Partial Splenic Embolization Using n-Butyl Cyanoacrylate Glue: A Technical Overview

Abstract

Partial splenic embolization (PSE) is a minimally invasive alternative to splenectomy for conditions such as hypersplenism, portal hypertension, and splenic artery steal syndrome. Although no consensus exists regarding the optimal embolic agent, n-butyl cyanoacrylate (n-BCA) has gained increasing interest due to its ability to provide rapid, durable occlusion independent of the coagulation cascade, along with its potential antimicrobial effects. This review outlines techniques, outcomes, and challenges of PSE using n-BCA. The procedure is typically performed via femoral or radial/brachial access, often facilitated by long sheaths or “mother-child” systems to navigate tortuous anatomy. A dilute n-BCA-Lipiodol mixture (1:5–1:6) supplemented with tantalum for radiopacity is delivered through a D5W-primed microcatheter under fluoroscopic guidance. Multiple delivery strategies may be used to optimize distal distribution and minimize reflux, with careful catheter withdrawal to avoid entrapment. Post-embolization syndrome and periprocedural pain are common but usually managed effectively with multimodal analgesia, while serious complications such as abscess, portal vein thrombosis, or non-target embolization remain uncommon. Clinical studies demonstrate that n-BCA achieves high technical success, rapid splenic devascularization, and significant early increases in platelet and leukocyte counts, thereby enabling systemic therapies in patients with oncologic hypersplenism. Compared with other embolics, n-BCA reduces recanalization risk, shortens procedure time, and allows viscosity-based customization, although direct head-to-head trials in PSE remain limited. Additionally, n-BCA exhibits antimicrobial activity and favorable infection profiles. n-BCA is a safe and effective embolic agent for PSE, offering both durable mechanical occlusion and potential infection-mitigating properties. Further comparative studies are warranted to confirm long-term outcomes and define its role relative to particulate and mechanical agents.

Keywords

partial splenic embolization - n-butyl cyanoacrylate - hypersplenism - vascular occlusion - embolization

Introduction

Partial splenic artery embolization (PSE) is a minimally invasive procedure that eliminates the operative risks associated with splenectomy. PSE involves occluding blood flow to a specific part of the spleen while preserving perfusion to the remainder of the organ. It can be used to treat conditions like hypersplenic thrombocytopenia, sinistral portal hypertension, and splenic artery steal syndrome.[1] [2] [3]

There is no general consensus regarding the embolic agent of choice for PSE.[4] [5] Traditionally, gelatin sponge, coils, and particles have been used. n-Butyl cyanoacrylate (n-BCA) has also been used in PSE because of its rapid and durable occlusive properties.[6] [7] n-BCA is a stable comonomer that rapidly polymerizes upon contact with ionic substances, such as blood, independent of the coagulation cascade.[8] This review describes the technique, benefits, and potential risks associated with the use of n-BCA for PSE.

Technique

Overview

The splenic artery usually divides into the superior and inferior branches near the splenic hilum, and each branch further divides into 4 to 6 segmental intrasplenic branches with few communicating branches between them.[3] Occlusion of the segmental branches terminates blood flow to the downstream splenic parenchyma, while the non-embolized segments remain perfused.

The PSE procedure can be complicated by extra- and intrasplenic anastomosis and anatomical variations of the splenic artery, which are common in the general population.[3] These variations may complicate the catheterization process, lead to uneven embolization of splenic parenchyma, and may also cause non-target embolization. Interventional radiologists should be aware of these variations in the origin and course of the splenic artery and its branches before performing the PSE procedure.

Patient Selection Criteria, Indications, and Contraindications

PSE is used to treat several non-traumatic conditions including idiopathic thrombocytopenic purpura, autoimmune hemolytic anemia, spherocytosis, refractory thrombocytopenia, and neutropenia associated with hypersplenism, portal hypertension and its sequelae, and splenic artery steal syndrome after liver transplantation.[3] [9] In patients with cirrhosis due to hepatitis C virus and hypersplenism, PSE is also used as pretreatment to reduce cytopenia, which enables antiviral therapy at higher dosages for a sustained duration. PSE is an alternative for patients who do not respond well to other therapies, including medical management with corticosteroids or immunoglobulin therapy in hematologic disorders, prior to considering splenectomy.[3]

Contraindications of PSE include systemic infections that may increase the risk of splenic abscess post-procedure, as well as abnormal coagulation tests.[3] Additional contraindications to performing arteriograms, which are necessary for PSE, include severe allergies to contrast media, significant renal impairment, and pre-existing arterial occlusions that prevent catheter navigation. While some contraindications, like systemic infections and abnormal coagulation, can be treated before the procedure, others, such as irreversible arterial occlusions, cannot be treated, thereby precluding the use of PSE in these patients.

