Histoacryl embolization

Cyanoacrylate (Histoacryl) is a tissue adhesive used in duraplasty. The sites at which it is used should be carefully chosen. Cyanoacrylates are also in use for embolization of arteriovenous malformations in the brain. The risk of this procedure is the creation of pulmonary emboli 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, appear to be more likely to cause this complication (1). 

The technique of intranidal embolization with Histoacryl requires tremendous experience on the part of the operator, because the injection is fast (from a few seconds to 1-2 min) and clinical consequences or improper gluing are disastrous. 

Prior to injection of glue, the dead space of the catheter and hub must be filled with 5% dextrose solution to avoid polymerization of the glue within the catheter. In some cases, however, this unexplained rapid polymerization may happen. The main reason is probably poor quality control of Histoacryl or Lipiodol. The operator should always push the glue slowly through the microcatheter and follow its progression at the level of its distal tip. If the glue does not exit the tip of the catheter, and even if there is no increased resistance to pressure on the syringe, the operator should never increase the injection pressure. The major risk is catheter rupture and major artery occlusion or embolization of distal normal arteries. 

A 36-year-old man had a pulmonary embolus after percutaneous embolization of a varicocele with enbucrilate (Histoacryl ) -I- lipiodol [26 ]. 

Prytula A, Veereman-Wauters G, Duval EL. Pulmonary embolism due to injection of Histoacryl and Lipiodol during endoscopic sclerotherapy of fundic varices. Acta Gastroenterol Belg 2008 71(4) 387-9. 

Fig. 13.3. Liver histopathology of the resected parenchyma 4 weeks after portal embolization with Histoacryl. Portal branch (P) filled with cyanoacrylate (C). Bile duct (B) presenting a massive periductal fibrosis (arrows)...

The embolizing agents are the same as those used for adults. The gelatin sponge particles (Surgifoam, Ethicon, Johnson Johnson Co., Somerville, New Jersey) are used for a temporary occlusion, and the polyvinyl alcohol particles (Contour, Boston Scientific Corp., Fremont, CA) for a permanent occlusion. Tissue adhesive N-butyl-2-cyanoacry-late (Indermil, Tyco, Norwalk, USA) or enbucrilate (Histoacryl, Braun, Aesculap) opacified with oily contrast media and alcohol can also used in pediatrics. 

CAs have been shown to be successful in the closure of pancreatic fistulas, biliary fistulas, and G1 fistulas. Seewald and coworkers reported successful closure of pancreatic fistulas in 8 of 12 patients using endoscopic injection of Histoacryl into the fistulous tract and endoscopic drainage. Seven of the eight successful patients required only one treatment over a median follow-up period of 21 months. Closure was temporary in two patients, unsuccessful in one patient, and there was one death within 24 h of treatment from pulmonary embolism. 

Lee GH, Kim JH, Lee KJ, et ai. Life-threatening intraabdominal arterial embolization after histoacryl injection for bleeding gastric ulcer. Endoscopy. 2000 32 422-424. 

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