the use of cyanoacrylate adhesives in peripheral embolization · 2012-09-11 · the use of...

The Use of Cyanoacrylate Adhesivesin Peripheral EmbolizationJeffrey S. Pollak, MD, and Robert I. White, Jr, MD

Although liquid adhesives or glue have been used as embolic agents for nearly three decades, experience with themoutside of neurointerventional indications is generally limited. Cyanoacrylates are the main liquid adhesives used inthe vascular system and have an important role in managing vascular abnormalities, especially arteriovenousmalformations. Vascular occlusion results as these agents polymerize on exposure to the ions in blood. A descriptionof the properties, biologic interactions, techniques of use, and indications for acrylic embolization in the peripheralcirculation is especially pertinent at this time because of the recent approval of n-butyl cyanoacrylate by the UnitedStates Food and Drug Administration.

Index terms: Arteries, embolization • Arteriovenous malformations • Cyanoacrylate

J Vasc Interv Radiol 2001; 12:907–913

Abbreviations: AVF 5 arteriovenous fistula, AVM 5 arteriovenous malformation, D5W 5 5% dextrose, n-BCA 5 n-butyl cyanoacrylate

EMBOLIZATION agents can be catego-rized by their physical and biologicproperties, which in turn affect theirlevel of occlusion and tissue response.Most interventional radiologists arequite familiar with the use of mechani-cal agents, primarily coil emboli and,less commonly, detachable balloons,and with particulate agents such as gel-atin sponge and polyvinyl alcoholparticles. Although many intervention-alists have likely had some exposure tothe use of 95% or absolute ethanol, ex-perience with liquid agents for emboli-zation is generally much more limited,especially adhesives or “glues.” This isparticularly true in the United States,where, until recently, no Food and DrugAdministration (FDA)-approved gluehad been available for more than adecade. Nevertheless, this type of agenthas an important role in managing vas-cular abnormalities, especially arterio-venous malformations (AVMs), as iswell known to interventional neuroradi-

ologists (1–6). Despite their limitedavailability, we have had the opportu-nity to use cyanoacrylate tissue adhe-sives in a number of patients when webelieved that this type of agent wasuniquely indicated.

CHEMICAL PROPERTIES OFCYANOACRYLATES

The main liquid adhesives used inendovascular procedures are cyano-acrylates. The monomeric form of thisconsists of an ethylene molecule witha cyano group and an ester attached toone of the carbons (Fig 1). The estercan have various hydrocarbons at-tached to it (the R position). The hy-drocarbon in this position also contrib-utes to the name of the cyanoacrylate;eg, isobutyl cyanoacrylate, n-butyl cy-anoacrylate (n-BCA) (Fig 2), or 2-hexylcyanoacrylate. When exposed to ananion, such as a hydroxyl moietyfound in water or the various anionsfound in blood, polymerization is ini-tiated, with bonding of the ethyleneunits. The longer the hydrocarbon is atR position, the slower the rate of po-lymerization, the less heat releasedduring polymerization, and the lowerthe histotoxicity (7,8).

Because of their low viscosity, cya-noacrylates are easy to deliver throughmicrocatheters; however, their lack of

radiopacity and their rapid polymer-ization when in contact with blood canmake precise, safe occlusion difficultto achieve. Modifications to addressthese problems include the addition ofpowdered metals, typically tantalumor tungsten, and iodized oils (9). Tan-talum has been noted to result in aslow initiation of polymerization, so itshould be added to the embolic mix-ture shortly before its use (10). Iodizedoils not only opacify the agent but alsoslow the polymerization time, al-though this effect was found to be lesspronounced when mixing n-BCA withiophendylate (Pantopaque; LafayettePharmacol, Lafayette, IN) than whenmixing isobutyl cyanoacrylate with io-phendylate (10). Another side effect ofthe oils is to promote a less uniform,more flocculent polymer (7). The addi-tion of glacial acetic has also been de-scribed as a method for delaying po-lymerization (10,11). Currently, wemix monomeric glue with Ethiodol(Savage Laboratories, Melville, NY) inratios varying from 1:1 to 1:4.

