Glue Embolization Research Articles

Treatment of Residual Facial Arteriovenous Malformations after Embolization with Percutaneous Cryotherapy

This report presents 4 patients (mean age, 22 y; range, 17–26 y) with facial arteriovenous malformations (AVMs) who underwent arterial ethanol and N-butyl cyanoacrylate embolization followed by percutaneous cryoablation of residual inaccessible AVMs. After the procedure, minor complications classified as type B according to the Society of Interventional Radiology (SIR) classification system occurred in 75% (3/4) of patients. One patient achieved 90% obliteration of AVM, and 3 patients had complete obliteration of AVM at 1-year follow-up. This reports shows that percutaneous ablation may be a viable treatment option for residual facial AVMs after ethanol and glue embolization.

Inducing false lumen thrombosis for retrograde type A aortic dissection

BackgroundHow to choose the proximal landing zone in endovascular interventions for a patient with a patent retrograde false lumen in dissection of the ascending aorta and aortic arch remains unclear. This study sought to report the safety and efficiency of inducing thrombosis of the retrograde false lumen to enhance a proximal landing zone to treat retrograde type A aortic dissection. MethodsThis study included 9 patients with retrograde type A aortic dissection treated with a 2-stage operation strategy between January 2015 and January 2016. Coil and Onyx glue embolization was performed to create a thrombogenic environment in the retrograde false lumen of the ascending aorta and aortic arch as the first-stage operation, followed by thoracic endovascular aortic repair (TEVAR) with the chimney technique as the second-stage operation. ResultsComplete thrombosis in a retrograde false lumen of the ascending aorta and aortic arch was found in all 9 patients before the second-stage operation was performed. The rate of successful TEVAR was 100%, with the single-chimney technique performed in 6 patients to reconstruct the left subclavian artery and the double-chimney technique performed in 3 patients to reconstruct the left common carotid artery. No morbidities, no stent graft–induced new dissection, or deaths occurred in the hospital and during the 12-month follow-up period. Positive morphological remodeling was evidenced in all cases. ConclusionsThe short-term outcomes of the patients in this study were satisfactory. Inducing thrombosis of the retrograde false lumen to enhance the proximal landing zone for TEVAR may be a safe and effective approach to treating retrograde type A aortic dissection.

Lymphatic Intervention Techniques: Look Beyond Thoracic Duct Embolization

In this issue of the Journal of Vascular and Interventional Radiology, Baek et al ( 1 Baek Y. Won J.H. Chang S.J. et al. Lymphatic embolization for the treatment of pelvic lymphoceles: preliminary experience in five patients. J Vasc Interv Radiol. 2016; (May 27, 2016. www.jvir.org; published online. http://dx.doi.org/10.1016/j.jvir.2016.04.011) PubMed Google Scholar ) and Hur et al ( 2 Hur S. Shin J.H. Lee I.J. et al. Early experience in the management of postoperative lymphatic leakage using lipiodol lymphangiography and adjunctive glue embolization. J Vasc Interv Radiol. 2016; 27: 1177-1186 Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar ) describe successful treatment of series of patients with lymphatic leaks by using two relatively new lymphatic embolization techniques. The first is a direct injection of N-butyl cyanoacrylate (NBCA) glue into the site of lymph extravasation (also called “lymphatic pseudoaneurysm” by Hur et al [2]). The second technique embolizes the lymph flow proximal to the leak by injecting N-BCA glue into the lymph node upstream of the leak. Lymphatic Embolization for the Treatment of Pelvic Lymphoceles: Preliminary Experience in Five PatientsJournal of Vascular and Interventional RadiologyVol. 27Issue 8PreviewTo retrospectively assess the outcome of lymphatic embolization in the treatment of pelvic lymphoceles. Full-Text PDF

Comparison of Clinical Outcomes following Glue versus Polyvinyl Alcohol Portal Vein Embolization for Hypertrophy of the Future Liver Remnant prior to Right Hepatectomy