Patient Preparation and Pre-procedure Protocol

The Society of Interventional Radiology (SIR) standards of practice guidelines recommend broad-spectrum antibiotic prophylaxis if >70% of the spleen is expected to be embolized in PSE. Although there is no consensus on the first-choice antibiotic, some of the recommended regimens include 10 mg/kg/d Gentamicin with 100 mg/kg/d cefoxitin sodium beginning 2 hours before the procedure or cefoperazone every 12 hours post-procedure. They should be continued for a minimum of 5 days post-PSE. Amoxicillin and clavulanate potassium (3 g/d) and ofloxacin (400 mg/d) can also be administered as an alternative.[10]

In addition, patients may also receive vaccinations against encapsulated organisms such as Pneumococcal pneumonia, Meningococcal infection, and Hemophilus influenzae type-b, 2 weeks before the procedure. In the event of an emergency procedure, it can be given 2 weeks post-PSE.[11] Vaccinations are not routinely required for PSE but should be recommended in cases of 100% splenic parenchymal embolization.

All patients should also be given proper information to reduce infectious complications. This guidance should include maintaining good hygiene at the procedure site, recognizing early signs of infection such as fever, chills, or unusual pain, and understanding the critical importance of seeking immediate medical attention if these symptoms occur.

A pre-procedure computed tomography (CT) scan should be performed to estimate the degree of splenic embolization and the amount of viable tissue that will remain. This scan can also be used to calculate the volume of the spleen supplied by the targeted arterial branches ([Fig. 1A, B]). The embolization target is to achieve 50 to 70% infarction of the spleen.[12] [13] Lower pole splenic branches are generally preferred in PSE to minimize pain and complications such as pleural effusion and subdiaphragmatic abscess.[11]

Fig. 1 (A, B) Calculation of the volume of spleen supplied by the splenic artery branches. Upper spleen (red) volume = 1,025 cm². Lower spleen (blue) volume = 1,190 cm².

Embolization Procedure Details

Vascular access for PSE is obtained via transfemoral or transradial/brachial approaches. Although transfemoral access is more common, transradial/brachial access may offer a more favorable angle for cannulation of the celiac artery in patients with steep vessel takeoffs. It also facilitates hemostasis, shortens procedure time, eliminates the need for post-procedure movement restriction, and may be associated with lower complication rates.[14] [15] [16] [17]

Adequate sheath and catheter length must be planned in advance to ensure sufficient working length for splenic artery selection. In cases of aortic ectasia or tortuous visceral origins, advancing a long 5- to 6-F sheath or guide catheter into the celiac or proximal splenic artery provides improved support, reduces kickback during microcatheter work, and facilitates check injections without loss of position. A “mother-child” configuration, using a diagnostic catheter nested within a larger guide, can further augment stability.[14] Establishing stable access in the celiac or proximal splenic segment is particularly important during glue delivery, as it minimizes reflux and decreases procedure time. For tortuous or angulated anatomy, hydrophilic diagnostic catheters, stiff or exchange-length guidewires, and long sheath/guide extensions can be employed to optimize navigation.[14] Additional stabilization may also be achieved with buddy-wire or anchoring techniques, in which a secondary guidewire is placed in parallel to act as a stabilizing rail or anchor. This reduces catheter kickback, improves torque transmission, and facilitates selective cannulation.