BIOLOGIC INTERACTIONS

The deposition of cyanoacrylatewithin a vessel results in an acute in-flammatory reaction in the wall andsurrounding tissues. This progressesto a chronic and granulomatous pro-

From the Section of Vascular and Interventional Ra-diology, Department of Radiology, Yale UniversitySchool of Medicine, PO Box 208042, New Haven, CT06520-8042 Received November 13, 2000; revisionrequested January 9, 2001; revision received andaccepted March 15. Address correspondence toJ.S.P., E-mail: [email protected]

© SCVIR, 2001

Review Article

907

cess after approximately 1 month,with foreign body giant cells and fi-brosis (10,12,13). Although the occlu-sion created by glue may be perma-nent (14), recanalization has also beenobserved, especially when only partialembolization was achieved rather thantotal and solid casting of the nidus of alesion (10,15,16). Histologically, ex-travascular extrusion of the glue andthe development of capillaries withinembolized vessels have been described.Isobutyl 2-cyanoacrylate has beenshown to dissipate on long-term fol-low-up in incompletely occludedAVMs (16).

Whereas sarcomas have been re-ported to develop in laboratory ani-mals exposed to large doses of isobu-tyl 2-cyanoacrylate, no malignanciesin humans have been clearly demon-strated to be caused by cyanoacrylates(1,7,10,17). Nevertheless, this observa-tion prompted the manufacturer tocease production of isobutyl cyanoac-rylate in the late 1980s. Since then, n-BCA has been the principal glue usedfor embolotherapy.

AVAILABILITY OF ACRYLICADHESIVES IN THE UNITEDSTATES

Until recently, there was no ap-proved tissue adhesive for endovascu-lar use in the United States, leaving theinterventionalist in the uncomfortableposition of having to obtain an agent

such as Histoacryl (n-BCA; B. Braun,Melsungen, Germany) from outsidethe country when it was essential fortreating a patient. In the latter half of2000, Trufill n-BCA (Cordis, MiamiLakes, FL) was approved by the FDAfor the presurgical devascularizationof cerebral AVMs. The Trufill n-BCALiquid Embolic System has three com-ponents: one or two 1-g tubes of n-BCA, 10 mL of ethiodized oil, and 1 gof tantalum powder, which can bemixed together. Although not specifi-cally indicated for use in the periph-eral circulation, it is likely that thisagent will replace Histoacryl for pe-ripheral applications in the US. Al-though the legal ramifications of theuse of an agent not approved for anyindication are not entirely clear, theconsensus of courts around the nationhold that off-label use of FDA-ap-proved devices and materials is part ofthe practice of medicine (18).

Another cyanoacrylate currentlyundergoing evaluation in the UnitedStates is Neuracryl M (Prohold Tech-nologies, El Cajon, CA). It consistsof a 2-hexyl-cyanoacrylate compound(Neuracryl M1) that is intended to bemixed with an esterified fatty acid andgold particles to retard polymerizationand provide radiopacity (19). Thisagent is not far along in the FDA ap-proval process.

INDICATIONS FOR ACRYLICEMBOLIZATION IN THEPERIPHERAL CIRCULATION

The principal pathologic processbenefiting from treatment with anacrylic adhesive is an AVM. The abil-ity of a liquid agent to penetrate andocclude at the level of the nidus of thislesion is critically important. Becauseembolization coils and detachable bal-loons occlude large vessels, they gen-erally have no role in the embolizationof complex AVMs outside the lungs.Polyvinyl alcohol particles have beenused, but determining the appropriatesize to use is problematic, leading tothe risk of paradoxic embolization tothe lungs (20). Although 95% or abso-lute ethanol has been used by some(21), many interventionalists find alco-hol to have great risks, including in-jury to adjacent normal tissues, partic-ularly mucosal surfaces, skin, andneurologic tissue (22–24), and cardio-pulmonary collapse caused by escape

to the right side of the heart and pul-monary bed. Our practice is to limitthe use of ethanol to organs in whichthe potential for nontarget tissue in-jury is minuscule, such as the kidney.We also use ethanol as a sclerosingagent for direct puncture therapy ofvenous malformations.

Because complex, multichanneledsystemic AVMs are difficult (if at allpossible) to eradicate, therapy should beconsidered only when significant symp-toms are present. Patients need to beaware that treatment is often palliativeand should be prepared for the possibil-ity of future procedures. It is best toapproach these patients in a multidisci-plinary fashion, with the input of a va-riety of other physicians. For extremityand superficial lesions, we work closelywith plastic surgeons and occasionallywith orthopedic and vascular surgeons,especially when treating larger, moreextensive abnormalities.