PurposeTo report outcomes after portal vein embolization (PVE) and right hepatectomy in patients receiving embolization with N-butyl cyanoacrylate (NBCA) glue + central AMPLATZER Vascular Plug (AVP; glue group) or polyvinyl alcohol (PVA) particles ± coils (PVA group). Materials and MethodsBetween March 2008 and August 2013, all patients having PVE with NBCA + AVP or PVA ± coils before right hepatectomy were retrospectively reviewed; 85 patients underwent PVE with NBCA + AVP (n = 45) or PVA ± coils (n = 40). The groups were compared using Mann-Whitney U and χ2 tests. ResultsTechnical success of embolization was 100%. Degree of hypertrophy (16.2% ± 7.8 vs 12.3% ± 7.62, P = .009) and kinetic growth rate (3.5%/wk ± 2.0 vs 2.6%/wk ± 1.9, P = .016) were greater in the glue group versus the PVA group. Contrast volume (66.1 mL ± 44.8 vs 189.87 mL ± 62.6, P < .001) and fluoroscopy time (11.2 min ± 7.8 vs 23.49 min ± 11.7, P < .001) were significantly less during the PVE procedure in the glue group. Surgical outcomes were comparable between groups, including the number of patients unable to go onto surgery (P = 1.0), surgical complications (P = .30), length of hospital stay (P = .68), and intensive care unit admissions (P = .71). There was 1 major complication (hepatic abscess) in each group after PVE. ConclusionsPVE performed with NBCA + AVP compared with PVA ± coils resulted in greater degree of hypertrophy of the future liver remnant, less fluoroscopic time and contrast volume, and similar complication rates.

Early Experience in the Management of Postoperative Lymphatic Leakage Using Lipiodol Lymphangiography and Adjunctive Glue Embolization

PurposeTo evaluate the safety and efficacy of Lipiodol lymphangiography and 3 adjunctive N-butyl cyanoacrylate (NBCA) glue embolization techniques for the management of postoperative lymphatic leakage. Materials and MethodsThis retrospective study included 27 patients with postoperative lymphatic leakage (17 with ascites, 3 with chylothorax, 6 with lymphoceles, and 1 with a skin fistula) who underwent Lipiodol lymphangiography for diagnostic and therapeutic purposes in 3 tertiary referral centers between August 2010 and January 2016. Adjunctive glue embolization was performed as needed by using 3 different techniques: “lymphopseudoaneurysm” embolization, closest upstream lymph node embolization, or direct upstream lymphatic vessel embolization. ResultsSixteen patients were observed to determine the therapeutic effect of lymphangiography, and 8 patients (50%) recovered without further embolization. In 16 patients, including 11 who underwent immediate embolization after lymphangiography and 5 who underwent delayed embolization, a total of 28 embolizations (12 lymphopseudoaneurysms, 14 lymph nodes, and 2 lymphatic vessels) were performed. The technical and clinical success rates of the adjunctive embolizations were 89% (25 of 28) and 94% (15 of 16), respectively. The overall clinical success rate was 85% (23 of 27). The median time from initial lymphangiography to recovery was 5 days. No procedure-related major complications were reported. ConclusionsLipiodol lymphangiography and adjunctive glue embolization techniques appear safe and provide promising efficacy for the management of postoperative lymphatic leakage.

F.05 Characterization of NBCA glue polymerization for embolization of brain AVM’s

Background: Brain arteriovenous malformations (AVM’s) are abnormal connections between arteries and veins. Endovascular glue embolization with N-butyl cyanoacrylate (NBCA) is an accepted form of treatment, with most complications related to timing of polymerization. Current literature reports a wide range of polymerization times with large discrepancies between in-vivo and in-vitro results. Methods: Polymerization time was measured for mixtures of lipiodol/NBCA of 50/50, 60/40, 70/30. The influence of pH, temperature and presence of biological catalysts on polymerization rate was investigated in-vivo using submerged droplet tests. PVA-C, silicone and endothelium surfaces were compared and contact angles were measured to assess physical interaction with NBCA. High-speed video of glue injection through a microcatheter was captured to characterize coaxial flow. Results: Polymerization rate increases with pH and temperature. A hydrophilic substrate such as PVA-C provides surface properties that are most similar to endothelium. Endothelium provides a catalytic surface that increases the rate of polymerization. Blood products further increase the polymerization rate with RBC’s providing almost instantaneous polymerization of NBCA upon contact. Characterization of coaxial flow shows dripping to jetting transition with significant wall effect. Conclusions: We have successfully deconstructed and characterized the dynamic behavior of NBCA embolization. A refined understanding of NBCA behavior could help reduce embolization-related complications.

