Jpn J Intervent Radiol Vol.29 No.3 2014

State of the Art
Current Status of Arterial Embolization with N-butyl-2-cyanoacrylate and Histopathological Influences after the Embolization

An Introduction  
Department of Radiology, Dokkyo Medical University Koshigaya Hospital
Manabu Nakata

1. Embolization with N-butyl-2-cyanoacrylate for Gastrointestinal Hemorrhage

Department of Radiology, Nippon Medical School
Takahiko Mine, Daisuke Yasui, Satoru Murata, Shiro Onozawa
Tatsuo Ueda, Hidenori Yamaguchi, Fumie Sugihara, Shin-ichiro Kumita
Department of Radiology, Nippon Medical School Chiba Hokusou Hospital
Hiroshi Kawamata
Center for minimal invasive treatment, Nippon Medical School Musashikosugi Hospital
Hiroyuki Tajima

Selective transcatheter arterial embolization (TAE) for gastrointestinal hemorrhage (GIH) has been proposed as a less hazardous alternative to surgery, especially in high-risk patients, and is now considered as the first-line intervention for massive GIH after failed endoscopic treatment. N-Butyl cyanoacrylate (NBCA) is a permanent liquid embolic material with a marked hemostatic effect and a low incidence of re-bleeding. NBCA has been increasingly used for controlling nonvariceal GIH. The morbidity of bowel ischemic events after TAE using NBCA (NBCA-TAE) has been pointed out, however, a causal relationship between NBCA and bowel ischemia has not been clearly established. This article reviewed the indication and role of NBCA-TAE while describing the behavior of NBCA within the circulation, administration techniques and therapeutic outcome, so as to outline the appropriate use of NBCA.

Key words

  • Gastrointestinal hemorrhage
  • NBCA
  • Gastroduodenal ulcer
  • Bowel ischemia

2. Transcatheter Arterial Embolization with N-Butyl-2-cyanoacrylate for Pancreatic and Surrounding Tissue Bleedingt

Department of Radiology and Center for Endovascular Therapy, Kobe University Hospital
Takuya Okada, Masato Yamaguchi, Akhmadu Muradi, Naoto Katayama
Eisuke Ueshima, Yutaka Koide, Keitaro Sofue, Koji Sugimoto

N-Butyl-2-cyanoacrylate (NBCA) has been widely used for transcatheter arterial embolization (TAE) of acute arterial hemorrhages and aneurysms. Compare to conventional TAE with coils and gelatin sponges, the TAE using NBCA (NBCA-TAE) is more easily applicable in small and tortuous vascular anatomies, associated with a lower risk of recurrent bleeding after successful intervention. Furthermore, the presence of coagulopathy does not affect the physiologic hemostasis effect of NBCA. Thus, bleeding in the pancreas and surrounding tissues, including pseudoaneurysms complicating pancreatitis or pancreatectomy, pancreatic cancer and duodenal ulcer, can be favorably treated with NBCA-TAE. This review describes methods, clinical outcomes and safety of NBCA-TAE for managing acute bleeding of pancreas and its surrounding tissues based on a single-center experience and results of animal experimentation.

Key words

  • N-Butyl-2-cyanoacrylate(NBCA)
  • Pancreas
  • Animal experimentation

3. Transcatheter Arterial Embolization for Obstetric Hemorrhage

Department of Radiology, Wakayama Medical University
Tetsuo Sonomura, Motoki Nakai, Akira Ikoma, Kouhei Nakata
Hiroki Sanda, Hiroki Minamiguchi, Morio Sato
Department of Radiology, Seisikai Watanabe Hospital
Nobuyuki Kawai

Obstetric hemorrhage has a high mortality rate, with massive hemorrhage commonly leading to a coagulopathic condition. Therefore, prompt hemostasis is essential for obstetric hemorrhage. However, an emergency peripartum hysterectomy has a high risk of maternal morbidity and fatality. On the other hand, uterine artery embolization (UAE) is an effective treatment for dealing with obstetric hemorrhages, because it is minimally invasive, has a high success rate and can preserve fertility. In a coagulopathic condition, the recurrent hemorrhage rate is higher for gelatin sponge particles (GSPs) than for N-butyl cyanoacrylate (NBCA). Recently, UAE with NBCA is becoming more frequently performed clinically for postpartum hemorrhages. We report here clinical UAE performed in our hospital, and animal research results on the degree of uterine damage caused by UAE with GSPs and NBCA in swine.

