary materials. Novel EUS-based methods offer a unique opportunity to directly visualize and access gastric varices for treatment and obliteration. This may provide key advantages over current endoscopic or angiographic treatments. Comparative studies investigating the benefit of EUS over conventional therapy are needed.
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Affiliation(s)
| | - Alireza Sedarat
- Division of Digestive Diseases, UCLA Vatche and Tamar Manoukian, Los Angeles, CA USA
- Santa Monica, USA
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Balloon-Assisted Percutaneous Transhepatic Antegrade Embolization with 2-Octyl Cyanoacrylate for the Treatment of Isolated Gastric Varices with Large Gastrorenal Shunts. BIOMED RESEARCH INTERNATIONAL 2019; 2019:2674758. [PMID: 31073523 PMCID: PMC6470428 DOI: 10.1155/2019/2674758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 02/21/2019] [Indexed: 12/12/2022]
Abstract
Aims To evaluate the safety and effectiveness of percutaneous transhepatic antegrade embolization (PTAE) with 2-octyl cyanoacrylate assisted with balloon occlusion of the left renal vein or gastrorenal shunts (GRSs) for the treatment of isolated gastric varices (IGVs) with large GRSs. Methods Thirty patients with IGVs associated with large GRSs who had underwent PTAE assisted with a balloon to block the opening of the GRS in the left renal vein were retrospectively evaluated and followed up. Clinical and laboratory data were collected to evaluate the technical success of the procedure, complications, changes in the liver function using Child-Pugh scores, worsening of the esophageal varices, the rebleeding rate, and survival. Laboratory data obtained before and after PTAE were compared (paired-sample t-test). Results PTAE was technically successful in all 30 patients. No serious complications were observed except for one nonsymptomatic pulmonary embolism. During a mean follow-up of 30 months, rebleeding was observed in 4/30 (13.3%) patients, worsening of esophageal varices was observed in 4/30 (13.3%) patients, and newly developed or aggravated ascites were observed on CT in 3/30 (10%) patients. Significant improvement was observed in Child-Pugh scores (p=0.009) and the international normalized ratio (INR) (p=0.004) at 3 months after PTAE. The cumulative survival rates at 1, 2, 3, and 5 years were 96.3%, 96.3%, 79.9%, and 79.9%, respectively. Conclusion Balloon-assisted PTAE with 2-octyl cyanoacrylate is technically feasible, safe, and effective for the treatment of IGV associated with a large GRS.
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