4:03 PMAbstract No. 423 - Glue embolization of pediatric non-head and neck venous malformations

4:03 PMAbstract No. 423 - Glue embolization of pediatric non-head and neck venous malformations

Occlusion of Posterior Fossa Dural Sinuses in Vein of Galen Malformation.

Spontaneous or progressive occlusion of the posterior fossa dural sinuses is often observed in patients with vein of Galen malformation, which can affect the clinical course. The aim of this study was to examine the patency of the posterior fossa dural sinuses in patients with vein of Galen malformation and to analyze the clinical and angiographic course of this condition. We retrospectively reviewed 61 consecutive children with vein of Galen malformations. Clinical presentation, management, outcome, and angiographic change were analyzed for the patients with attention paid to all dural sinus occlusions. Twenty patients (32.8%) demonstrated spontaneous sinus occlusion, mostly in the sigmoid sinus. This condition was not observed in neonates and was first discovered during infancy or childhood. Progression of sinus occlusion was seen in 10 patients, and the conditions of 6 of them deteriorated in accordance with the progression of sinus occlusion. After total or subtotal obliteration of the malformation by transarterial glue embolization, 13 patients recovered to healthy, 3 patients had only mild developmental delay, and 4 patients remained neurologically disabled. Spontaneous sinus occlusion is not a rare condition and can result in neurologic deterioration in the natural history of untreated vein of Galen malformation. If signs of progressive sinus occlusion are noticed, early arteriovenous shunt reduction or elimination by transarterial glue embolization is expected to prevent permanent brain damage.

Risk factor analysis for massive lymphatic ascites after laparoscopic retroperitonal lymphadenectomy in gynecologic cancers and treatment using intranodal lymphangiography with glue embolization.

ObjectiveTo evaluate risk factors for massive lymphatic ascites after laparoscopic retroperitoneal lymphadenectomy in gynecologic cancer and the feasibility of treatments using intranodal lymphangiography (INLAG) with glue embolization.MethodsA retrospective analysis of 234 patients with gynecologic cancer who received laparoscopic retroperitonal lymphadenectomy between April 2006 and November 2015 was done. In June 2014, INLAG with glue embolization was initiated to manage massive lymphatic ascites. All possible clinicopathologic factors related to massive lymphatic ascites were determined in the pre-INLAG group (n=163). Clinical courses between pre-INLAG group and post-INLAG group (n=71) were compared.ResultsIn the pre-INLAG group (n=163), four patients (2.5%) developed massive lymphatic ascites postoperatively. Postoperative lymphatic ascites was associated with liver cirrhosis (three cirrhotic patients, p<0.001). In the post-INLAG group, one patient with massive lymphatic ascites had a congestive heart failure and first received INLAG with glue embolization. She had pelvic drain removed within 7 days after INLAG. The mean duration of pelvic drain and hospital stay decreased after the introduction of INLAG (13.2 days vs. 10.9 days, p=0.001; 15.2 days vs. 12.6 days, p=0.001). There was no evidence of recurrence after this procedure.ConclusionUnderlying medical conditions related to the reduced effective circulating volume, such as liver cirrhosis and heart failure, may be associated with massive lymphatic ascites after retroperitoneal lymphadenectomy. INLAG with glue embolization can be an alternative treatment options to treat leaking lymphatic channels in patients with massive lymphatic leakage.

Dural arteriovenous fistula in the falx cerebri treated with transarterial embolization using n-butyl cyanoacrylate

Background:A dural arteriovenous fistula in the falx cerebri is a relatively rare lesion, with only two cases reported till date. One was treated with direct surgery, and the other was followed-up conservatively. Advances in catheter design and embolic materials have made safe and curative transarterial embolization of dural arteriovenous fistulas possible in the current era.Case Description:We describe a 67-year-old man with left putaminal hemorrhage who was diagnosed with an arteriovenous fistula in the anterior part of the falx cerebri that was treated with curative transarterial glue embolization through the middle meningeal artery by using n-butyl cyanoacrylate.Conclusion:Although the procedure was safely performed, understanding the potential risks of the migration of embolic materials into the ophthalmic and anterior cerebral artery system is mandatory.

