Abstract
A 68-year-old male with liver cirrhosis presented with dizziness and dyspnea two days after endoscopic Histoacryl occlusion of gastric varicses. Imaging revealed a large endovascular embolization of Histoacryl glue, spanning from porto-caval collaterals via the inferior vena cava to the right atrium, partially occluding right atrial inflow. This case report describes the successful removal of this large net-like mass of Histoacryl glue using thrombectomy devices from the inferior vena cava and the right atrium. Postprocedure imaging showed near-complete clearance with residual fragments in the superior mesenteric vein and small emboli in the pulmonary arteries. The patient was discharged in stable condition. Histoacryl glue can cause severe complications if embolized. This case highlights the potential of advanced thrombectomy devices for managing embolic complications from endovascular treatments.
Keywords: Histoacryl embolus, Thrombectomy, Liver cirrhosis, Interventional radiology, Cardiology, Gastroenterology, Gastric varices
Background
N-Butyl-2-Cyanoacrylate (Histoacryl) application is a well-established treatment of gastric varices in patients with liver cirrhosis, effectively reducing the risk of variceal bleeding. Despite its benefits, the procedure carries the risk of glue migration to other parts of the vascular system, causing serious complications such as pulmonary embolism or cardiac involvement. Previous reports have documented instances of Histoacryl embolization to the heart and pulmonary vasculature managed conservatively with anticoagulation [1,2]. The advent of mechanical thrombectomy devices now offers new opportunities in managing these complications by physically removing the embolic material [3], [4], [5]. This case report highlights the first successful use of such devices in combination to treat a Histoacryl embolus in the right atrium (RA) and the inferior vena cava (IVC).
Case presentation
Patient details: A 68-year-old male with a medical history of portal hypertension with gastric varices due to alcoholic liver cirrhosis (Child-Pugh A), hypothyroidism, hypercholesterolemia, and chronic obstructive pulmonary disease (COPD) presented to the emergency department with symptoms of dizziness and dyspnea.
Clinical background
The patient had undergone an elective endoscopic procedure for the treatment of fundic varices to prevent potential bleeding during the planned sclerosing procedure with Aethoxysclerol, an unexpected peri-interventional bleed occurred which was managed successfully using Histoacryl embolization and the patient was subsequently discharged from the hospital.
Two days after the procedure, the patient presented again to the emergency department of the same hospital with dizziness and dyspnea. CT scan confirmed the presence of a small pulmonary embolism and Histoacryl material lodged in the IVC extending far into the RA. Echocardiography showed a large and mobile mass in the right atrium, with intermittend partial occlusion of the tricuspid valve (Fig. 1). Given the significant deterioration in the patient's condition, and the immediate threat to his life, he was transferred by helicopter to our university hospital for advanced care.
Fig. 1.
Distribution of Histoacryl (blue arrow): (A) coronal maximum intensity projection (MIP) reformations in native CT images from the referring hospital. (B) Coronal MIP reformations in pulmonary arterial contrast-enhanced CT images. C: Echocardiogram showing a large mass in the right atrium (RA) significantly affecting right ventricular filling.
Intervention procedure
Preintervention preparation: The patient was positioned supine, and the procedural area was sterilized. Sedation was achieved with 1 mg of Lorazepam administered sublingually, along with continuous intravenous infusion of Piritramid (7.5 mg), Metoclopramid (10 mg), Metamizol (1 g), and 3.5 mg Midazolam. Oxygenation was maintained via nasal cannula at 3 L O2/min. The patient presented with thrombocytopenia of 20,000 platelets, requiring transfusion with platelet concentrates (PC).
Access and imaging: Ultrasound-guided puncture of the right femoral vein was performed, and a 6F sheath and a 5F Pigtail catheter (both, Merit Medical) was placed using the Seldinger technique. Cavography confirmed a large Histoacryl mass (Fig. 2) compromising the RA and IVC. A long Amplatz stiff wire (Boston Scientific) was positioned in the left axillary vein to stabilize the system.
Fig. 2.
Cavography revealing a large Histoacryl mass (blue arrow) impacting the right atrium (RA) and inferior vena cava (IVC): (A) unenhanced digital subtraction angiography (DSA) highlighting the distribution of Histoacryl from fundal varices along the mesenteric vein into the IVC and extending into the right heart. (B) Contrast-enhanced images confirming these findings.
