Endovascular Use of Cyanoacrylate-Lipiodol Mixture for Peripheral Embolization: Properties, Techniques, Pitfalls, and Applications

Abstract

Endovascular embolization agents are particles and fluids that can be released into the bloodstream through a catheter to mechanically and/or biologically occlude a target vessel, either temporarily or permanently. Vascular embolization agents are available as solids, liquids, and suspensions. Although liquid adhesives (glues) have been used as embolic agents for decades, experience with them for peripheral applications is generally limited. Cyanoacrylates are the main liquid adhesives used for endovascular interventions and have a major role in managing vascular abnormalities, bleeding, and many vascular diseases. They can only be injected as a mixture with ethiodized oil, which provides radiopacity and modulates the polymerization rate. This review describes the characteristics, properties, mechanisms of action, modalities of use, and indications of the cyanoacrylate-Lipiodol^® combination for peripheral embolization.

Keywords: arteries; cyanoacrylate; glue; interventional radiology; transcatheter embolization; veins.

Figure 1

Chemical structure of two cyanoacrylate glues (N-butyl cyanoacrylate). (A) N-butyl-2-cyanoacrylate (NBCA) (Histoacryl^®). (B) N-butyl-2-cyanoacrylate (NBCA) + metacryloxysulfolane (NBCA-MS) (Glubran^®2).

Figure 2

Chemical structure of monomeric cyanoacrylate. The R represents an alkyl group.

Figure 3

Example of extension of polymerization of glue according the lipiodol ratio. (A) Glue/lipiodol mixture in a 1:1 ratio (50% NBCA). (B) On the left glue/lipiodol mixture in a 1:4 ratio (20% NBCA) showing delayed polymerization with more extensive cast in surface.

Figure 4

Features and preparation of glue and lipiodol as a mixture before embolization. (A) Lipiodol^® 10 mL vial and Glubran^®2 1 mL vial. (B) Preparation of the glue/lipiodol mixture with 2 separated 5 mL plastic luer-locked syringes and a plastic 3-way stopcock in a smooth manner.

Figure 5

Superficial painful buttock arteriovenous malformation (AVM) in a 61-year-old patient. (A) Axial magnetic resonance imaging shows posterior subcutaneous contrast enhancement at the arterial phase, corresponding to the AVM. (B) Direct puncture of the nidus with a 21-gauge metallic needle and opacification of the nidus. (C) Embolization with a Glubran^®2/Lipiodol^® mixture of a 1:5 ratio. (D) Final result after complete embolization of the nidus.

Figure 6

Prophylactic selective embolization of a large angiomyolipoma of the right kidney. (A) Angiography shows two feeding arteries to the angiomylipoma which is hypervascular. (B) Final control after selective and fast embolization of the two arterial branches with a Glubran^®2/Lipiodol^® mixture of a 1:6 ratio. (C) Computed tomography scan at day 14 showing lipiodol uptake by the angiomyolipoma which is totally devascularized.

Figure 7

Refractory upper gastrointestinal hemorrhage from a gastric ulcer of the less curvature in a 64-year-old patient with coagulation disorders and hemodynamic instability. (A) Catheterism of the left gastric artery demonstrated extravasation of contrast medium from a small feeding branch of the less curvature (arrow). (B) Superselective angiogram of the bleeding artery, guided by an endoscopic metallic clip, confirmed active bleeding (arrow). (C) After selective microcatheterism, hemorrhage was controlled after superselective embolization of the feeding artery using a MagicGlue^®/Lipiodol^® mixture (1:3 ratio) (arrows). (D) Final control angiography showed successful superselective occlusion of the bleeding arterial branch, respecting collaterals (arrow). The patient stopped to bleed immediately.

Figure 8

Typical left varicocele embolization with glue. (A) Left gonadal vein phlebography: a 5 French catheter is inserted in the left spermatic vein. A microcatheter is placed below the iliopectineal line and the dead space is filled with dextrose 5%, to avoid intracatheter glue polymerization. Embolization procedure is then performed using glue mixed with lipiodol at a ratio of 1:1 to get fast polymerization and avoid migration in case of reflux. Lipiodol–glue mixture is then injected under strict fluoroscopy, with continuous injection performed manually and a display of real-time distribution. The glue injection begins in the distal intrapelvic segment of the gonadal vein, and the catheter is withdrawn slowly while injecting NBCA under fluoroscopic control. Injection is then stopped before the pampiniform plexus is reached. The microcatheter is then removed when the glue fills the venous space selected beforehand. (B) Here we can see the cast of glue along the left spermatic vein after embolization.

Figure 9

Type 2 endoleak from lumbar ateries. (A) Computer tomography (CT) scan with contrast injection in procubitus position showing posterior opacification of the periprothetic aneusrysmal sac (nidus). (B) Translumbar puncture of the nidus of the endoleak under CT guidance with a metallic needle. Insertion of a microcatheter inside and embolization of the nidus with a Glubran^®2/lipiodol mixture (1:4 ratio) until complete nidus opacification.

Figure 10

Example of a 62-year-old patient who developed a painful pulsatile mass with groin hematoma following coronary angioplasty. (A) Duplex ultrasound (US) at the groin puncture site demonstrated a large false aneurysm (FA) arising from the right proximal superficial femoral artery. (B) Angiography by crossover from the left side confirmed the FA from the superficial femoral artery (arrow). (C) The FA sac was then punctured under US guidance with a metallic needle with hyperechoic tip (arrow). (D) After inflating a Mustang^TM balloon of appropriate size in the parent artery in front of the FA neck in order to avoid reflux, a Glubran^®2/lipiodol of a ratio of 1:1 was injected into the FA sac under fluoroscopic guidance until complete filling of the FA (arrow). (E) Arteriogram after deflating the balloon demonstrated, few minutes after glue injection, no NBCA migration (arrow). (F) Final angiography after embolization showed complete occlusion of the FA (arrow) and confirmed patency of the parent artery.