Temporary Inferior Vena Cava Filters: Indications, Retrieval Rates and Follow-Up Management at a Single Academic Institution

Objectives: This study assessed the safety and efficacy of cyanoacrylate glue embolization (CGE) for the treatment of refluxing varicose veins. Methods: A prospective registry was created starting January 2014 for all patients with refluxing varicose veins undergoing CGE at a single center. Neither tumescent anesthesia nor postinterventional compression stockings were incorporated into the treatment. All patients underwent clinical examination and duplex ultrasound evaluation at 2 and 6 months postprocedure. Results: CGE was performed in 67 patients or 103 extremities with 108 vein segments. Target vein segments included 82.4% (89 of 108) great saphenous veins, 12.0% (13 of 108) short saphenous veins, and 5.6% (6 of 108) accessory saphenous veins. The treated segment lengths had a range from 12 cm to 63 cm. Technical success, defined as complete closure of the refluxing vein immediately after the procedure diagnosed by duplex ultrasound, occurred in 100% (108 of 108) of vein segments. The procedure was well tolerated, with only 10.4% (7 of 67) of patients experiencing venospasm. Ultrasound results were available for 80.6% (54 of 67) and 46.3% (31 of 67) of patients at 2 and 6 months, respectively. Only one of 108 target vein segments demonstrated recanalization. The target vein segment occlusion rate at 6 months was 96.8% (30 of 31). No cellulitis or postprocedural paresthesia was reported. No serious adverse events, including deep vein thrombosis, occurred. Conclusions: CGE of refluxing varicose veins is safe and effective without the use of compression stockings or tumescent anesthesia at 6 months.

Double Coaxial Microcatheter Technique for Glue Embolization of Renal Arteriovenous Malformations.

To demonstrate the technical benefit of the double coaxial microcatheter technique for embolization of renal arteriovenous malformations (AVMs) with n-butyl cyanoacrylate and iodized oil (glue). Six consecutive patients (1 man and 5 women; mean age 61 years; range 44-77 years) with renal AVMs were included. Five patients had hematuria, and one had a risk of heart failure due to a large intrarenal arteriovenous shunt. All patients underwent transarterial embolization using glue and the double coaxial microcatheter technique with outer 2.6F and inner 1.9F microcatheters. After glue injection, the inner microcatheter was retracted, while the outer microcatheter was retained. We assessed the complications and clinical outcomes of this technique. Technical success was achieved in all patients. In 9 sessions, 34 feeding arteries were embolized with glue using the double coaxial microcatheter technique, 1 was embolized with glue using a single microcatheter, and 2 were embolized with coils. The double coaxial microcatheter technique was useful for selecting small tortuous feeding arteries, preventing glue reflux to the proximal arteries, and approaching multiple feeding arteries without complete retraction of the microcatheters. As a minor complication, glue migrated into the venous system in four patients without any sequelae. In all patients, favorable clinical outcomes, including hematuria cessation in five patients and improvement of the large intrarenal arteriovenous shunt in one patient, were obtained without deterioration of renal function. Glue embolization with the double coaxial microcatheter technique was useful for treating renal AVMs with multiple tortuous feeding arteries.

SU‐E‐T‐415: Experimental Determination of the Relative Stopping Power of TRUFILL N‐BCA Liquid Embolic System in a Clinical Proton Beam