Simple arteriovenous connections,as exemplified by the classical ac-quired arteriovenous fistula (AVF),are generally best managed by embo-lization with a mechanical agent if itcan be placed directly across the originof the fistula and the segment of arterybeing occluded is not critical. The useof glue in large, high-flow AVFs car-ries a significant risk of paradoxic em-bolization, although the initial place-ment of coils to slow flow mayenhance the safety of this (25). Smalllesions in which a catheter or micro-catheter cannot be placed across theAVF may be successfully occludedwith use of glue (26,27).

Although aneurysms are generallybest embolized with mechanical agents,glue has occasionally been found to behelpful, especially when used as anadjunct to coils (28). Glue is particu-larly useful when a direct puncture isnecessary to approach an aneurysm.This approach has also been describedfor the embolization of tumors (29,30).

Some other uses reported for gluein the peripheral vasculature includeembolization for gastrointestinal bleed-ing (31), deep dorsal vein emboliza-tion for the treatment of impotencecaused by veno-occlusive dysfunction(32), internal spermatic vein emboliza-tion for the treatment of varicocele(33), in conjunction with iodized oil inthe hepatic arteries for hepatocellularcarcinoma (17) or neuroendocrine me-tastases (34), and embolization of en-

Figure 1. Monomeric cyanoacrylate. TheR represents an alkyl group.

Figure 2. N-butyl-2-cyanoacrylate.

908 • Cyanoacrylate Adhesives in Peripheral Embolization August 2001 JVIR

doleaks after placement of an endo-vascular stent-graft (35).

TECHNIQUE

The goal when embolizing an AVMis to occlude at the level of the nidus.When using cyanoacrylate, this meanscreating a cast of glue within thenidus. Embolization of only the feed-

ing arteries will only create greaterproblems in the future, because thelesion recruits collateral flow throughmore complex and difficult-to-ap-proach routes. In fact, such measurescan result in a larger, more symptom-atic AVM and are justified only in cer-tain preoperative situations. The tech-nique of glue embolization for an AVFis similar to that used for an AVM,

keeping in mind the ability to sacrificethe arterial segment of the lesion beingoccluded.

Acrylic embolization is always per-formed through a microcatheter that ispositioned as close as possible to thenidus (Figs 3a,b). Proper placement isconfirmed by contrast injections andcomparison to earlier diagnosticangiograms. The microcatheter is typ-ically placed through a less-selective 5-or 6-F catheter. This can be a guidingcatheter if injections through the outercatheter are desired. The outer cathe-ter provides a stable position in theproximal vessel and allows rapid ex-change of microcatheters occluded byglue and angiography of the emboli-zed circulation. Evaluation of the ter-ritory supplied by the microcatheter aswell as estimation of the volume ofglue needed for embolization is per-formed by test injections of contrastmaterial through this catheter. Al-though provocative testing with an in-jection of amobarbital is typically per-formed for intracranial AVMs toassess the possibility of causing a sig-nificant neurologic deficit, it has notbeen our practice to inject lidocaine toassess for potential supply to a periph-eral nerve when treating peripheralAVMs.

The method used for the test injec-tions of contrast material should pre-cisely identify the anatomy and simu-late the conditions of the plannedembolization. In an extremity, we willoften use a tourniquet or blood pressurecuff inflated central to the lesion to slowflow during diagnostic injections. Thiswill more readily identify the arteriessupplying the nidus and filling of non-pathologic branches. Alternatively, anocclusion balloon can be used in a moreproximal artery to accomplish this orthe microcatheter may be wedged in thefeeding artery to restrict pericatheterflow. Although we will occasionally usea tourniquet or occlusion balloon toslow delivery of the glue, the glue isusually injected without these. If the mi-crocatheter is sufficiently close to the ni-dus (generally within 1 cm), the glueshould be suitably deposited within it.For peripheral lesions in the extremities,small orthodontic bands can be placedaround the digits just before the embo-lization to limit the risk of nontargetdigital artery embolization.

A three-way stopcock is attached tothe microcatheter. A 1-mL Luer lock

Figure 3. Images from a 34-year-old man with a high-flow AVM in his right shoulder.(a) Selective subclavian arteriogram demonstrates the hypervascular AVM supplied bymedial and lateral humeral circumflex arteries. (b) A 3-F coaxial microcatheter placedthrough a 5-F catheter is positioned into the nidus supplied by the lateral humeralcircumflex artery. A 0.5-mL test injection of contrast material fills the nidus. Two sequen-tial 0.5-mL boluses of a 1:1 n-BCA/iodized oil mixture opacified with tungsten powderwere then injected. Each bolus was flushed into the nidus with 3 mL of D5W. (c)Radiopaque glue is evident within the malformation after completion of embolization ofthe supply from the lateral and medial humeral circumflex arteries. (d) A completionnonselective angiogram demonstrates preservation of flow in the circumflex humeralarteries and substantial obliteration of the nidi.

