N-butyl-2-cyanoacrylate (Histoacryl) complication : A case report

To the Editor: The tissue adhesive N-butyl-2-cyanoacrylate (Histoacryl, Trihawk International, Montreal, Canada) is a well-known and effective modality for treatment of gastric varices secondary to portal hypertension of various causes. It has been used safely in many centers for up to 20 years.1,2 Nonetheless, in a minority of cases, its use has been associated with adverse effects like portal vein thrombosis. We report on the management of a secondary bleeding complication by placement of a transjugular intrahepatic portosystemic shunt (TIPS). A 41-year-old woman was referred to our hospital with esophageal and gastric varices secondary to liver disease due to bilharziasis. She had multiple episodes of upper gastrointestinal bleeding. Esophagogastroduodenoscopy identified two esophageal and three gastric varices with evidence of hypertensive gastritis. A total volume of 2.5 cc of cyanoacrylate mixed with Lipiodol in a 1:1 ratio was injected at three different sites in the gastric varices. The patient started complaining of severe central abdominal pain, associated with generalized tenderness and rigidity 30 minutes after the procedure, but was hemodynamically stable. A plain abdominal radiograph obtained immediately showed no evidence of visceral perforation, but there was radio-opaque material widely spread in the distribution of the portal vessels (Figure 1). A CT scan of the abdomen showed multiple areas of dense material in the vessels of the upper abdomen, including the portal vein and its intrahepatic branches, as well as the splenic, splenorenal collaterals, and renal and cardinal veins. Thrombosis of the portal and splenic veins was also seen (Figure 2). Ultrasound Doppler showed hyperechoic material in the portal vein with turbulent blood flow in keeping with thrombosis. The superior mesenteric vein was patent.