Acute fatal pulmonary embolism during cyanoacrylate injection in gastric varices

Marion-Audibert, Anne-Marie; Schoeffler, M.; Wallet, Florent; Duperret, S.; Mabrut, J.‐Y.; Bancel, Brigitte; Péré-Vergé, Denis; Wander, L.; Souquet, Jean-Christophe

doi:10.1016/j.gcb.2008.07.009

Cited by 29 publications

(27 citation statements)

References 18 publications

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“…The lungs act as a filter to most emboli, however, systemic embolisation to the spleen, cerebral and coronary arteries can occur through arteriovenous pulmonary shunt or paradoxical embolisation via patent foramen ovale or atrial septal defect 21. An alternative migration pathway is via the superior vena cava and the azygos vein but Depuey et al proposed that this occurs more commonly with oesophageal than cardial or gastric varices 20. In the case reported here, it is difficult to have complete diagnostic certainty when it comes to predicting the pathway of glue migration which resulted in the multiple pulmonary emboli; however from figure 2, it is likely that cyanoacrylate travelled through a gastrorenal shunt as embolic material can be seen in splenorenal varices.…”

Section: Discussionmentioning

confidence: 99%

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Delayed onset pulmonary glue emboli in a ventilated patient: a rare complication following endoscopic cyanoacrylate injection for gastric variceal haemorrhage

et al. 2014

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SUMMARYCyanoacrylate injection is a recognised endoscopic treatment option for variceal haemorrhage. We describe a 34-year old man with hepatitis B cirrhosis who presented to the hospital with upper gastrointestinal haemorrhage from gastric and oesophageal varices. Haemostasis was achieved via cyanoacrylate injection sclerotherapy and banding. Ten days later, the patient developed acute hypoxia and fever. His chest radiograph showed wide-spread pulmonary shadowing. A noncontrast CT scan confirmed multiple emboli of injected glue material from the varix with parenchymal changes either suggesting acute lung injury or pulmonary oedema. He gradually recovered with supportive treatment and was discharged home. On follow-up, he remained asymptomatic from a chest perspective. This case report discusses the rare complication of pulmonary embolisation of cyanoacrylate glue from variceal injection sites and the diagnostic dilemmas involved. Emphasis is placed on the importance of maintaining high index of clinical suspicion when assessing patients with possible procedure related complications. BACKGROUND

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Section: Discussionmentioning

confidence: 99%

“…A spectrum of clinical presentations ranging from asymptomatic to sudden death has been reported so far. These included pleuritic chest pain, dyspnoea, cough, fever, tachycardia, hypoxia and cardiorespiratory arrest 2–4 13 14 17 18 20 21 24. When the patient is symptomatic, chest radiograph or non-contrast CT will aid the diagnosis.…”

Section: Discussionmentioning

confidence: 99%

Delayed onset pulmonary glue emboli in a ventilated patient: a rare complication following endoscopic cyanoacrylate injection for gastric variceal haemorrhage

et al. 2014

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“…Nevertheless, it is also important to bear in mind that cyanoacrylate congeners are regularly used as sealants in ocular surgery for corneal perforations, sealing corneal cataract wounds, the table. 86,87 Autopsy has confirmed the presence of glue in the pulmonary artery and its branches. 87 Other serious embolic complications include thrombosis of the portal vein, splenic vein, superior mesenteric vein, left renal vein, iliac vein, inferior vena cava, and splenic infarction as well as coronary and cerebral emboli.…”

Section: Technique For Injection Preparation For Injectionmentioning

confidence: 95%

Gluing Gastric Varices in 2012: Lessons Learnt Over 25 Years

Saraswat¹,

Verma²

2012

Journal of Clinical and Experimental Hepatology

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Bleeding from gastric varices (GV) continues to pose a challenge to the endoscopist and no consensus has been reached on the best way for treating these patients. Gastric variceal obturation (GVO) with the tissue adhesive, N-2-butyl-cyanoacrylate (NBC), is considered the treatment of first-choice for this condition in most parts of the world. The liquid monomer polymerizes into a solid cast, obturating the vessel within 10-20 s of coming in contact with ionic solutions such as blood. Gastric variceal obturation achieves hemostasis in over 90% of patients with active bleeding, eradicates GV in over 80% of these patients, and re-bleeding occurs in 3-30%. These results are comparable with those of transjugular intrahepatic portosystemic shunting (TIPS; over 90% hemostasis in acute bleeding with re-bleeding in 15-30%). Though, there has been no direct comparison with GVO, balloon-occluded retrograde transvenous obliteration of GV (BRTO) achieves near 100% obliteration with recurrence in 0-10% and is superior to TIPS for hemostasis in active bleeding when used in combination with transcatheter sclerotherapy. Several complications have been described for GVO including thromboembolic complications which occur in 0.5-4.3% and may be devastating in some. Many of the complications and the variability in results of GVO can be attributed to variations in injection technique. The use of a standardized injection technique has been reported to achieve 100% hemostasis and obliteration with 6.9% re-bleeding and no embolic complications. Gastric variceal obturation with NBC continues to be the first-choice therapy for GV bleeding outside Japan. Adherence to a standard injection technique will maximize hemostasis and eradication of GV while minimizing complications of therapy.

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“…A recent controlled trial published in abstract form compared the tissue adhesive cyanoacrylate with propranolol, and found lower bleeding with cyanoacrylate [67], although there was no difference in survival. When considering endoscopic therapy, one has to be aware of the iatrogenic complications of tissue adhesives, in particular peripheral embolisation, with a number of fatalities reported in the literature [68,69]. The use of b-blockers is perhaps the safer option, but conclusive recommendation for primary prophylaxis in patients with gastric varices requires further large controlled trials.…”

Section: Gastric Varicesmentioning

confidence: 99%

Overview of the methods and therapies for the primary prevention of variceal bleeding

Tripathi

2010

Expert Review of Gastroenterology & Hepatology

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Patients with cirrhosis develop varices at a rate of 5% per year, and a third of patients with high-risk varices will bleed. The mortality associated with variceal haemorrhage is typically 20%, and still exceeds that of myocardial infarction. Current options to prevent the first variceal bleed include noncardioselective beta-blockers or variceal band ligation. In patients with medium-to-large esophageal varices, both therapies reduce the risk of bleeding by 50% or more. The choice of therapy should take into account patient choice and local availability; although for most patients drug therapy is the preferred first-line treatment. There has been recent interest in carvedilol, with promising initial data. Further studies are necessary before universal recommendation. There is no role for drug therapy in patients without varices, and the use of beta-blockers for patients with small varices is controversial.

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Acute fatal pulmonary embolism during cyanoacrylate injection in gastric varices

Cited by 29 publications

References 18 publications

Delayed onset pulmonary glue emboli in a ventilated patient: a rare complication following endoscopic cyanoacrylate injection for gastric variceal haemorrhage

Delayed onset pulmonary glue emboli in a ventilated patient: a rare complication following endoscopic cyanoacrylate injection for gastric variceal haemorrhage

Gluing Gastric Varices in 2012: Lessons Learnt Over 25 Years

Overview of the methods and therapies for the primary prevention of variceal bleeding

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