Pollak and White • 909Volume 12 Number 8

syringe is used on one end of the stop-cock for the delivery of varying vol-umes of contrast material and a 3-mLsyringe is attached to the other end forthe delivery of a 5% dextrose (D5W)flush (Fig 4). Several digital angio-grams are then obtained with use ofvolumes of contrast between 0.1 and0.6 mL, followed by a D5W flush (Fig3b). It is important to have two oper-ators for this procedure: one to injectthe contrast material and the other toinject the D5W. Strict attention shouldbe paid to the opacification of anydraining veins from the nidus, inwhich case the flush should bestopped. Performing this maneuverseveral times will allow for the deter-mination of the volume of contrastmaterial (and therefore the maximumamount of glue) that will fill the nidusand just start to appear in the venousoutflow. Additionally, it will allow fora smooth interaction between the twooperators. The volume of glue neededis usually less than the volume of con-trast material because thrombosedblood elements will be incorporated in

the occlusion (10,36). Typical volumesof glue will be from 0.1 to 0.6 mL.

Any contact with an ionic substancemust be avoided when handlingcyanoacrylate. The monomer shouldbe aspirated in a clean 3-mL syringeand kept on a separate embolizationtable. Because polycarbonate can bedestroyed by cyanoacrylate (7),polypropylene syringes should beused or contact with polycarbonate sy-ringes and stopcocks should be brief,and the equipment should then bediscarded. In addition to appropriatesterile and protective attire, personnelin the room should wear eye protec-tion to avoid potential contact with theglue. The acrylic is then added to aglass receptacle containing the desiredvolume of Ethiodol (Savage Labora-tories). Although, in the past, we occa-sionally added tantalum or tungstenpowder to the oil to further increasethe final mixture’s radiopacity, wecurrently do not use any powderedmetals. The ratio of n-BCA to Ethiodolwill vary from 1:1 to 1:4. The speedwith which the contrast materialreaches the nidus and first appears inthe draining veins will determine theappropriate dilution for the glue. Thelonger this takes, the more diluted theglue should be; however, in vitro, theglue can be diluted with iodized oil toa concentration of only approximately30% before the polymerization timebecomes excessively long (9). If thetime to reach the nidus seems too long(more than 3–4 sec), concern should beraised whether the microcatheter issufficiently close to the nidus. If thetime is too short, with the test injec-tions of contrast material difficult tovisualize on digital angiograms, moreaggressive methods to arrest flow maybe beneficial, such as increasing thepressure on a cuff around an extrem-ity, using an occlusion balloon, orwedging of the catheter in the vessel.Because the in vivo polymerizationtime for n-BCA appears to be morerapid than the in vitro time, one needsto make the dilution slightly greaterthan might be expected (37). This phe-nomenon may be a result of a fasterpolymerization speed of cyanoacry-lates at body temperature than atroom temperature and the greateravailability of anions intravascularly,especially when the glue is forced intocontact with the endothelium at vesselbifurcations and areas of acute angu-

lation or marked vessel narrowing(10,37). The estimated in vivo poly-merization times for glue:oil mixturesbetween 1:1 and 1:4 are 1–4 seconds,with a linear relationship to themixture.

Clean towels are placed about thehub of the microcatheter and a freshthree-way stopcock is attached to it.The catheter is flushed several timeswith the dextrose solution to clear it ofany residual saline or blood. Anotherclean towel is then placed under thehub of the catheter. The estimated vol-ume of glue is drawn up in a 1-mLLuer lock syringe and connected toone injection port of the three-waystopcock while a 3-mL syringe of D5Wis connected to the other port. The glueis then injected by one physician. Theswitch of the three-way stopcock isimmediately opened to the other portand the D5W injected by the otherphysician, advancing the glue com-pletely out of the microcatheter andinto the nidus. When the glue fullyexits the catheter and no longer passesdistal to the catheter tip, the catheter isretracted proximal to the trailing edgeof the glue to avoid the possibility ofit adhering to the intraluminal glue.Decreased catheter adhesion by cya-noacrylates has been shown in vitrowith hydrophilic-coated microcath-eters and with certain preparations of2-hexyl cyanoacrylate as compared ton-BCA (19,38). The delivery is care-fully monitored fluoroscopically. If thebody region prevents easy visualiza-tion of the opacified glue, a roadmapimage can be used.

