Fixing Visceral Pseudoaneurysms with N-Butyl Cyanoacrylate Glue

Recent research from Madhusudhan, et al. has demonstrated that conventional wisdom may not always apply to every visceral aneurysm undergoing endovascular repair. In an upcoming article from JVIR, the group reports their retrospective review of 31 patients with visceral PSAs treated with NBCA. Common indications for using glue included preservation of a major feeding artery, difficult catheterization secondary to arterial tortuosity, failed coil embolization, and short landing zone for coils. The mean amount of glue used was a surprisingly petite 0.24 mL (range, 0.1-1.1 mL). Immediate technical success was seen in all patients with recurrence in 3 (9.7%) and overall clinical success in 90.3%. Major complications were seen in 3 patients (9.7%) and included nontarget embolizations to liver and spleen as well as catheter adhesion and fracture. The authors used a modified technique for glue injection with no more than 0.3 mL (3:7 ratio of NBCA to lipiodol) injected at one time. The aliquots of glue were flushed from the deadspace of the catheter with 50% dextrose until it opacified the PSA. The sequence was then repeated until embolization was complete. The authors concluded that NBCA is a safe and effective embolization agent for treatment of PSA.

Commentary:

The endovascular repair of visceral pseudoaneurysms encompasses a heterogenous set of technical challenges that have been well described using conventional techniques of coil embolization. In the majority of cases, classic coil embolization to exclude the PSA is both technically achievable and well tolerated. However, in a minority of cases, this approach may not be possible secondary to anatomic challenges. Alternative techniques to overcome these challenges include covered stent placement and stent-assisted coil embolization. With NBCA, the interventionalist has yet another tool to overcome these often challenging cases. The authors’ description and figures highlighting potential complications associated with use of NBCA for PSA repair highlight the need for the operator to be familiar and experienced in the use of this embolization agent prior to its use in these challenging circumstances.

Figure 2. Preservation of major feeding artery. A 40-year-old woman presented with acute gastrointestinal bleeding after cholecystectomy. (a) DSA image showing PSA (arrow) arising from the right posterior hepatic artery. (b) Image obtained after embolization showing NBCA cast in the PSA (arrow) with microcatheter in situ. (c) Image obtained after embolization showing preserved divisions of the right hepatic artery (white arrows) with nonopacification of the PSA (black arrow). Use of a microcoil in this case would have occluded the right posterior hepatic artery with risk of hepatic ischemia/infarct. Use of NBCA preserved the artery.

Figure 6. Complications. (a) Reflux of NBCA into the branches of the right hepatic artery (arrows) during embolization of cystic artery PSA (arrowhead). (b) Reflux of NBCA into branches of the splenic artery (arrow) during embolization of splenic artery PSA (arrowhead). (c) Microcatheter fracture in the splenic artery (white arrows) with NBCA cast (black arrows).

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Madhusudhan KS, et al. Endovascular embolization of visceral artery pseudoaneurysms using a modified injection technique with N-Butyl cyanoacrylate glue. Journal of Vascular and Interventional Radiology 2015. DOI: 10.1016/j.jvir.2015.07.008

Post Author:
Luke R. Wilkins, MD