Mastering Glue Embolization: Technical Tips
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1 Mastering Glue Embolization: Technical Tips Ziv J Haskal MD GEST Director, Co Founder Professor of Radiology Editor, JVIR University of Virginia
2 Disclosures Speaker s Bureau: Bard Peripheral Vascular Penumbra WL Gore Medtronic Research support: Sequana Medical Medtronic
3 Glue Toward the Master s End of the Scale of Embolic Materials 0: Pushable Coils in an end organ anatomy 10: Glue dot in a vasa recta
4 In the U.S. : It s nbca No sponsor training for peripheral IRs because it is on label for neuro applications; if you have no neuro specialist in your hospital, you might have glue access (at all). (-): Concerns about gluing catheter in place, unpredictable aspects, giving up access (+): Coagulopathy irrelevant; flexible; casts beautifully; great downstream penetration a bit of art.
5 Yet, Glue is, IMO, An Essential Embolization Tool; I use it a lot Big spaces: dilute (1:5-1:8). Portal Vein Embolization Mid sized: 1:3ish Bronchial, AVMs, bleeding, etc Small: vasa recta: 1:1/ 1:2 bullet or dot
6 PVE:Best place to train in glue use Can essential sculpt an occlusion by segment resected Long 6 Fr Sheath, safety wire 4Fr RIM and microcath
7 Another example Continuous flushing, ~1:7-1:8 allows use of same microcath; very efficient Seg4 preserved
8 PVE Sandwich technique: D5W glue D5W glue Sandwich: Push Glue (know dead-space of cath (eg Echelon is 0.34cc)), then D5W, then Glue then D5W Glue D5W Glue DW5 Glue Multiple individual syringes
9 Glue Preparation: Proper Mindset Requires meticulous technique: Separate tray, new drapes Polycarb syringes: 6/10cc (oil), 3cc (D5W), 1cc (glue) Bowl of D5W Glass shot glass for glue/oil/tantalum Needles to decant glue or load it 3way stopcock (if this is your technique, not mine) New Gloves, new towels Fortune favors the prepared mind. Louis Pasteur
10 Syringes Reduce error/ tactile feedback 1 cut for D5W (3cc) 2 cuts for glue (1cc) Begin flushing, bring syringes to table Inject under fluoro, or negative roadmap Consider a test aliquot if new to glue or uncertain about flow
11 Mid sized: Bronchial or Epigastric Rectus sheath hematoma patients- often coagulopathic, small vessels (means gelfoam is not ideal-mixtures of air and gelfoam). Some have reported failed coil embo (requiring direct embo and thrombin later get it done in one )
12 Rectus sheath hematoma, elevated INR, transfusions 1:3 nbca: note the casting
13 Glue Tail Catheter may not get stuck within the glue, but glue may get stuck to the tip and be dragged back with the tip risk of nontarget embo. Be aware of this, plan for it by working quickly, and, when possible, keeping a base catheter in place to strip off a glue tail if needed
14 Watch out for the Glue Tail Push out with base cath (vs. strip it off against the catheter) Risk situations bronchial, epigastric, SMA, GDA, AVMs, extremity trauma etc
15 Thin, Distal Casting Far Reach Renal CA bleeding met emerging through the skin
16 1:5 Thin Glue: Note Casting
17 Accomplished With 2 Glue Injections through microcaths (Can t imagine what would have worked as well and easily))
18 Hypotensive, splenic injury quick
19 Glue cast. (Granted other agents could have been used)
20 Glue Uterine AVM (Thin) Glue Cast
21 Glue Bullets and Glue Dots Glue bullet: 1cc D5W syringe with glue topper (reconnaissance) Know the deadspace. Calculate the volume Prep the table Glue drop injected above D5W pusher below
22 Bullet/ Dot Fill 1cc syringe with D5w, leaving cc space for glue (holding vertical). Begin Flushing microcath. Inject glue onto the D5W, carry to table and inject One 1cc syringe
23 Tracheal Road Rash Coagulopathic ICU patient with uncontrolled bleeding after inadvertent scope injury to bronchus. No chronic lung disease, no enlarged bronchial arteries?tracheal artery?
24 Normal (Tiny) Difficult Bronchials (0.014 micro and wire) 1:3 glue bullet No tolerance for spillback
25 Normal (Tiny) Difficult Bronchials (0.014 micro and wire) 2 days later pre 1:3 glue bullet No tolerance for spillback
26 Last Week: Glue Bullet: Coil Adjunct in Coagulopathic OLT patient Elevated HA velocities, incr LFTs unanticipated APF at PTBD After several coils: continued rapid flow. One 0.1 cc 1:1 glue dot done A dot -- ~0.1cc glue tip
27 Venous Liquid use together with Arterial
28 Glue Sclero Ziv J Haskal MD
29 A Variation To Experiment With: N-butyl Cyanoacrylate, Ethanol, and Lipiodol as a New Embolic Material ratios of 1 4 parts NBCA and 1 3 parts ethanol /1 part of lipiodol; a 1:1 ratio of NBCA With high ratios of ethanol, the NLE polymerization configuration solid-like properties with potent occlusive ability and negligible adhesion to the microcatheter 1:1:3 NBCA/oil/EtOH injected through a 22g needle! (Kawai et al JVIR 2012:23: )
30 Conclusions Hopefully I ve illustrated a framework for considering glue use It is, in the US, still a rarer Master s level agent however, for a busy and diverse embolization practice, it provides essential and currently irreplaceable characteristics and outcomes
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