Angiography is then performed,with injection performed through themicrocatheter or the outer coaxial cath-eter if the microcatheter was completelyremoved. This will determine the needfor further embolization. It is safest touse a new microcatheter for each injec-tion of glue. It may be difficult to injectthrough the microcatheter after the firstdeposition, presumably because of theadherence of small amounts of glue inits lumen. This makes subsequent acry-late administration more difficult andless controllable. However, if the spe-cific branch being treated was difficultto catheterize, we occasionally will re-use the same microcatheter if it remainseasy to inject through. Angiography ofthe main arterial feeder is performed atthe end to demonstrate the degree of

Figure 4. A three-way stopcock with1-mL and 3-mL Luer lock syringesattached. For test injections and determina-tions of the volume of glue and rate ofinjection, the 1-mL syringe is filled withvarying amounts of contrast material. Thevolume of glue/iodized oil mixture is sim-ulated by injecting contrast material andthe rate of injection is simulated by flush-ing D5W with the 3-mL syringe. When thevolume and rate of injection are selected, anew stopcock is used and fresh 1-mL and3-mL Luer lock syringes are filled with theglue mixture and 5% D5W solution,respectively. Approximately 50% of thetime, a second glue application can be per-formed through the 3-F microcatheter be-fore the catheter occludes.


embolization of the nidus and the pres-ence of any residual feeders (Figs 3c,d).

If a 3-way stopcock is not used, themicrocatheter should be flushed mul-tiple times with D5W after the testangiograms. A 1–3-mL syringe con-taining the desired volume of gluemixture is attached and the injection isperformed under careful fluoroscopicmonitoring. When no further distalpassage of the cyanoacrylate is ob-served, the microcatheter is rapidly re-moved while aspirating with thesyringe.

Although we have minimal experi-ence with direct puncture and emboli-zation of AVMs, it has been describedfor craniofacial lesions with use ofacrylic (4) and for peripheral lesionswith use of a variety of other agents(39). We have used acrylic adhesive toocclude aneurysms and AVFs by di-rect puncture of the lesion or a feedingartery. This method is typicallyneeded when conventional catheter-ization of a lesion is difficult or im-possible, such as when the feedingarteries have previously been inappro-priately embolized without occlusionof the actual lesion. Embolization canbe performed through either the punc-ture needle or a catheter, with the lat-ter preferred if it is a feeding arterypunctured to achieve a more distal lo-cation, closer to the lesion. Still, the siteof puncture will usually be included inthe embolization. This has the addedbenefit of avoiding bleeding when theaccess is removed. Alternatively, theaccess track may be embolized with acoil or gelatin sponge pledget.

Although endoaneurysmal fillingwith glue may be sufficient, it is tech-nically difficult to accomplish thiswith complete coverage of the originof the aneurysm. When treating an an-eurysm by direct puncture, we try toreflux the glue for a short distance intoall its connecting arteries, assuming allthese can be sacrificed. When treatingan AVF, care must be taken to avoidparadoxical embolization to the lungs.If the fistula or its origin can be cath-eterized, it is probably preferable touse mechanical agents, whereas glue ispreferred when such a selective posi-tion is not reached. After several testinjections with contrast material to de-termine the appropriate amount anddilution of glue, the acrylic is injectedunder fluoroscopic guidance in thesame manner as previously described.

A third alternative for approachingvascular lesions is retrograde venouscatheterization (39,40). This optionmay be feasible if there are sizableveins draining the lesion (preferably asingle large vein) that can be entered.Glue may be injected while a flow oc-clusion technique (eg, occlusion bal-loon, compression) is used to promotereflux into the lesion.

SIDE EFFECTS, PITFALLS,AND RISKS OF ACRYLICEMBOLIZATION

As with other agents, a postembo-lization syndrome can occur after oc-clusion with glue. Nausea and vomit-ing can be treated with antiemeticsand fever can be treated withantipyretics. Pain can be treated withanalgesics; a patient-controlled anal-gesia pump can be used if needed.Additionally, corticosteroids maylimit local edema caused by thrombo-sis after the embolization of AVMs.

