Case Report: Internal Carotid Artery Thrombosis: A Rare Complication After Fibrin Glue Injection for Cavernous Sinus Hemostasis

Background: Fibrin glue injection within the cavernous sinus (CS) is a demonstrably safe and simple technique to control venous bleeding with a low complication rate. However, this technique does have inherent risks. We illustrate 2 cases of internal carotid artery (ICA) thrombosis after fibrin glue injection in the CS for hemostasis.Methods: After encountering this complication recently, we conducted a retrospective review of the surgical database of 2 senior neurosurgeons who specialize in cerebrovascular and skull base surgery to identify patients with any complications associated with the use of fibrin glue injection for hemostasis. Approval was given by respective institutional review boards, and patient consent was obtained.Results: Of more than 10,000 microsurgery procedures performed by 2 senior neurosurgeons with a combined experience of 40 years, including procedures for aneurysms and skull base tumors, 2 cases were identified involving ICA thrombosis after fibrin glue injection in the CS for hemostasis. Both cases involved severe ischemic complications as a result of the ICA thrombosis. In this article, we present their clinical presentation, characteristics, management, and outcomes.Conclusion: Direct injection of fibrin glue into the CS for hemostasis can effectively control venous bleeding and facilitate complex dissections. However, it can be associated with ICA thrombosis, with subsequent serious ischemia and poor prognosis. Although this complication appears to be rare, increased awareness of this problem should temper the routine use of fibrin glue in anterior clinoidectomy and transcavernous approaches.

Positive white nipple sign on esophageal varices: Not a just bystander; our experience

Background and study aims The goal of this study was to assess whether a white nipple sign on esophageal varices is of no prognostic significance or mandates more attention. Patients and methods We retrospectively analyzed data from 2601 patients undergoing upper gastrointestinal endoscopy for variceal bleed from January 2008 to January 2020. Intraprocedural events like onset of active spurt while performing endoscopy, active spurt while attempting to band the varix with a nipple, need for rescue glue therapy required to control bleed in cases of failed endoscopic variceal ligation (EVL), slipping of band and rebleed despite successful band application, need for emergency intubation, and pulmonary aspiration-related complications were noted. Results A total of 2601 patients underwent endoscopy for variceal bleeding. Of them, 631 had a positive white nipple sign. Of that subgroup, 137 (21.7 %) patients developed active spurt during endoscopy. In patients with the white nipple sign, 12.3 % required endotracheal intubation and 6.7 % developed aspiration pneumonia, which were significantly higher than in those without the sign. Rescue glue injection in esophageal varices was needed in 5.6 % as compared to 0.6 % in those without white nipple. Conclusions The white nipple sign is not only a predictor of recent bleed, but it carries statistically significant increased risk of intraoperative bleeding, need for endotracheal intubation, esophageal glue injections, and aspiration-related complications. Therefore, it is not just a bystander, but rather, a sign of increased danger and a need to be more vigilant with patient management.

Percutaneous glue embolization of arteriovenous fistula of in situ saphenous vein bypass graft: Case report and literature review

Objectives Arteriovenous fistulas (AVFs) of an in situ saphenous vein bypass can be managed surgically or through endovascular coil embolization. The complications associated with the surgical wounds required for side branch ligature can be minimized through selective vein ligature and interrupted small incisions, but endovascular methods are time-consuming and limited by vein size. In this case report, we describe percutaneous ultrasound (US)-guided balloon-assisted direct glue injection as an alternative treatment strategy for AVF closure. Methods We treated a patient with a delayed AVF in a femoral-popliteal in situ saphenous vein bypass. The patient came to our attention for the recurrence of chronic limb-threatening ischemia (CTLI) 4 years after the initial bypass creation. Ultrasound and computed tomography angiography (CTA) showed a double tandem graft in significant stenosis below an AVF connected with the deep venous system. Treatment included percutaneous angioplasty of the bypass stenosis and contemporary AVF closure via ultrasound-guided glue injection. Results We successfully performed endovascular angioplasty with a drug-eluting balloon of the bypass stenosis and ultrasound-guided fistula embolization with cyanoacrylate Glubran 2. Angiography after the procedure showed bypass graft patency, no residual stenosis, and complete closure of the AVF. Results were confirmed with US. Conclusions Percutaneous embolization using glue could be a useful technique for AVF closure. It is a minimally invasive method that reduces the need for skin incisions during in situ saphenous grafting or endovascular revascularization.

Ectopic Embolism after Endoscopic Glue Injection

: A 55-year-old male with a 7-year history of liver cirrhosis was admitted to our department due to recurrent hematemesis and melena. He had been treated with endoscopic tissue glue injection and/or band ligation for gastroesophageal variceal bleeding. He denied any history of viral hepatitis infection or alcohol abuse. At this admission, his pulse rate was 88b.p.m., and blood pressure was 110/51mmHg. Hemoglobin concentration was 81g/L, platelet count was 38X109/L, total bilirubin was 28.4umol/L, and albumin was 24.2g/L. Except for ascites, splenomegaly, and portal vein thrombosis, contrast-enhanced computed tomography scans showed high density within gastric fundal varices, gastro-renal shunt, left renal vein, and inferior vena cava (arrows), suggesting a diagnosis of ectopic embolism from tissue glue injected during a prior endoscopic procedure. Upper gastrointestinal endoscopy demonstrated esophageal varices, post-endoscopic gastric fundal glue removal, and portal hypertensive gastropathy. Esophageal variceal ligation was performed. After that, he was discharged without any other complaints. Currently, endoscopic variceal therapy, mainly including variceal band ligation, sclerotherapy, glue injection, and haemostatic powder spraying is the mainstay treatment option of acute variceal bleeding in liver cirrhosis [1]. There is a benefit of endoscopic glue injection for gastric fundal variceal bleeding in terms of increasing the rate of initial hemostasis and reducing the rate of rebleeding as compared to variceal band ligation [2-3]. Therefore, endoscopic glue injection has been widely employed in cirrhotic patients with gastric variceal bleeding. However, there are some severe complications related to endoscopic glue injection [4-5], especially thromboembolism. The current case further showed a possibility of asymptomatic ectopic embolism after endoscopic glue injection, suggesting that a close surveillance of embolism within portosystemic collateral vessels should be necessary.

Ultrasound-guided cyanoacrylate injection for the treatment of incompetent perforator veins

Objective The use of cyanoacrylate products (CA) in incompetent perforator vein (IPV) treatment has not been thoroughly examined. The primary objective of this study is to describe the technique of ultra sound guided direct injection of IPV with CA, and secondarily to determine early closure rates and safety of this technique. Methods A retrospective analysis of patients undergoing IPV injection at two centres between 2015-2018 was conducted. Demographics, CEAP classification and IPV location were collected. Outcomes were assessed at two follow-up appointments. Results A total of 83 perforator vein injections were completed. CEAP classifications include C2 – C6 classes. Location of perforators were posteromedial (6%), femoral canal (9%), paratibial (14%), and posterior-tibial (71%). IPV closure rates were 96.3% at initial follow-up (16 ± 2 days). Closure rates decreased to 86.5% at second follow-up (72 ± 9 days). There were no deep vein thromboses during follow-up. One patient developed septic thrombophlebitis that was successfully managed with antibiotics. Conclusion Ultrasound-guided CA glue injection is a simple and low risk procedure that effectively closes incompetent perforator veins.