Bucrylate treatment of bleeding gastric varices: 12 years' experience

BACKGROUND AND STUDY AIMS

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Symptomatic pulmonary complications from liquid acrylate embolization of brain arteriovenous malformations

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The pathology of arteriovenous malformations of the brain treated by embolotherapy. II. Results of embolization with multiple agents

Light microscopic and immunohistochemical examination was undertaken of intracranial arteriovenous malformations (AVMs) surgically resected from 18 patients, each of whom had undergone preoperative angiographic embolization with multiple agents. Distinct patterns of tissue reaction to these agents were noted, even when more than one substance was present in a vascular lumen. Avitene produced the mildest tissue response but resulted in relatively early endothelialization and recanalization. Cyanoacrylates were longer-lasting but associated with more acute and chronic (including granulomatous) inflammation and vessel wall changes. Polyvinyl alcohol foam/ethanol mixture had intermediate properties. Endothelial proliferation over embolization material was confirmed using immunohistochemical application of an antibody to cell proliferation-specific proteins. The significance of these findings for combined endovascular and surgical treatment of cerebral vascular malformations is discussed.

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

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

Complications of transthoracic needle biopsy decreased with isobutyl 2-cyanoacrylate: a pilot study

To explore the possibility of performing percutaneous lung biopsy safely in patients mechanically ventilated with positive-end expiratory pressure (PEEP), transthoracic needle biopsy was performed in 16 anesthetized mongrel dogs mechanically ventilated with 10 cm H2O of PEEP. To obtain the biopsy sample, a 25-gauge "skinny needle" was passed through a 20-gauge sheath and placed up to 6.25 cm deep. After satisfactory samples were obtained, both needles were withdrawn in the control group, but in the treated group, the outer sheath was used to inject 0.5 ml of isobutyl 2-cyanoacrylate to seal the needle track. Pneumothorax was present in 7 (87.5%) of 8 dogs in the control group and in 2 (25%) of 8 dogs in the treated group (p = .0147). Lung tissue exhibited an apparent foreign-body granulomatous inflammatory reaction. This technique could extend the benefits of transthoracic needle biopsy to mechanically ventilated patients, but further studies to prove the safety of isobutyl 2-cyanoacrylate are necessary.

[Endoscopic obturation of esophagogastric varices with bucrylate. II. Morphologic study based on 12 autopsy cases]

The authors report the results of postmortem histopathological studies in 12 patients who had been treated by endoscopic obliteration of esophagogastric varices with Bucrylate (isobutyl-2-cyanoacrylate). All patients had cirrhosis; 11 patients were Pugh classe C. Eleven patients had esophageal injections. Acute esophageal lesions were characterized by ulcerations in obliterated varices and diffusion of Bucrylate into the esophageal wall. Chronic lesions were characterized by disappearance of varices and Bucrylate, extending fibrosis of the esophageal wall and re-epithelialization of the mucosa. In one patient who had received gastric injections only, non ulcerated Bucrylate filled gastric varices were seen. Bucrylate seems to have a dual action on esophageal varices: immediate obliteration and acute necrosis of the vascular endothelium. Necrosis causes diffusion of Bucrylate through the esophageal wall, and later, secondary fibrosis whereas the product is progressively eliminated into the esophageal lumen.

[Endoscopic obturation of esophagogastric varices with bucrylate. I. Clinical study of 49 patients]