Complications related to acrylicembolization can be minimized bycareful attention to the specific vascu-lar anatomy and the information ob-tained from the test injections withcontrast material. When concern existsabout the precise volume of glueneeded, the interventionalist shoulderr to the side of using too small avolume. Ischemic injury from regionalnontarget tissue embolization may becaused by the glue entering a branchdistal to the catheter tip or refluxingproximal to the planned site ofocclusion. Reflux can occur from theuse of too large a volume of glueand/or an inappropriate speed of in-jection of the glue or D5W flush. If asmall piece of glue becomes adherentto the catheter tip, it could be strippedoff in a more proximal artery duringretraction of the catheter (especiallywhen reaching the outer coaxial cath-eter) and could embolize to a nontar-get location.

Gluing of the catheter tip in placemay be related to reflux, early poly-merization, or delayed retraction ofthe microcatheter. If this occurs, itmay be necessary to break the cath-eter and leave the distal fragment inplace— hopefully, the level of thebreak will be quite distal to avoid thepresence of the proximal end of themicrocatheter fragment in a major

vessel. If there is concern that trac-tion on the catheter may result inrupture of the vessel, it may be pref-erable to cut the catheter at the levelof the arterial entry site and secure itto the groin. A role for anticoagula-tion will depend on the whether thecatheter can be removed surgically,the degree to which it occludes flowin any critical vessels, and the risk ofbleeding from the AVM.

Paradoxical embolization of glueresults from late polymerization, afterpassing through the nidus of an AVM.Occlusion of the venous outflow mayoccur, which can lead to elevated pres-sure in the nidus or remaining drain-ing veins. This increases the risk ofrupture and bleeding with CNS le-sions (41); however, this does not seemto be a major issue with peripherallesions. As the volume of glue is usu-ally quite small, pulmonary embolismis usually asymptomatic (42).

RESULTS OF ACRYLICEMBOLIZATION FORNONNEUROLOGIC AVMS

The reported experience with cya-noacrylate embolization outside of thecentral nervous system and head andneck is small. Our own experience in-dicates that localized AVMs may becurable or controllable with emboliza-tion and/or resective surgery. This isespecially true if they are well circum-scribed and not intrinsically involvedwith critical structures. Our review ofthe outcome of embolotherapy and oc-casional adjunctive surgery for 20high-flow extremity AVMs showedgood long-term palliation when the le-sion was limited (43). However, dif-fuse, infiltrating lesions involvingcritical structures and all major arte-rial trunks in a region have a highlikelihood of eventually requiringamputation. Although we were ableto palliate malformations in thelower extremities that involved allthree trifurcation arteries for severalyears, many of these patients even-tually underwent an amputation.

CONCLUSIONS

Cyanoacrylate embolotherapy re-quires careful assessment of patientsand their vascular anatomy, meticu-


lous attention to technical details, anda reasonable degree of experience. Al-though they are more demanding touse than many other embolic agents,they do have a unique role in treatingcomplex AVMs and, occasionally,other abnormalities. With the recentapproval of a cyanoacrylate for endo-vascular indications in the UnitedStates, interventionalists should be-come more familiar with these agentsoutside the neurologic system.

References1. Debrun GM, Aletich V, Ausman JI,

Charbel F, Dujovny M. Embolizationof the nidus of brain arteriovenousmalformations with n-butyl cyano-acrylate. Neurosurgery 1997; 40:112–120.

2. DeMeritt JS, Pile-Spellman J, Mast H, etal. Outcome analysis of preoperativeembolization with N-butyl cyano-acrylate in cerebral arteriovenousmalformations. Am J Neuroradiol1995; 16:1801–1807.

3. Gobin YP, Laurent A, Merienne L, et al.Treatment of brain arteriovenous mal-formations by embolization andradiosurgery. J Neurosurg 1996; 85:19–28.

4. Han MH, Seong SO, Kim HD, ChangKH, Yeon KM, Han MC. Craniofa-cial arteriovenous malformation: pre-operative embolization with directpuncture and injection of n-butylcyanoacrylate. Radiology 1999; 211:661– 666.

5. Wikholm G, Lundqvist C, Svendsen P.Embolization of cerebral arteriovenousmalformations: part I—technique,morphology, and complications. Neu-rosurgery 1996; 39:448–457.

