ISET: Glue Works When Coils Fail

HOLLYWOOD, Fla. – In situations where coils or other methods didn’t complete the embolization job, doctors reached into their bag of off-label tricks and found cyanoacrylate glue — approved for use in cerebral aneurysms — which appeared to be successful in closing difficult endoleaks and hemorrhages elsewhere in the body, researchers reported here.

In a retrospective look at the off-label use of cyanoacrylate glue (n-butyl-2-cyanoacrylate, Trufill), Amit Ramjit, MD, a resident in diagnostic radiology at Staten Island (New York) University Hospital, Northwell Health, identified 14 cases in which the substance was used by the hospital’s five interventional radiologists from 2016 to 2018.

“Cyanoacrylate glue is used relatively frequently for non-cerebral measures, as reported in the medical literature,” Ramjit told MedPage Today at his poster presentation at the 2019 International Symposium on Endovascular Therapy. “But because these uses are off-label, it had not been extensively studied. Cyanoacrylate glue can be used to embolize visceral aneurysms, gastrointestinal hemorrhage, or reduce flow in arteriovenous fistulas.”

He suggested that “liquid embolic agents can offer the interventional radiologist another tool to treat these various conditions when traditional means fail.”

“Due to the rapid polymerization of cyanoacrylate when in contact with blood, glue is considered to require more technical expertise relative to re-deployable endovascular coils,” Ramjit continued. “The most commonly cited risk of liquid embolic agents is non-target embolization or bowel ischemia.”

Ramjit explained that in reviewing his hospitals records, he found that the glue was most commonly used in endoleaks, such as those occurring after placement of abdominal aortic aneurysm (AAA) graft stents. Six of the 14 cases described were aimed at fixing this problem, especially when coils or other embolization procedures failed or were not practical.

“The AAAs are probably the most common endoleak situation we have,” he said. The interventional radiologist would seek help in stopping an endoleak after the device has been positioned. “The first choice is to use coils but then, for whatever reason, there is still evidence of bleeding, so we use the glue,” Ramjit said. “The glue can flow into smaller places, which gives it a unique role in some of these cases.”

He said that the off-label use of the glue is most often employed as a second-line treatment to correct ongoing bleeding, but there are also cases in which because of the size or location of the bleed, the glue would be applied as a first-line treatment. “Our institution routinely uses cyanoacrylate glue as an option in certain situations, primarily where superselective cannulation cannot technically be achieved,” he said.

“In all these cases, we just had to employ the glue one time,” Ramjit said, adding that technical success was achieved in all cases. He described one case in which the glue was deployed after several attempts to correct colonic bleeding. The patient eventually required surgery and colostomy, but Ramjit said he did not consider that the glue caused this complication.

He said that in five cases the glue was used in emergent gastrointestinal or postoperative hemorrhage. The glue was also used in cases of arteriovenous fistula or arteriovenous malformation.

Francisco Contreras, MD, an interventional radiologist at Florida State University, University of Central Florida, and Florida Hospital in Orlando, who was not involved with the study, told MedPage Today that using glue in situations such as endoleaks is a reasonable approach: “Even though cyanoacrylate glue is approved for use in the brain, we often will adopt technology that is aimed at one part of the body and use it in other areas where things are similar in terms of physiology.”