Purpose:Patients who undergo n‐BCA glue embolization as part of treatment for AVMs are later referred for proton therapy. Knowing the relative stopping power of the glue accurately allows us to perform accurate dose calculations. In this study we experimentally determine the relative stopping power of an n‐BCA mixture in a 126 MeV and 149.6 MeV proton beams.Methods:One unit of the TRUFILL™ n‐BCA liquid embolic system consists of 1g unit of n‐BCA, 1g unit of Tantalum powder and one 10mL vial of Ethiodized oil. The physician mixed 3:1 Ethiodized oil to n‐BCA. Five units (20cc) of the n‐BCA liquid embolic glue were prepared and placed in a 6cm × 3cm x3cm Lucite container. The container was placed in front of a water tank in the proton beam path. A diamond detector (active volume 0.004mm3) was used to measure distal edge of depth dose of a modulated 126 MeV proton beam collimated using a 3cm brass aperture. The procedure was repeated with a container carrying the same amount of water placed in front of the water tank. The difference in the depth dose measured with glue and with water was used to determine the relative stopping power of the glue. The same determination was done earlier at 149.6 MeV using a different smaller sample (4cc) of n‐BCA.Results:The relative stopping power of this particular n‐BCA mixture was determined to be 1.06 at both 126 MeV and 149.6 MeV. We are working on obtaining the composition data of the n‐BCA glue so we can perform Monte Carlo calculations.Conclusion:Accurate value of the stopping power of the n‐BCA glue in the proton beam was determined to be 1.06. It will improve the accuracy of dose calculations in proton radiosurgery procedures on AVM patients with n‐BCA embolization.

Preliminary findings of arterial embolization with balloon-occluded and flow-dependent histoacryl glue embolization in a swine model.

To evaluate the potential usefulness of the balloon-occluded histoacryl glue embolization (B-glue) technique. Both flow-dependent (no balloon occlusion) and B-glue techniques were used for 24 intercostal arteries of two female swine. N-butyl 2-cyanoacrylate (NBCA) was diluted with lipiodol to a 50 % solution, which was infused after occluding the arteries with microballoon catheters. The embolization range, fragmentation, reflux, adhesion, and glue particle attachment were compared between flow-dependent and B-glue techniques. The B-glue technique was performed in a controlled fashion resulting in successful arterial occlusion without fragmented migration of the injected glue cast. Reflux occurred less frequently with the B-glue technique and was significantly different (p = 0.039) [Corrected] from that for the flow-dependent technique. Catheters were safely removed from the arterial walls, although in one instance (8.3 %), large glue particles were found to be attached to the catheter tip on removal. Conversely, the flow-dependent technique was more difficult to control and resulted in several instances of higher rates of fragmentation. The B-glue technique can efficiently control NBCA delivery with lower rates of reflux.

Late limb embolization of biological glue after repair of aortic dissection

Late limb embolization of biological glue after repair of aortic dissection

5:18 PM, Abstract No. 85 - Use of liquid embolic agents in the treatment of aortopulmonary collaterals in pediatric patients with congenital heart disease

Purpose: To assess the technique and clinical outcomes for pre-operative n-butyl cyanoacrylate glue embolization of pediatric head and neck venous malformations. Materials and Methods: A retrospective analysis was conducted over a 9-year period at a tertiary care pediatric hospital to identify cases of head and neck venous malformations that were embolized with n-BCA prior to resection. 24 embolizations were performed in 22 patients. 7 patients were male, and mean age was 12.4 years (range 2-25). Primary clinical symptoms included pain (65%), swelling (61%), cosmetic disfigurement (87%), and bleeding (9%). 41.7% of patients had received prior intervention including surgical resection, laser ablation therapy, or sclerotherapy. Sites treated included cheek (n1⁄47), perimandibular regions (n1⁄45), lip (n1⁄44), neck (n1⁄44), tongue (n1⁄43), periorbital regions (n1⁄42), and temporalis muscle (n1⁄41). Mean volume of n-BCA used was 2.69mL; all embolizations were performed through direct percutaneous punctures via 21 or 23 gauge needles, using a range of 1:1 to 1:5 dilutions of n-BCA in ethiodized oil. Prior to injecting the embolization mixture, biplane digital subtraction venography was performed. Same-day pre-operative glue embolization and surgical resection took place for 21 out of 22 patients. Results: All patients were transported to the OR under stable conditions. Technical success rates for both embolization and resection were 100%. One patient had clinically insignificant embolization of a small amount of glue to a subsegmental pulmonary artery. No other complications were recorded. Adjunctive sclerotherapy or further glue embolization with resection was performed in 3 out of 22 patients who had large lesions. Average hospital stay was 1.5 days, with follow up scheduled for 1 week, 1 month, and 6 months. Follow-up indicated successful alleviation of primary symptoms for all patients based on clinical findings. Conclusion: Pre-operative n-BCA glue embolization of pediatric head and neck venous malformations is a safe and effective treatment option for these lesions. Advantages include the ability to achieve a more complete resection with diminished surgical blood loss. Technical and clinical success rates in this series were 100%.