6. Lundqvist C, Wikholm G, Svendsen P.Embolization of cerebral arteriovenousmalformations: part II—aspects ofcomplications and late outcome. Neu-rosurgery 1996; 39:460–467.

7. Kerber CW, Wong W. Liquid acrylicadhesive agents in interventionalneuroradiology. Neurosurg Clin N Am2000; 11:85–99.

8. Toriumi DM, Raslan WF, Friedman M,Tardy ME. Histotoxicity of cyanoac-rylate tissue adhesives: a comparativestudy. Arch Otolaryngol Head NeckSurg 1990; 116:546–550.

9. Cromwell LD, Kerber CW. Modifica-tion of cyanoacrylate for therapeuticembolization: preliminary experience.Am J Roentgenol 1979; 132:799–801.

10. Brothers MF, Kaufmann JC, Fox AJ,Deveikis JP. n-Butyl 2-cyanoacry-late—substitute for IBCA in interven-tional neuroradiology: histopathologic

and polymerization time studies. Am JNeuroradiol 1989; 10:777–786.

11. Spiegel SM, Vinuela F, Goldwasser JM,Fox AJ, Pelz DM. Adjusting the poly-merization time of isobutyl-2 cyano-acrylate. Am J Neuroradiol 1986;7:109–112.

12. White RI Jr, Strandberg JV, Gross GS,Barth KH. Therapeutic embolizationwith long-term occluding agents andtheir effects on embolized tissues. Ra-diology 1977; 125:677–687.

13. Vinters HV, Galil KA, Lundie MJ,Kaufmann JC. The histotoxicity ofcyanoacrylates: a selective review.Neuroradiology 1985; 27:279–291.

14. Wikholm G. Occlusion of cerebral ar-teriovenous malformations with N-bu-tyl cyano-acrylate is permanent. Am JNeuroradiol 1995; 16:479–482.

15. Gruber A, Mazal PR, Bavinzski G,Killer M, Budka H, Richling B.Repermeation of partially embolizedcerebral arteriovenous malforma-tions: a clinical, radiologic, and histo-logic study. Am J Neuroradiol 1996;17:1323–1231.

16. Rao VR, Mandalam KR, Gupta AK,Kumar S, Joseph S. Dissolution ofisobutyl 2-cyanoacrylate on long-termfollow-up. Am J Neuroradiol 1989; 10:135–141.

17. Berghammer P, Pfeffel F, WinkelbauerF, et al. Arterial hepatic embolizationof unresectable hepatocellular carci-noma using a cyanoacrylate/lipiodolmixture. Cardiovasc Intervent Radiol1998; 21:214–218.

18. Smith JJ, Berlin L. Informed consentwhen using medical devices for indica-tions not approved by the Food andDrug Administration. AJR Am J Roent-genol 1999; 173:879–882.

19. Barr JD, Hoffman EJ, Davis BR, EdgarKA, Jacobs CR. Microcatheter adhe-sion of cyanoacrylates: comparison ofnormal butyl cyanoacrylate to 2-hexylcyanoacrylate. J Vasc Interv Radiol1999; 10:165–168.

20. Repa I, Moradian GP, Dehner LP, etal. Mortalities associated with useof a commercial suspension of poly-vinyl alcohol. Radiology 1989; 170:395–399.

21. Yakes WF, Rossi P, Odink H. How Ido it. Arteriovenous malformationmanagement. Cardiovasc Intervent Ra-diol 1996; 19:65–71.

22. Jungreis CA. Skull-base tumors: eth-anol embolization of the cavernous ca-rotid artery. Radiology 1991; 181:741–743.

23. Latshaw RF, Pearlman RL, SchaitkinBM, Griffith JW, Weidner WA. In-traarterial ethanol as a long-term occlu-sive agent in renal, hepatic, and gastro-splenic arteries of pigs. CardiovascIntervent Radiol 1985; 8:24–30.

24. Dickey KW, Pollak JS, Meier GH III,Denny DF, White RI, Jr. Managementof large high-flow arteriovenous mal-formations of the shoulder and up-per extremity with transcatheterembolotherapy. J Vasc Interv Radiol1995; 6:765–773.

25. Cekirge S, Oguzkurt L, Saatci I, BoyvatF, Balkanci F. Embolization of a high-output postnephrectomy aortocavalfistula with Gianturco coils andcyanoacrylate. Cardiovasc InterventRadiol 1996; 19:56–58.

