Fatal N-Butyl-2-Cyanoacrylate Pulmonary Embolism after Sclerotherapy for Variceal Bleeding

A 30-year-old man presented with hematemesis. Five years earlier, he had been diagnosed with Escherichia coli liver abscesses, without a clear underlying cause being identified. Although he recovered with antibiotic treatment, extensive thrombosis of the portal, splenic, and superior mesenteric veins remained. The patient received prophylactic propanolol for a large fundic varix, and oral anticoagulants during the first year as well. Endoscopic evaluation during the current admission revealed bleeding from the fundic varix, and an injection of 1 ml N-butyl-2-cyanoacrylate (enbucrilate, Histoacryl), 0.5/0.8 (v/v) diluted with Lipiodol, was administered. Although the hemorrhage was temporarily stopped, repeated cyanoacrylate injections (two injections of 1 ml) and subsequent placement of a Sengstaken-Blakemore tube had to be carried out due to recurrent severe bleeding.

The same day, a partial gastrectomy, splenectomy, and esophageal transection were performed. Postoperative chest radiography (Figure [1], left) and computed tomography (Figure [1], top right) revealed multiple cyanoacrylate pulmonary emboli. Mechanical ventilation had to be started. Abdominal sepsis from a subphrenic abscess, with multiple organ failure, subsequently occurred. Intravenous heparin therapy was started due to deep vein thrombosis in both legs. The patient showed further pulmonary deterioration (Figure [1], bottom right). Thirty-seven days after the initial sclerotherapy, he died of abdominal sepsis and deteriorating pulmonary function. No recurrent bleeding had occurred since the surgical procedure.

Figure 1 Left: A chest radiograph showing multiple pulmonary emboli (white arrows) and two large fragments of Cyanoacrylate in the upper abdomen (black arrows). Top right: Postoperative computed tomogram, showing multiple cyanoacrylate pulmonary emboli on both sides (arrows), with an increased signal intensity in the segmental and subsegmental pulmonary arteries. Bottom right: Computed tomograph approximately 2 weeks after the onset of the pulmonary emboli, showing pulmonary infarction, formation of bullae, extensive consolidation, pleural effusions, and residual enbucrilate (arrows).

Although cyanoacrylate is generally regarded as the first-line treatment for bleeding gastric varices [1], complications may occur, such as the needle adhering to the varix, pyrexia, deep ulceration due to accidental paravariceal injection, and in particular pulmonary embolism [2] [3]. Risk factors for pulmonary embolism are: more than 1 ml cyanoacrylate-Lipiodol per injection, excess Lipiodol (cyanoacrylate/lipiodol ratio below 5 : 8 v/v), injection of excess distilled water with the needle still located in the varix [4], and slow injection, especially in case of varices with a high flow rate and a large diameter [5]. Surgery is still a valuable treatment alternative, especially in cases of left-sided portal hypertension.

Endoscopy_UCTN_Code_CPL_1AH_2AC

References

• 1 Lo G H, Lai K H, Cheng J S. et al . A prospective, randomized trial of butyl cyanoacrylate injection versus band ligation in the management of bleeding gastric varices.  Hepatology. 2001;  33 1060-1064
• 2 Tsokos M, Bartel A, Schoel R. et al . [Fatal pulmonary embolism after endoscopic embolization of downhill esophageal varix; in German].  Dtsch Med Wochenschr. 1998;  123 691-695
• 3 Naga M, Foda A. An unusual complication of Histoacryl injection.  Endoscopy. 1997;  29 140
• 4 Seewald S, Sriram P V, Naga M. et al . Cyanoacrylate glue in gastric variceal bleeding.  Endoscopy. 2002;  34 926-932
• 5 Suga T, Akamatsu T, Kawamura Y. et al . Actual behavior of N-butyl-2-cyanoacrylate (Histoacryl) in a blood vessel: a model of the varix.  Endoscopy. 2002;  34 73-77