Once the celiac trunk is selected, arteriography of the celiac trunk and its branches is performed with 15 to 25 mL of contrast at a rate of 4 to 5 mL/s. This is done to assess the patency of the blood vessels, the size of the spleen, and its vascularization. Branches of the splenic artery are identified, which include the left gastroepiploic, short gastric, and pancreatic arteries. Selection and arteriography of the splenic artery is subsequently performed to better delineate the arterial anatomy for embolization planning ([Fig. 2A, B]). The n-BCA embolic mixture is then prepared at the back table. A 1 to 3 mL mixture of n-BCA and ethiodized oil (lipiodol) at a dilution of 1:5/1:6 is recommended for PSE. This dilution ratio delays the polymerization of n-BCA upon contact with blood, which allows the mixture to reach the distal parenchymal vascular bed before polymerization. Radiological visibility of the n-BCA-lipiodol mixture may be improved by adding powdered heavy metal (usually tantalum). When preparing the n-BCA-lipiodol mixture, care must be taken to avoid contamination with ionic solutions, such as normal saline or blood, to prevent accelerated polymerization, which may lead to premature occlusion of the catheter. As a result, a separate sterile back table and a change of gloves are recommended for preparing the mixture. n-BCA is provided in a sterile 1 mL container (TRUFILL n-BCA Liquid Embolic Systems; Johnson & Johnson MedTech, New Brunswick, New Jersey). At our institution, a glass bowl is used for the mixing of components. The 1 mL vial of n-BCA is squeezed into the glass bowl. The tantalum powder is then added to the n-BCA, and the desired volume of lipiodol is added to determine the mixture ratio. The mixture is homogenized with a sterile wooden spatula (such as a tongue depressor). A syringe containing the n-BCA mixture and a syringe with 5% dextrose in water (D5W) are attached to a three-way stopcock for delivery through a microcatheter ([Fig. 3]). A microcatheter is typically preferred for this procedure because it has less dead space, leading to less waste of the mixture.

Fig. 2 (A) Selective splenic artery angiogram showing the blood supply to the spleen. (B) Distal cannulation of the splenic artery branch supplying the lower pole of the spleen.

Fig. 3 (A) 1 mL vial of glue is dispensed into the glass bowl. (B) The tantalum powder is then added to the n-BCA. (C) Desired volume of lipiodol is added to the mixture to determine the n-BCA to lipiodol ratio. The mixture is homogenized with a sterile wooden tongue depressor. (D) A syringe of n-BCA and a syringe with D5W are then attached to a three-way stop cock for delivery of both solutions through the catheter.

The microcatheter is first flushed thoroughly with D5W to clear out any ionic solutions from its lumen (D5W priming) to prevent premature glue polymerization and occlusion of the catheter.[18] The mixture of n-BCA and lipiodol/tantalum (1–3 mL of 1:5/1:6 dilution) is then slowly injected under fluoroscopic guidance[13] [18] to visualize the distribution of glue until complete occlusion of the feeding branches ([Fig. 4A]). The speed of n-BCA polymerization depends on the n-BCA/lipiodol ratio and the presence of 5% dextrose solution in the catheter and the vascular bed.[14]

Fig. 4 (A) Embolization of lower pole branches with n-BCA-lipiodol mixture (arrows). (B) Post-embolization angiogram of splenic artery showing remnant blood supply only to the upper pole.

The use of n-BCA in splenic and peripheral embolization can be performed with several distinct delivery strategies.[6] [18] [19] [20] The flooding or free-flow technique (described above) involves a slow, continuous injection of a dilute n-BCA-lipiodol mixture into a flowing vessel, which permits distal parenchymal penetration. This approach requires meticulous D5W priming and a steady injection to prevent reflux and is most useful in PSE when distal occlusion is desired, typically using lower concentrations (1:5–1:6) to delay polymerization. In the sandwich technique, a brief D5W flush is delivered before and after the glue aliquot, creating a nonionic column that limits premature proximal polymerization and facilitates safe catheter withdrawal. The wedge position technique advances the microcatheter to a near-wedged position or temporarily reduces flow, thereby promoting formation of a shorter, more controlled glue cast with reduced reflux and a lower risk of collateral non-target embolization. The plug or plug-and-push technique begins with a small proximal plug of concentrated glue at the catheter tip, against which a more dilute mixture is subsequently injected. This allows for precise segmental occlusion with minimal reflux, although the risk of catheter entrapment is greater if withdrawal is delayed.

Several precautions are critical to avoid catheter gluing. The system should be primed with D5W before glue delivery, injection should be continuous, without unnecessary pauses; and the aliquot size and glue dilution must be planned so that polymerization is completed beyond the catheter tip.[18] [19] [21] Once the desired embolization target is achieved, the operator should immediately cease glue delivery and withdraw the microcatheter in one smooth motion.[6] [22]

Although rare, catheter entrapment has been reported,[22] [23] and bailout strategies include snaring the trapped segment via secondary access or surgical removal when endovascular methods fail. Current practice guidelines[6] emphasize strict D5W priming, careful selection of n-BCA concentration, and operator experience as key factors to minimize premature polymerization, reflux, and catheter adhesion.