The authors report the results of endoscopic obliteration of recently bleeding esophagogastric varices with Bucrylate (isobutyl-2-cyanoacrylate) in 49 patients. Forty-five patients had cirrhosis; in all patients, propranolol was contraindicated or had failed, hepatocellular function was poor, or early rebleeding had occurred. In 15 cases, injections were made during active bleeding of esophageal or gastric varices; in 14 cases, the hemorrhage stopped immediately. The cumulative percentages of patients free of variceal rebleeding 1.6 and 12 months after inclusion were 88.63 and 58 p. 100 respectively. The cumulative percentages of patients surviving 1, 12 and 18 months after inclusion were 70, 53 and 46 p. 100 respectively. The cumulative percentages of survival at 6 months after inclusion were 100.63 and 13 p. 100 in grade A, B and C patients respectively. The major causes of death were liver failure and sepsis; autopsy revealed mediastinitis in 3 patients. Long-lasting esophageal strictures developed in two patients. This procedure differs from endoscopic sclerotherapy in that gastric varices can be adequately obliterated and the risk of early rebleeding seems to be decreased.

[Cerebrovascular accidents after endoscopic obturation of esophageal varices with isobutyl-2-cyanoacrylate in 2 patients]

We report 2 cases of cerebral stroke in cirrhotic patients following endoscopic obturation of esophageal varices with Isobutyl-2-Cyanoacrylate. In both cases, hemiplegia appeared several hours after the procedure. A brain CT scan showed radiodense material in the cerebral arteries due to dissemination of Isobutyl-2-Cyanoacrylate. One patient died, the other improved slowly. Different hypotheses may be raised: defectuous injection into the arterial circulation, systemic emboli via portopulmonary venous shunts, delayed polymerization of Isobutyl-2-Cyanoacrylate. Systemic emboli have been reported previously following percutaneous transhepatic obliteration of esophageal varices, suggesting portopulmonary venous shunts. In spite of these 2 complications, this procedure remains useful in stopping acute variceal bleeding and in preventing recurrent bleeding.

Long-term pathological follow-up of cerebral arteriovenous malformations treated by embolization with bucrylate

We examined 17 intracranial arteriovenous malformations that were resected after treatment by embolization using bucrylate (isobutyl-2-cyanoacrylate). In nine specimens removed 5 days to 16 months after embolization therapy, a series of pathologic changes was seen, including patchy mural angionecrosis (adjacent to bucrylate fragments) up to six weeks after embolization, the presence of bucrylate in vessel walls and fibromuscular intimal cushions, and the occurrence (after several months) of entirely extravascular bucrylate. Occasional parts of recanalized vascular malformations were identified. Bucrylate was present within arteriovenous malformations as late as 16 months after embolization, although the amount appeared to be diminished. These findings suggest a specific sequence of events in the interaction between bucrylate and mural components within the malformations and may explain some important complications of embolization therapy (e.g., delayed hemorrhage after embolization).

Transcatheter arterial embolization--major complications and their prevention

A thorough account is given of the complications of embolization techniques in nonneurovascular areas, including hepatic infarction, renal and splenic abscess formation. Infarction of the urinary bladder, gallbladder, stomach, and bowel are discussed. Suggestions are offered to prevent complications from embolization where possible. Specific agents for embolization are detailed and their relative merits are compared; ethyl alcohol has recently gained popularity for treating esophageal varices and infarcting renal tumors. Care is advocated when using alcohol in the renal arteries; employing this agent is currently contraindicated in the celiac and mesenteric arteries. Coils and balloon systems are also described along with their potential complications.

Experience with bucrylate (isobutyl-2-cyanoacrylate) embolization of cerebral arteriovenous malformations during surgery

The clinical experience with five patients selected for embolization of cerebral arteriovenous malformations with bucrylate (isobutyl-2-cyanoacrylate) during surgery is described. Bucrylate embolization was used to obliterate one arteriovenous malformation with a dominant nutrient arterial network, and to facilitate surgical resection in two other cases. The extent of the embolization in one of these cases was limited because of segmental perfusion of the AVM nidus by different nutrient arteries. Histological examination of this arteriovenous malformation, resected 56 days after embolization, suggested bucrylate has minimal histotoxicity. Two arteriovenous malformations were found at operation to be unsuitable for embolization because of technical problems with access and exposure of nutrient arteries, and also because of vagaries in the angiographic data before surgery. In two cases, rapid polymerization of bucrylate resulted in gluing of the injection catheters into the arterial lumen. Two patients experienced transient postoperative neurological deficits after bucrylate embolization. Because of the potential hazards of the technique, direct bucrylate embolization of cerebral arteriovenous malformations should only be considered for those lesions felt unsuitable for direct microsurgical excision, and where facilities exist for recording angiographic data before surgery.

