N-butyl-2-cyanoacrylate (Histoacryl) has been in use for almost 20 years for acute
control of hemorrhage from gastric varices [1]. We present here a rarely reported complication associated with its use.
A 65-year-old man, who had been diagnosed 20 years previously with noncirrhotic portal
hypertension due to bilharziasis, was admitted with gastric variceal bleeding. He
had undergone esophageal variceal eradication in the past. The varices were injected
with cyanoacrylate diluted with Lipiodol (1.5 ml/2.1ml). After several hours, the
patient complained of chest pain and an inability to see. Investigation revealed inferior
wall myocardial infarction and cortical blindness. Noncontrast computed tomography
of the brain showed multiple hyperdense foci suggestive of cyanoacrylate emboli in
the cerebral arteries, and bilateral occipital infarcts (Figure [1]).
Figure 1 Computed tomography of the brain, showing an infarct in the right occipital area (a, arrows) and left occipital area (b, arrows), as well as cyanoacrylate emboli.
Further investigation in another center revealed that he had a patent foramen ovale
(PFO). This was closed with a 25-mm Amplatzer PFO-occluding device via a percutaneous
approach. Following this, a transjugular intrahepatic portosystemic shunt was placed.
The patient’s vision improved, and he became able to perceive color, recognize faces,
and count fingers at a distance of 2 m. Two months later, he was asymptomatic.
Acute gastrointestinal bleeding from large gastric varices is an infrequent but potentially
life-threatening event. Cyanoacrylate glue is increasingly being used for hemostasis
in this situation [2]. Lipiodol is often used as a diluent with the glue. It prevents rapid polymerization
inside the injector and makes the injection radiopaque [1].
Embolism with glue occurs in less than 1 % of cases, mainly in the lungs, portal vein,
heart, splenic circulation, and rarely the brain [1]
[3]. In this case, the patient did not have a pulmonary embolism, probably due to the
presence of an intracardiac shunt. Patent foramen ovale occurs in 20 - 30 % of adults.
In most instances, it is diagnosed after episodes of paradoxical embolism [4].
Larger volumes of glue injected, fast blood flow in large vessels, and slow injection
may result in fragmentation of the glue and hence embolization [2]
[5]. A combined radiographic/endoscopic approach for varices larger than 10 mm, dilution
of the glue with Lipiodol at ratios not exceeding 1 : 1, and even injection without
admixture with Lipiodol have been suggested as methods of avoiding this [2]. Cerebral stroke is still a rare complication after the injection of cyanoacrylate.
Modified injection techniques might be able to prevent this potentially life-threatening
complication.
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