A cone-beam CT can be performed to determine the volume of the embolized spleen. Finally, a post-embolization splenic angiogram is performed to confirm the extent of embolization ([Fig. 4B]).

Post-procedure Care and Complication Management

The patient is admitted for observation for any adverse events/complications, as detailed in the next paragraph, and broad-spectrum antibiotics are continued for at least 5 days post-procedure.[10] A post-procedure CT scan at 1-month can be done to assess the percentage of splenic infarction, residual splenic volume, and to ensure that the embolized vessels have not recanalized. After PSE, the improvement in hematologic parameters is monitored through complete blood counts (CBC) to evaluate the immediate response and long-term effects. CBCs are scheduled at 2 weeks to assess initial changes, followed by subsequent evaluations at 6 months and 1 year to track longer-term trends and adjust patient management accordingly. The liver function test can also be monitored in patients with cirrhosis.[24] [25]

Post-embolization syndrome, characterized by daily intermittent fever below 39°C, nausea/vomiting, abdominal pain/fullness, and loss of appetite, is common after the PSE procedure.[24] Post-embolization syndrome is typically self-limiting and resolves with supportive care in 5 to 10 days.[25] Patients may also be hospitalized for 1 to 2 days if the post-embolization syndrome pain is severe. Patients often experience left upper-quadrant abdominal pain and referred shoulder pain due to ischemia of splenic tissue. Management is centered on antibiotic prophylaxis and pain management. Pain management typically involves multimodal analgesia. Intravenous opioids (e.g., morphine, hydromorphone) are used immediately post-procedure for severe pain, while acetaminophen and non-steroidal anti-inflammatory drugs may be used in patients without contraindications to reduce opioid requirements. Some centers also use patient-controlled analgesia pumps during the first 24 to 48 hours. Adjunctive medications, such as antiemetics and anxiolytics, may also be prescribed to address nausea and discomfort. Adequate pain control not only improves patient comfort but also reduces the risk of complications such as atelectasis. Other rare complications include severe infections like splenic abscess/peritonitis (that may require antibiotics, drainage, or surgical intervention), contrast nephropathy, portal vein thrombosis, and non-target embolization.[24]

Outcomes

PSE has demonstrated marked efficacy in the management of its established indications. A review on PSE by Hadduck and McWilliams[9] showed that within 2 weeks of PSE, both platelet and white blood cell values significantly increased. Pre-PSE platelet counts improved from 37.4–56 K/μL to 80–240.7 K/μL across multiple studies at the 2-week mark. Leukocyte counts also increased from 2.3–4.2 K/μL to 4.0–12.6 K/μL. There was also a direct relationship between the percentage of spleen targeted via PSE and the magnitude of the response of circulating platelets and leukocytes. They also mention the gradual decline in both leukocyte and platelet values in the months and years following PSE.

PSE also improved portal hemodynamics in cirrhotic patients. It led to improved hepatic function and a decrease in the incidence and magnitude of ascites and variceal bleeding. PSE was also a safe and effective option in the non-surgical management of splenic artery steal syndrome.

Additionally, a study reported that the technical success rate of PSE with n-BCA in oncological patients with hypersplenism-related thrombocytopenia requiring systemic chemotherapy was 100%. Platelet counts increased significantly from 74 K/μL to a peak level of 272 K/μL 10 days after PSE. All patients in the study went on to receive systemic chemotherapy following PSE.[13] Although existing studies demonstrate n-BCA to be an effective embolic agent for splenic embolization,[13] [26] direct head-to-head comparisons with other embolic materials remain limited, underscoring the need for further comparative research.

The stepwise approach to PSE with n-BCA is summarized in the workflow flowchart shown in [Fig. 5].

Fig. 5 Stepwise workflow of partial splenic embolization (PSE) using n-butyl cyanoacrylate (n-BCA).

