Use of NBCA in GI bleeding

Glue in Upper & Lower GI
Bleeding: New Gold Standard?
Ji Hoon Shin, MD
Department of Radiology
University of Ulsan College of Medicine
Asan Medical Center
Seoul, Korea
Ji Hoon Shin, M.D., Ph.D.
• No relevant financial relationship reported
Contents
 Introduction of NBCA
 Key Issues on NBCA for GI bleeding
(systemic review)
- Safety
- Effectiveness
- Best indications
 Clinical Cases
 Summary
Mechanism to embolize vessel
N-butyl cyanoacrylate
Tissue adhesive and suture substitute
After contacting with blood plasma, NBCA starts to
polymerize and occlude vessels
1) Cast and thrombus formation
2) Adhesion of NBCA to the inner vascular wall
3) Endothelial damage by chemical and heat production
Takeuchi et al, Jpn J Radiol (2014)
Application other than cerebral AVM
 Used outside US for gastric variceal bleeding,
ulcer bleeding & fistula closure
 Increasing articles of NBCA for GI bleeding
JVIR 2014 Jan
Three key issues on NBCA for GI bleeding
 Is glue safe in real world?
 Is recurrent bleeding less common after glue use?
 In what circumstances is glue the agent of choice?
Records identified
through database
search: (n= 319)
Additional records
identified through
other sources: (n= 4)
Records screened:
(n = 288)
Records excluded:
(n = 254)
Eligibility
Records after duplicates
removed: (n = 288)
Full-text articles assessed
for eligibility: (n = 34)
Full-text articles excluded,
with reasons: (n = 14)
Included
Screening
Identification
Systemic review of NBCA use in GI bleeding
Studies included:
(n = 20)
(unsubmitted data)
General Characteristics of the Included Studies
Eligible patients:
(n = 591)
GI bleeding:
(n = 527)
NBCA TAE:
(n = 462)
Non-GI bleeding:
(n = 64)
Non-NBCA TAE:
(n = 65)
Duplicated Patien
ts: (n = 2)
Patients included:
(n = 460)
Patients excluded:
(n = 131)
Demographics and Clinical Characteristics of Patients
Embolic Agents Used in 453 Patients
Clinical Outcomes of the Patients
Is glue safe in real world?
Major complication – 3.7% (17/460)
- Higher in LGIB (5.0%) than UGIB (2.9%)
Upper GI bleeding (n=8)
Lower GI bleeding (n=9)
Ulceration (n=4)
Bowel infarct (n=5)
Hepatic abscess (n=2)
Ulceration (n=3)
Hepatic infarct (n=1)
Lower limb ischemia (n=1)
Bowel infarct (n=1)
- Two cases of mortality (ulcer, bowel infarction)
- Not higher than other reports (0 – 16%)
Group A without
antimesenteric border
zone involvement
Group B with
antimesenteric border
zone involvement
Jae HJ, et al. JVIR 2008
Localized embolization
Segmental embolization
Bowel infarction after TAE
M/65
Lymphoma
Melena
4 days later
Died of septic shock 44 days after TAE
Is recurrent bleeding less common
after glue use?
Recurrent bleeding rate
-After coil embolization 10-30%
-After other embolization 33% (9-66%)
-After glue embolization: 16.5%
Higher in UGIB (18.6%) than LGIB (13.3%)
Rebleeding-related 30-day mortality; 5.5%
Ramaswamy RS et al. World J Radiol 2014
In what circumstances is Glue the
agent of choice?
When microcatheter tip could not reach bleeding focus
(small & tortuous vessel)
When brisk and rapid bleeding is there
When simultaneous collateral embolization is necessary
When coagulopathy is present
When adjunctive embolization after using other embolic
materials is necessary
F/59
-
Duodenal ulcer bleeding, hematemesis
incomplete endoscopic hemostasis
Hb 6.6
NBCA:lipiodol = 1:1.5
M/54 ERCP-induced pancreatitis, hematochezia
s/p embolization of short gastric artery (3 weeks ago, GSP & coils)
Which embolic agent to embolize this pseudoaneurysm ?
Embolic agent to choose
1. Coils
2. GSP
3. GSP + coils
4. Vascular plug
5. Liquid embolic agent
NBCA embolization (25%, 1:3 ratio) with manual compression of
the greater curvature of the stomach  successful glue cast of
both proximal & distal parts of the pseudoaneurysm
M/67
Duodenal ulcer, Hematemesis
Selective GDA angiogram
Embolization with coils & NBCA
F/73
-
Multiple colon diverticula
Hematochezia one day ago
Hb 8.9
Brisk & rapid bleeding
Summary
Case by case basis
Conclusion
Glue in Upper & Lower GI Bleeding: New Gold Standard?
•
•
•
•
Case by case basis (best indication)
One of major embolic materials for GI bleeding
Recurrent bleeding is less
Major complication is not higher
 Transition to New Gold Standard
Thank you
Ji Hoon Shin, M.D.
[email protected]