Mastering Glue
Embolization: Technical Tips
Ziv J Haskal MD
GEST Director, Co Founder
Professor of Radiology
Editor, JVIR
University of Virginia
Disclosures
Speaker’s Bureau:
Bard Peripheral Vascular
Penumbra
WL Gore
Medtronic
Research support:
Sequana Medical
Medtronic
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
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.
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’
PVE:Best place to train in glue use
• Can essential ‘sculpt’ an
occlusion by segment
resected
Long 6 Fr Sheath, 0.018 safety wire 4Fr RIM and microcath
Another example
• Continuous flushing, ~1:7- 1:8 allows use of same microcath; very efficient
Seg4 preserved
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
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
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
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”)
Rectus sheath hematoma,
elevated INR, transfusions
1:3 nBCA: note the casting
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
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
Thin, Distal Casting—Far Reach
• Renal CA bleeding met emerging through the skin
1:5 Thin Glue: Note Casting
Accomplished With 2 Glue Injections
through 0.014” microcaths
(Can’t imagine what would have worked as well and easily))
Hypotensive,
splenic injury
quick
• Glue cast. (Granted other agents
could have been used)
Glue
(Thin) Glue Cast
Uterine AVM
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

Bullet/ Dot
• Fill 1cc syringe with D5w, leaving 0.1-0.3cc
space for glue (holding vertical).
• Begin Flushing microcath.
• Inject glue onto the D5W, carry to table and
inject
One 1cc syringe
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?
Normal (Tiny) Difficult Bronchials
(0.014” micro and 0.010” wire)
•
1:3 glue bullet
No tolerance for spillback
Normal (Tiny) Difficult Bronchials
(0.014” micro and 0.010” wire)
•
2 days later
1:3 glue bullet
No tolerance for spillback
pre
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’
Venous Liquid use together with Arterial
Glue
Sclero
Ziv J Haskal MD
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
(Kawai et al JVIR 2012:23:1516-21)
1:1:3 NBCA/oil/EtOH
injected through a
22g needle!
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