5:09 PM, Abstract No. 84 - Pre-operative n-butyl-2-cyanoacrylate glue embolization of pediatric head and neck venous malformations: technique and clinical outcomes

5:09 PM, Abstract No. 84 - Pre-operative n-butyl-2-cyanoacrylate glue embolization of pediatric head and neck venous malformations: technique and clinical outcomes

A Sinister Cause of Hematemesis

Question: A 52-year-old man with myelofibrosis presented to the emergency room with hematemesis. Earlier that day, he had experienced cough, rhinorrhea, and pharyngitis. On the evening of admission, he vomited blood, prompting him to seek medical attention. He denied fevers, chills, chest pain, abdominal pain, melena, hematochezia, prior history of upper gastrointestinal bleeding, nonsteroidal anti-inflammatory drug ingestion, or alcohol abuse. He was afebrile and hemodynamically stable. Physical examination was significant for splenomegaly and brown, guaiac-positive stool. His abdomen was nontender and nondistended without overt evidence of hepatomegaly. Pertinent laboratory results were as follows: blood urea nitrogen, 34 mg/dL; International Normalized Ratio, 1.3; white blood cell count 4.6 K/μL; platelets, 194 K/μL; and hemoglobin, 12.5 g/dL, which decreased to 9.6 g/dL on repeat 6 hours later. On presentation, he was given an intravenous bolus of esomeprazole 80 mg and initiated on an intravenous esomeprazole drip at 8 mg/h. An urgent upper endoscopy revealed isolated gastric varices with recent evidence of bleeding (Figure A, yellow arrow). He was given a bolus of intravenous octreotide 50 μg followed by an intravenous octreotide drip at 50 μg/h and ceftriaxone 1 g/d. The patient was transferred to the intensive care unit for further monitoring. What was the cause of this patient’s gastric varices (GV) and what is the next appropriate step? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. CT of the abdomen and pelvis revealed marked splenomegaly and prominent gastric (Figure B, C, arrow), paragastric, splenic, and mesenteric varices (Figure B, C, arrowhead). The patient underwent a liver biopsy, which revealed extramedullary hematopoiesis without evidence of fibrosis or nodular regenerative hyperplasia. Measurement of hepatic venous pressure gradient was 8 mmHg, confirming absence of right-sided portal hypertension. In our patient, sinistral portal hypertension and gastric variceal bleeding occurred secondary to splenomegaly from increased splenic blood flow owing to myelofibrosis-induced extramedullary hematopoiesis. Isolated GV are less prevalent than esophageal or gastroesophageal varices. Our patient had type 1 varices (IGV1), which are confined to the fundus. A common cause of IGV1 is splenic vein thrombosis and this diagnosis should be excluded. Initial management of gastric variceal bleed includes antibiotics, vasoactive drugs, and selective transfusion.1Garcia-Pagan J.C. Barrufet M. Cardenas A. et al.Management of gastric varices.Clin Gastroenterol Hepatol. 2014; 12: 919-928Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar Beyond this initial management, studies have documented the use of splenectomy, splenic embolization, endoscopic variceal obturation (EVO) using tissue adhesives such as cyanoacrylate (CA), endoscopic injection sclerotherapy (EIS), variceal band ligation (EBL), transjugular intrahepatic portosystemic shunt and balloon-occluded retrograde transvenous obliteration.2Goh B.K. Chen J.J. Tan H.K. et al.Acute variceal bleed in a patient with idiopathic myelofibrosis successfully treated with endoscopic variceal band ligation.Dig Dis Sci. 2007; 52: 173-175Crossref PubMed Scopus (2) Google Scholar CA has demonstrated higher hemostasis and lower rebleeding rates compared with EBL and EIS. A recent study has shown that endoscopic ultrasonographic (EUS)-guided therapy for fundal varices with CA and coils may improve efficacy and decrease embolization of glue.3Binmoeller K.F. Weilert F. Shah J.N. et al.EUS-guided transesophageal treatment of gastric fundal varices with combined coiling and cyanoacrylate glue injection (with videos).Gastrointest Endosc. 2011; 74: 1019-1025Abstract Full Text Full Text PDF PubMed Scopus (145) Google Scholar CA is not currently available in the United States. However, many experts agree that, in patients with bleeding gastric fundal varices, the use of CA is preferred where available, with EBL as an alternative.1Garcia-Pagan J.C. Barrufet M. Cardenas A. et al.Management of gastric varices.Clin Gastroenterol Hepatol. 2014; 12: 919-928Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar Splenectomy can be definitive treatment in patients with GV associated with sinistral portal hypertension.1Garcia-Pagan J.C. Barrufet M. Cardenas A. et al.Management of gastric varices.Clin Gastroenterol Hepatol. 2014; 12: 919-928Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar In patients with myelofibrosis and splenomegaly, splenectomy is reserved for those with drug-refractory, symptomatic splenomegaly associated with frequent transfusions, portal hypertension, or severe thrombocytopenia. In our patient, splenectomy was chosen over EVO or transjugular intrahepatic portosystemic shunt owing to lack of available CA in the United States and the lack of elevated right-sided portal pressures. Postoperatively, his white blood cell count was 6.7 K/μL and platelet count was 279 K/μL. He received low-molecular-weight heparin for splenic and portal vein thrombosis, as well as hydrea and interferon. Repeat endoscopy 1 year after surgery showed no evidence of any varices. This case highlights the need for larger scale, randomized, controlled trials to guide management of gastric variceal bleeding. In addition, not all effective endoscopic and interventional techniques to treat GV are widely available, making it difficult for providers to follow current recommendations.