Key words

  • TAE
  • UAE
  • NBCA
  • Obstetric hemorrhage

4. Bronchial Artery Embolization with N-butyl-2-cyanoacrylate

Department of Radiolody, Wakayama Medical University
Akira Ikoma, Motoki Nakai, Tetsuo Sonomura, Morio Sato

The liquid embolic material n-butyl-2-cyanoacrylate (NBCA) is widely used in various vascular interventional radiology procedures, and its use has recently been reported for bronchial artery embolization (BAE). NBCA in a mixture with lipiodol has the advantage of a low rate of post-embolic recanalization compared with that of other embolic materials such as metallic coils and gelatin sponge. Because the operator must adjust the concentration of NBCA-lipiodol to control the polymerization time, to avoid major complications it is important that procedures in which NBCA is used are performed by experienced interventional radiologists. Here we describe the technical aspects of BAE with NBCA, the safety of the procedure, potential pitfalls such as pathological change after BAE, our clinical experience, and experimental results.

Key words

  • Bronchial artery embolization
  • N-butyl-2-cyanoacrylate
  • Hemoptysis

5. Preoperative Embolization with NBCA for Intracranial Hypervascular Tumors

Department of Neurosurgery, Hokkaido University Graduate School of Medicine
Toshiya Osanai

Particles such as PVA, Microbead and Gelform powder have been used for embolization of intracranial hypervascular tumors. However, particulate materials have been sometimes described as having high risk of bleeding after embolization and less benefit.
NBCA, the liquid material used for the embolization of AVM, has been reported as a promising embolization material for hypervascular brain tumors recently. In this article we note the efficacy of NBCA as an embolization materials, the way to use NBCA in a practical manner, complications occurring during the embolization procedure, and previously reported histopathological findings.

Key words

  • NBCA
  • Intracranial hypervascular tumor
  • Histopathological findings

Case Reports

A Case of Recanalization after Embolization of the Left Gastric Artery Using Amplatzer Vascular Plug I

Department of Radiology, St. Marianna University, School of Medicine
Shinji Saruya, Kenji Murakami, Kazuki Hashimoto, Yasunori Arai
Yukihisa Ogawa, Shingo Hamaguchi, Yasuo Nakajima

The Amplatzer vascular plug (AVP) is recognized as a more effective device that can embolize peripheral vessels in a faster and safer fashion. Unlike embolic materials such as coil and glue, the AVP is retractable and may be easily repositioned. It not only ensures permanent occlusion but also offers lesser risks of recanalization than coils. To our knowledge, definite causes of post-embolization recanalization with the Amplatzer vascular plug I (AVP I) have not yet been reported.
We here report a case of ovarian cancer metastases to abdominal organs in a 50 year-old female in whom the left gastric artery post-embolization recanalization occurred with AVP I.
The AVP I size as well as the detaching position site was not properly selected for a successful AVP I embolization.
We selected a smaller AVP I size and chose the detaching position within the curved portion of the vessel, hence making it an unstable location resulting in unsuccessful embolization.
Adequate selection of AVP size and proper selection of detaching position are important parameters to consider for successful embolization.

Key words

  • Vascular Plug
  • Recanalization
  • Embolization

Case Reports

A Case of Isolated Superior Mesenteric Artery Dissection with Severe Stenosis of The True Lumen in Which Angiography Was Effective in Determining Treatment Strategy

Department of Emergency Medicine, Yokohama Sakae Kyosai Hospital
Tetsuya Takahashi
Department of Emergency and Critical Care Medicine and Radiology1),
Yokohama City Minato Red Cross Hospital
Toshitaka Ito, Hideho Endo1), Junji Hatakeyama, Tetsuhiro Takei, Keiichi Yagi

The patient was a man in his 30s, who presented with the chief complaint of epigastric pain of sudden onset. There were no signs of peritoneal irritation. Abdominal dynamic CT revealed dissection of the superior mesenteric artery in the arterial-phase images, approximately 3 cm from the origin. The true lumen was severely stenosed due to a thrombosed false lumen. No evidence of aortic dissection was observed. The gut wall was well visualized in the equilibrium phase. These results suggested isolated superior mesenteric artery dissection with severe stenosis of the true lumen, and angiography was performed to accurately assess the blood flow distribution. Superior mesenteric arteriography revealed only the middle colic artery and a few jejunal arteries branching from the proximal areas. Common hepatic arteriography revealed portions of the jejunal arteries through the pancreatic head arcades. Inferior mesenteric arteriography depicted the right colic, ileocolic arteries and peripheral superior mesenteric artery. Blood flow to the intestine was maintained by collateral circulation, and the patient recovered from the acute phase with conservative treatment. The findings suggested that accurate assessment of blood flow distribution by angiography enables selection of conservative treatment in the acute phase of isolated superior mesenteric artery dissection with severe stenosis of the true lumen.

Key words

  • Superior mesenteric artery
  • Dissection
  • Angiography