Aspiration thrombectomy: An initial attempt to remove the embolus using the FlowTriever device (Inari Medical) involved positioning a 24F sheath at the level of the diaphragm. Despite multiple attempts, the embolus could not be adequately removed. Recognizing the need for a different approach, we switched to the ClotTriever device (Inari Medical). The ClotTriever catheter (Inari Medical) was inserted through the sheath and advanced beyond the thrombus at the IVC/RA junction. Upon deployment, the coring element separated the clot from the vessel wall, and the captured thrombus was retracted into the sheath.
The ClotTriever (Inari Medical) successfully captured the Histoacryl material at the transition zone from the IVC to the right atrium (Fig. 3).
Fig. 3.
Post-thrombectomy images: (A) unenhanced view showing the 24F FlowTriever sheath and Amplatz wire with residual Histoacryl in fundal varices. (B) Final contrast-enhanced image of the right atrium (RA) and inferior vena cava (IVC) postintervention. (C) Detailed contrast-enhanced view of pulmonary arteries and the right-to-left heart transition postprocedure. (D) Echocardiogram indicating normalized cardiac function after mass removal. (E) Successfully retrieved Histoacryl.
A continuous vacuum syringe was attached to the 24F-sheath to ensure that any material in the sheath could not re-enter the body. Final imaging confirmed the complete removal of the embolus from the heart and IVC.
Outcome: The combination of Flow – and ClotTriever (Inari Medical) successfully extracted the Histoacryl thrombus from the RA and IVC. Postprocedure imaging confirmed near-complete clearance with only residual fragments remaining in the superior mesenteric vein. Echocardiography immediately after the thrombectomy showed the disappearance of the mass in the right atrium (Fig. 3).
Postprocedure Care: A pressure dressing was applied for 6 hours postintervention due to the patient's coagulopathy. Therapeutic anticoagulation was initiated, targeting a partial thromboplastin time (PTT) of 60-80 seconds during hospitalization to prevent further thromboembolic events. On the final contrast enhanced CT scan prior to discharge, new deposits of Histoacryl were observed in the pulmonary artery of the right lower lobe. Despite this new finding, and with no histoacrylic mass detected in the right atrium or IVC, the patient remained aysmptomatic and was discharged two days later. He is now scheduled for TIPS evalution in our hepatology clinic.
Discussion
This case highlights a rare but serious complication from Histoacryl use in a patient with a bleeding complication following elective sclerotherapy for gastric varices. Literature documents similar cases of Histoacryl migration, reinforcing the need for cautious application in elective settings [1,2] and [6].
Due to the patient's clinical deterioration we decided against a conservative management and for an urgent interventional approach [1], [2], [3], [4], [5], [6], [7], [8]. The FlowTriever and ClotTriever devices (Inari Medical), despite initial challenges, effectively managed the large Histoacryl embolus. The combination of the ClotTriever's (Inari Medical) mechanism and continuous aspiration pressure due to a 24F FlowTriever sheath (Inari Medical) proved crucial for complete removal of the large net-like embolus from the RA and IVC, underscoring the potential of these devices in complex cases [6].
Postprocedure imaging revealed new Histoacryl deposits subsegmental in pulmonary artery of the right lower lobe, highlighting the importance of vigilant follow-up [2,6]. Of note, Histoacryl is resorbed by the body over time [6]. Multidisciplinary collaboration between interventional radiology, cardiology and intensive care unit is vital for the successful outcome, emphasizing the need for a coordinated approach in managing such complications.
Conclusions
This case demonstrates the first successful combined use of FlowTriever and ClotTriever devices (Inari Medical) to manage a complex Histoacryl embolus, resulting in rapid clinical improvement. So far, no adequate endovascular therapy was available for such cases until now.
This case highlights the need for careful elective use of Histoacryl and described a novel strategy for the management of Histoacryl emboli in symptomatic patients, with the potential of prompt recovery and shortened hospital stays.
Patient consent
Written informed consent was obtained from the patient for publication of this case report and any accompanying images.
Availability of Data and Materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Funding
This study received no external funding.
Author contributions
Conceptualization, supervision, manuscript writing and review: E.C., S.G., K.V. Procedure performance: E.C., S.G., K.V. Imaging analysis, patient care, and follow-up: W.U., M.D., E.C., S.G., N.E., J.U., A.S. S.G. and K.V. contributed equally to the case. All authors read and approved the final manuscript.
Footnotes
Competing Interests: The authors declare that they have no competing interests.
Acknowledgments: The authors wish to thank the interventional radiology and cardiology teams for their collaboration and technical support.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.