Discussion

PSE can be an alternative to splenectomy for the treatment of several non-traumatic conditions, including portal hypertension and its sequelae, refractory cytopenias associated with hypersplenism; splenic artery steal syndrome; and several hematologic conditions, such as autoimmune hemolytic anemia and idiopathic thrombocytopenic purpura.[3] [9]

There is no consensus on the embolic agent of choice for PSE. When choosing an embolic agent, multiple factors must be considered, such as the size of target vessels, the number of embolic devices needed, and whether vessel occlusion should be temporary or permanent. Other important factors to consider include fluoroscopy time, radiation dose, and total procedure time. Microparticles, such as microspheres, coils, and plugs have traditionally been used to embolize the splenic artery.[3] [4] [5]

Mechanical embolic devices such as coils and plugs provide a relatively more proximal splenic arterial occlusion and, hence, may not be effective in achieving devascularization of the splenic parenchyma due to perfusion via collateral vessels. The collateral supply to the spleen can be maintained through several arteries, including the short gastric arteries, left gastroepiploic artery, and branches of the pancreatic arteries. Disadvantages of coil embolization include device migration, lack of precision (for pushable coils), and the need for multiple coils, increasing procedure time and cost. Detachable coils and vascular plugs allow for repositioning prior to device release, but their placement may be difficult in tortuous arteries.[3] [4] [5]

Embolization of distal intra-parenchymal branches of the splenic artery can overcome the disadvantage of revascularization and can be achieved by using microparticles or resorbable gelatin. Microparticles have been shown to be more effective with fewer complications compared with gelatin for this purpose.[27] Although microspheres are the most commonly used embolic agents for PSE, it is difficult to determine the appropriate particle size for embolization based on angiography. The radiation exposure is also higher compared with other embolic agents.[3] [4] [5]

n-BCA overcomes the above-mentioned disadvantages of revascularization and size determination associated with other embolic materials. It offers permanent embolization of blood vessels independent of coagulation disorders.[8] It has a higher technical success rate and may be more cost-effective compared with some other embolic agents.[28] The viscosity of n-BCA can be altered based on dilution with lipiodol, and hence, it is more customizable.[13] [18] A high n-BCA concentration (more than 50%) is used to occlude short vessel segments and prevents n-BCA from flowing out of the target vessel. In addition, high concentrations of n-BCA are also used for dilated vessels, such as varicose veins, to reduce the risk of n-BCA migration. Lower dilutions allow the n-BCA glue to flow more distally and are useful to occlude blood flow to the distal parenchyma and collateral arteries.[6]

A histological study[29] on n-BCA embolization showed vascular or perivascular inflammation, occasional angionecrosis, and consistent vessel occlusion due to a mix of embolic material and thrombus. No recanalization occurred in any n-BCA-embolized vessels, and vessel wall integrity was maintained without perivascular extravasation, highlighting n-BCA's effectiveness and safety in vascular occlusion.

In vitro studies have shown that n-BCA exhibits notable antimicrobial properties, particularly during its polymerization phase.[30] This effect may result the unique chemical interactions that occur as n-BCA polymerizes, potentially releasing substances toxic to bacteria or altering the local environment to be less conducive to bacterial survival. Clinical studies similarly suggest that the use of n-BCA in various settings is associated with reduced infection rates compared with conventional materials.[31] [32] [33] [34] These antimicrobial properties indicate that n-BCA might not only be effective as an embolic agent due to its physical occlusion capabilities but could also reduce the risk of infection post-embolization. This dual functionality could make n-BCA a preferable choice over PVA particles, which do not exhibit similar antimicrobial effects (unless they are dipped in an antibiotic like gentamycin before delivery). However, dedicated comparative studies in the setting of PSE are warranted to validate these potential benefits over other embolic agents.

Despite all these advantages, n-BCA has a few drawbacks. n-BCA must be mixed with lipiodol and tantalum to render the mixture radiopaque. Since this mixture modulates the embolization rate, an n-BCA-lipiodol ratio lower than 1:3 should be used to delay polymerization and allow the mixture to reach the distal splenic parenchyma. n-BCA usage also requires an experienced operator, as the risk of nontarget embolization is higher in operators who are unfamiliar with n-BCA embolization. There may also be some difficulty in accurately measuring the embolized splenic volume during the procedure. Several of these complications can be overcome by avoiding the non-target vessels and understanding material properties like viscosity, polymerization rate, and adhesive strength. These properties influence how quickly n-BCA solidifies upon contact with blood, its ease of delivery through catheters, and its ability to form a durable embolic seal within targeted vessels.

Conclusion

In conclusion, n-BCA is an effective embolic material for parenchymal splenic embolization, offering rapid occlusion with a relatively safe profile. n-BCA may enhance procedural efficiency by improving outcomes, reducing hospital stays, and lowering overall patient morbidity. Future studies comparing the outcomes of n-BCA with those of other embolic agents will further substantiate its utility in PSE.

Conflict of Interest

None declared.

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Publication History

Article published online:
12 January 2026