Tips and Tricks

Ezio Lanza MD

Today I am going to give you an overview on the different applications of Glubran®2, through some case reports in both elective and emergency settings.

CASE 1 – Gluteal AVM

Woman (50) – 1:4 ratio small “sandwich” boluses

We injected small boluses of mildly diluted glue, using a very small syringe (1ml), alternated with small amounts of glucose, in order to obtain a widespread distribution of the glue without sacrificing the micro-catheter. As you know, these cases require multiple interventions, and the goal is, of course, to maximize embolization in each session, while avoiding severe ischemia. The end result is that the upper part of the AVM has been successfully devascularized, while the lower part will be treated in a subsequent procedure.

CASE 2 – Coeliac Pseudoaneurysm from Superior Mesenteric after Pancreaticoduodenectomy

Man (59) – 1:3 ratio – 0.1 ml focal injection to avoid non-target embolization

In this case, I want to show you which are the metrics we have to get used to when we approach the use of cyanoacrylates: 0.1ml of glue is a reasonable amount and we need to get to terms with the fact that sometimes this is all we need when we are trying to avoid non-target embolization. In this case, we have a large coeliac hematoma and a pseudoaneurysm, which is active bleeding from the superior mesenteric artery. This may happen because, as you know, pancreaticoduodenectomy is a very invasive procedure. The difficulty here is that the pseudoaneurysm is pointing upwards in respect to the artery, so the catheterization was quite challenging, however once I managed to place the micro-catheter, the only thing left to do was to inject 0.1ml of glue to create some sort of a balloon, so to completely exclude the pseudoaneurysm.

CASE 3 – Gastric artery bleeding after pancreaticoduodenectomy

Man (80) – 0.15 ml superselective injection – 1:5 ratio

This was a large bleeding from the gastric artery and this patient’s haemoglobin levels were rapidly dropping. As you can imagine, in this case, embolizing agents other than liquid would be very difficult to deploy. Medium range of dilution, as 1:4/1:5, allowed for a good deployment of the glue inside the lumen of the bleeding bowel, while achieving the embolization of the vessel to successfully stop the bleeding.

CASE 4 -Adrenal Mass Bleeding

0.1 ml Glubran®2 – 1:3 ratio

This was a very unusual case of adrenal artery bleeding due to a tumour, which was causing a slow decrease of haemoglobin levels. Again, selective catheterization and a very small amount of glue – though in a much denser concentration – allowed to easily stop the bleeding.

CASE 5 -Iliac Bone Comminuted Fracture after RTA

Woman (72) – 1:9 ratio to reach multiple bleeding sites

This time we have a very different case, where we adopted a more diluted ratio in order to reach multiple, fast bleeding sites, with a single embolization. This diluted mixture allowed for quick, full and effective embolization of the bleeding spots.

CASE 6 – Robotic Kidney Surgery “when coiling is not enough”

Man (54) – 1:9 ratio – slow controlled injection

We do not normally use glue when it comes to the kidneys because it is a terminal vascularization, but when coiling is not enough you may need different embolic material. This was a particularly difficult case as it presented multiple bleeding, and it just would not stop with simple coiling of the arteries, so I decided to switch to glue. It was important to handle the syringe with care because, when you deal with terminal arteries, it is very easy to get backflow. I used a sandwich technique with a very diluted mixture, inserting small boluses from the tip of the micro-catheter inside the cavity formed by the surgery and the hemorrhage. By handling the syringe with care I was able to inject a block of glue that formed sort of a film from which I could build up and successfully managed to completely embolize the vessel, while avoiding backflow. I could still see some residual bleeding from the coiling technique I had used before, and, although I was confident it would stop sooner or later, which it eventually did, I believe that if I had started with glue rather than coiling, I could have reached the goal much faster.

CASE 7 -Pelvic CHO type 2 AVM – Large venous backflow

Man (54) – 1:4 ratio Glubran®2 + Amplatzer plug

This was a very unusual and challenging case: a large pelvic malformation with an aneurysmal venous sac. Dario and I got a bit creative and performed a double puncture in order to place three catheters: one inside the artery feeding the AVM, and two inside the draining vein. From the first, we started deploying a 22 mm type 3 Amplatzer plug – to stop the backflow and avoid a pulmonary embolism, – followed by our mixture. The plug successfully stopped the glue, and this allowed us to fill the aneurysmal sac. The final result was very satisfactory and the patient made a complete recovery.

CASE 8 – Forefoot AVM

Woman (35) – 0.1 ml Glubran®2 – 1:3 in the posterior tibial

In this case, we applied manual compression of the digital arteries in order to avoid embolization and stop the flow. Again, we used only a small amount of glue, in a highly dense ratio, and the final result was completely satisfactory, with preservation of the digital arteries and no signs of ischemia.

CASE 9 – Varicocele Embolization

Man (20) – 3 ml of Glubran®2 – 1:2 ratio

This was a case of very difficult anatomy, as we are talking about many different veins and collaterals, and I could not place the micro-catheter where I wanted to, so my stance was very proximal. I used a very dense mixture while asking the patient to do a strong Valsalva manoeuvre and apply manual compression of the left groin. Using this trick I was able to achieve distal embolization while not being distal at all. The final result was very good and we saw no further complications.

Q&A

Webinar Chat: In CASE 5, could you have opted for gelfoam, instead of glue?

Ezio Lanza, MD: Gelfoam is indeed an option: we use it when we are sure that the patient will be fit enough to undergo surgery, because, as you know, traumatologists will not operate on unstable patients. In that particular case, gelfoam could have meant too proximal an embolization, and I wanted to make sure I could reach the bleeding spots distally, to maximize stability and guarantee a safe surgical procedure. This is not to say that glue is our only option: sometimes it depends on experience and the confidence you have in using different materials, sometimes it depends on the goal.

Dario Poretti, MD: Can you use the micro-catheter multiple times?

Ezio Lanza, MD: If you favor the use of glucose and the sandwich technique, you can save your micro-catheter for multiple uses. So, basically, as long as you flush it with glucose, you can easily eliminate most of the residual glue and use it for up to 3 times (no more than that). In order to flush it effectively, the flow must be free of obstacles. Flushing your micro-catheter in the liver, for example, is perfectly safe, whereas you cannot do this in the kidney, as you would get early backflow. In such a situation, you should quickly extract your micro-catheter, leaving the main catheter in place, and flush it outside, on a towel.

Dario Poretti, MD: Does the glue pose a problem in terms of being able to retrieve your catheter? In other words, is there any risk for the catheter of getting stuck because of the glue?

Ezio Lanza, MD: I know for a fact that glue might cause problems with hydrophilic catheters, as it reacts to water and hydrophilic coating. I do not normally use such catheters, and I never found myself in the position of not being able to retrieve my instrument. You will often find a few centimeters of glue stuck to the tip of the catheter, but a quick and regular movement is all you need to be able to retrieve it.

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