26. Sapoval MR, Jebara VA, Raynaud AC,et al. Percutaneous embolization ofan arteriovenous fistula of the internalmammary pedicle following sternalwire insertion. Cathet Cardiovasc Di-agn 1993; 28:339–341.

27. Numan F, Cakirer S, Islak C, et al.Posttraumatic high-flow priapismtreated by N-butyl-cyanoacrylateembolization. Cardiovasc Intervent Ra-diol 1996; 19:278–280.

28. Yamakado K, Nakatsuka A, Tanaka N,Takano K, Matsumura K, Takeda K.Transcatheter arterial embolization ofruptured pseudoaneurysms with coilsand n-butyl cyanoacrylate. J Vasc In-terv Radiol 2000; 11:66–72.

29. Casasco A, Herbreteau D, Houdart E,et al. Devascularization of craniofa-cial tumors by percutaneous tumorpuncture. Am J Neuroradiol 1994; 15:1233–1239.

30. Chaloupka JC, Mangla S, Huddle DC,et al. Evolving experience with directpuncture therapeutic embolization foradjunctive and palliative managementof head and neck hypervascularneoplasms. Laryngoscope 1999; 109:1864–1872.

31. Toyoda H, Nakano S, Kumada T, et al.Estimation of usefulness of N-butyl-2-cyanoacrylate-lipiodol mixture intranscatheter arterial embolization forurgent control of life-threatening mas-sive bleeding from gastric or duodenalulcer. J Gastroenterol Hepatol 1996; 11:252–258.

32. Peskircioglu L, Tekin I, Boyvat F, Kara-bulut A, Ozkardes H. Embolizationof the deep dorsal vein for the treat-ment of erectile impotence due toveno-occlusive dysfunction. J Urol2000; 163:472–475.

33. Kunnen M, Comhaire F. Nonsurgicalcure of varicocele by transcatheter em-bolization of the internal spermaticvein(s) with a tissue adhesive(Bucrylate). In: Castaneda-Zuniga WR,Tadavarthy SM, eds. InterventionalRadiology. Baltimore: Williams &Wilkins, 1988:128–153.

34. Winkelbauer FW, Niederle B, Pi-etschmann F, et al. Hepatic arteryembolotherapy of hepatic metastasesfrom carcinoid tumors: value of using a


mixture of cyanoacrylate and ethio-dized oil. AJR Am J Roentgenol 1995;165:323–327.

35. Yamaguchi T, Maeda M, Abe H, et al.Embolization of perigraft leaks after en-dovascular stent-graft treatment of distalarch anastomotic pseudoaneurysm withcoil and n-butyl 2-cyanoacrylate. J VascInterv Radiol 1998; 9:61–64.

36. Rosen RJ. Abnormal arteriovenouscommunications. In: Baum S, PentecostMJ, eds. Abrams’ Angiography: Inter-ventional Radiology. Boston: Little,Brown, 1997:998–1030.

37. Widlus DM, Lammert GK, Brant A, etal. In vivo evaluation of iophendy-

late-cyanoacrylate mixtures. Radiology1992; 185:269–273.

38. Mathis JM, Evans AJ, DeNardo AJ, etal. Hydrophilic coatings diminish ad-hesion of glue to catheter: an in vitrosimulation of NBCA embolization. Am JNeuroradiol 1997; 18:1087–1091.

39. Gomes AS. Embolization therapy ofcongenital arteriovenous malforma-tions: use of alternate approaches. Ra-diology 1994; 190:191–198.

40. Jackson JE, Mansfield AO, Allison DJ.Treatment of high-flow vascular malfor-mations by venous embolization aided byflow occlusion techniques. Cardiovasc In-tervent Radiol 1996; 19:323–328.

41. Richling B, Killer M. Endovascularmanagement of patients with cerebralarteriovenous malformations. Neuro-surg Clin N Am 2000; 11:123–145.

42. Pelz DM, Lownie SP, Fox AJ, HuttonLC. Symptomatic pulmonary com-plications from liquid acrylate em-bolization of brain arteriovenousmalformations. Am J Neuroradiol1995; 16:19–26.

43. White RI Jr, Pollak J, Persing J, Hender-son KJ, Thomson JG, Burdge CM.Long-term outcome of embolotherapyand surgery for high-flow extremity ar-teriovenous malformation. J Vasc In-terv Radiol 2000;11:1285–1295.


the use of cyanoacrylate adhesives in peripheral embolization · 2012-09-11 · the use of...

Documents