Efficacy and limitations of transarterial acrylic glue embolization for intracranial dural arteriovenous fistulas.

The efficacy and limitations of transarterial acrylic glue embolization for the treatment of intracranial dural arteriovenous fistulas (DAVFs) were investigated. Thirty-four DAVFs treated by transarterial embolization using n-butyl cyanoacrylate were retrospectively reviewed. The locations of DAVFs were the transverse-sigmoid sinus in 11, tentorium in 10, cranial vault in 9, and superior sagittal sinus, jugular bulb, foramen magnum, and middle cranial fossa in 1 each. Borden classification was type I in 7, type II in 3, and type III in 24. Eight patients had undergone prior transvenous coil embolization. Complete obliteration rate was 56% immediately after embolization, 71% at follow-up angiography, and 85% after additional treatments (1 transvenous embolization and 4 direct surgery). Complications occurred in three patients, consisting of asymptomatic vessel perforations during cannulation in two patients and leakage of contrast medium resulting in medullary infarction in one patient. Transarterial glue embolization is highly effective for Borden type III DAVF with direct cortical venous drainage, but has limitations for Borden type I and II DAVFs in which the affected sinus is part of the normal venous circulation. Onyx is a new liquid embolic material and is becoming the treatment of choice for DAVF. The benefits of glue embolization compared to Onyx embolization are high thrombogenicity, and relatively low risks of cranial nerve palsies and of excessive migration into the draining veins of high flow fistula. Transarterial glue embolization continues to be useful for selected patients, and complete cure can be expected in most patients with fewer complications if combined with transvenous embolization or direct surgery.

Endovascular Approach for Treatment of Frontal Dural Arteriovenous Fistula through the Ophthalmic Arteries using Glue: A Case Presentation with Review of Literature

A rare case of right frontal bleed in elderly gentleman secondary to anterior cranial fossa dural arteriovenous fistula was detected on computed tomography angiogram, and complete endovascular embolization was achieved through ophthalmic arteries using glue as embolic material. Successful endovascular treatment along with surgical evacuation of subdural hematoma resulted in excellent recovery of the patient. Quick in-and-out approach using flow directed microcatheters and fast embolizing potential of glue may allow for rapid, safe, and successful embolization of such fistulas. The rarity of the location and the transarterial glue embolization of the nidus by micro catheter through both ophthalmic arteries makes this an interesting case for discussion.