Histopathologic effects of transarterial bucrylate occlusion of intracerebral arteries in mongrel dogs

Bucrylate was injected directly into the cerebral cortical arteries of mongrel dogs. Preparations for light and electron microscopy were obtained from 5 min to 5 months after the introduction of the polymer. A mixed pattern of damage to arterial endothelium was seen, including electron microscopic documentation of stripping away of the endothelium. Acute effects include a subocclusive thrombogenic matrix, which causes partial or complete thrombosis. The long-term reactions are those of a chronic inflammatory response to a foreign body.

Evaluation of three cyanoacrylate glues for ossicular reconstruction

We evaluated and compared the separate effects of ethyl, isobutyl, and fluoroalkyl cyanoacrylate on the promontory mucosa and surgically disarticulated incudostapedial joint in the adult cat middle ear. The animals were sacrificed at 10-, 30-, and 60-day intervals after glue application. All three cyanoacrylates elicited a chronic inflammatory response when placed directly on the promontory mucosa. The use of ethyl and isobutyl cyanoacrylate resulted in persisting discontinuity of the incudostapedial joint with erosion of the incus. Fluoroalkyl cyanoacrylate maintained incudostapedial continuity without ossicular erosion. Ethyl and isobutyl cyanoacrylate are probably not appropriate for middle ear surgery. The less toxic fluoroalkyl cyanoacrylate may be useful as an ossicular adhesive in selected cases. Our findings are further contrasted with those obtained in similar studies with methyl and butyl cyanoacrylate. The effects of each of the five cyanoacrylates are reviewed in the continuing search for a safe and effective ossicular adhesive.

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

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

Therapeutic embolization with long-term occluding agents and their effects on embolized tissues

The effects of long-term occlusion of branches of the celiac and renal arteries were studied in 13 pigs, using isobutyl 2-cyanoacrylate (ibc), the Gianturco-Anderson-Wallace wool coil, and lvalon. IBC permanently occluded 2- to 8-cm lengths of both vessels, including their branches so that collateral circulation was not able to preserve the tissue supplied by the occluded artery. Gastric ulcers, splenic and hepatic infarcts, and large, sterile biliary cysts were observed on postmortem examination. Permanent occlusion was also observed with the wool coil and lvalon, but the pathological results were much less deleterious. The authors conclude that IBC is presently unsafe for use in branches of the celiac artery.

Extraocular muscle transplantation

1. The transplantation of extraocular homografts in dogs and humans has been described. 2. The extraocular muscle tissue transplanted remains viable, but loses its characteristics of muscle tissue during the period of the normal healing process following extraocular muscle surgery. 3. Autogenous homograft of extraocular muscle has an advantage over artificial synthetic material with the absence of extrusion and less reaction. 4. This is a clinically usable procedure today, especially in the amblyopic ehe with high deviation to accomplish an additional lengthening of one extraocular muscle, particularly if extraocular muscle surgery has previously been performed.

Long-range effects of Ivalon sponge containing isobutyl cyanoacrylates on rat tissue. A quantitative planimetric study

This study on seventy rats was undertaken to determine the long-range effects of Ivalon sponge containing isobutyl cyanoacrylates (IBC). Histologic examination revealed that IBC sponge was well tolerated by the connective tissue. IBC sponge was most effective during the first 2 weeks of healing. At observation periods of 1 and 2 weeks, the percentage values for connective tissue formed in IBC-treated animals were 2.02 and 1.58 times higher than those in the untreated animals.