Urgent percutaneous transcatheter embolization of hemorrhagic hepatic lesions with N-butyl cyanoacrylate.
ABSTRACT To report on our clinical experience with and the success rate and safety of percutaneous transcatheter embolization with N-butyl cyanoacrylate (NBCA) as the lone primary embolic agent used for arterial embolization of hemorrhagic liver lesions.
This retrospective study enrolled all patients who presented to the emergency room with hemorrhagic liver lesions during a two-year period and were treated by percutaneous transcatheter embolization with NBCA.
Eight consecutive patients were evaluated, and 13 lesions were embolized exclusively with NBCA: eight pseudoaneurysms and five active bleeds. All patients were treated successfully using percutaneous transcatheter embolization with NBCA without re-bleedings or major complications.
Percutaneous transcatheter embolization with NBCA is a safe and effective method for treating hemorrhagic lesions.
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ABSTRACT: Pseudoaneurysms are common complications of interventional cardiovascular procedures and represent a significant burden for patients and for health-care systems. Ultrasound-guided thrombin injection is nowadays considered as the treatment of choice for iatrogenic pseudoaneurysms without indication to surgery, but accepted guidelines are currently lacking. In recent years, several novel therapeutic approaches have been suggested, often as limited, single-center experiences. In the present review, the authors focus on promising techniques that may represent an alternative to ultrasound-guided thrombin injection, further reducing the need for surgical treatment.Expert Review of Cardiovascular Therapy 05/2014;
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ABSTRACT: Abstract Massive hemobilia caused by hepatic artery pseudoaneurysm is an uncommon but potentially fatal complication that can occur after biliary intervention. Previous intervention or surgery, atherosclerotic disease, inflammation and even anatomic variants may make the pseudoaneurysm inaccessible to transcatheter approach, therefore it is not always feasible. The present report describes a case of successful embolization of a hepatic artery pseudoaneurysm with N-butyl cyanoacrylate via direct puncture as an alternative approach. The case presentation is followed by the technical points and the properties of N-butyl cyanoacrylate that are particularly advantageous for use in direct puncture procedures.Minimally invasive therapy & allied technologies: MITAT: official journal of the Society for Minimally Invasive Therapy 10/2013; 23(2). · 1.33 Impact Factor
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ABSTRACT: Pseudoaneurysms of intercostal artery are very rare. All the published cases have been caused by trauma, either iatrogenic or otherwise. They can cause hemothorax, retroperitoneal hemorrhage or can present as pulsatile chest mass. Doppler ultrasound, contrast-enhanced CT and conventional angiogram can accurately diagnose this condition. All the reported cases have been treated by embolisation, stenting or surgery. We report an unusual case of intercostal artery pseudoaneurysm arising as a complication of corrosive poisoning presenting with hematemesis and treated by glue embolisation. The authors believe this to be the first case of intercostal artery pseudoaneurysm that is non-traumatic, complicating corrosive poisoning and presenting with hematemesis.Indian Journal of Radiology and Imaging 04/2014; 24(2):135-8.
© Turkish Society of Radiology 2012
condition with many etiologies; trauma is the most common, followed
by iatrogenic and spontaneous lesions.
The hepatic artery anatomy is quite variable (1). In the most com-
mon pattern (Michels type 1 configuration), the common hepatic ar-
tery is the right branch of the trifurcation of the celiac trunk. After the
gastroduodenal artery arises, the common hepatic artery is called the
proper hepatic artery, which bifurcates into the right and left hepatic
arteries. Posteriorly, they divide and subdivide into segmental and sub-
Currently, the treatment of choice for hepatic lesions is an endovas-
cular approach, which can use a wide range of embolic materials. The
most commonly used materials are coils and absorbable gelatins, followed
by polyvinyl alcohol (PVA) particles, stent grafting, AMPLATZER plugs,
and N-butyl cyanoacrylate (NBCA), either alone or in combination (2–7).
Given the dual blood supply to the liver, the hepatic artery and its branch-
es can be embolized, and there is only a low risk of hepatic necrosis as
long as the portal vein shows no abnormalities on splenoportography (8).
This preliminary study describes our experience treating hemorrhagic
hepatic lesions using arterial embolization with NBCA alone as the first
epatic lesions may bleed as much from their blood supply (he-
patic artery or portal vein) as they do through their drainage
vein (hepatic vein). Hepatic arterial bleeding is a life-threatening
Material and methods
This was a retrospective study of patients treated for hemorrhagic he-
patic liver with NBCA as the lone embolic agent in urgent situations.
The Quality Improvement Guidelines for Percutaneous Transcatheter
Embolization (9) were used to define the terms used here. This study
was performed according to the World Medical Association Declaration
of Helsinki. Informed consent was obtained from all patients.
Patients and presentations
Eight consecutive patients with hemorrhagic lesions in the liver who
presented in the emergency room from October 2008 to November 2010
were studied retrospectively; these patients were treated by percutane-
ous transcatheter embolization with NBCA (Histoacryl, B. Braun AG,
Melsungen, Germany). Patients were seven men and one woman, with
ages ranging from 3 to 61 years (mean, 39.5 years). All patients pre-
sented with symptoms of hypotension and falling hemoglobin levels;
the lowest mean hemoglobin was 6.75±1.6 g/dL. Each patient received a
blood transfusion before embolization.
The hemorrhage was post-traumatic in four patients, and postvideolapar-
oscopic cholecystectomy, postduodenopancreatectomy, spontaneous
Urgent percutaneous transcatheter embolization of hemorrhagic
hepatic lesions with N-butyl cyanoacrylate
Lucas Moretti Monsignore, Sandro Scarpelini, José Sebastião Santos, Daniel Giansante Abud
From the Departments of Interventional Radiology (L.M.M.
firstname.lastname@example.org, D.G.A.), Emergency Surgery (S.S.),
and Digestive Surgery (J.S.S.), Medical School of Ribeirão Preto,
University of São Paulo (FMRP-USP), Ribeirão Preto/SP, Brazil.
Received 4 October 2011; revision requested 1 November 2011; revision
received 9 November 2011; accepted 10 November 2011.
Published online 11 January 2011
To report on our clinical experience with and the success rate
and safety of percutaneous transcatheter embolization with
N-butyl cyanoacrylate (NBCA) as the lone primary embolic
agent used for arterial embolization of hemorrhagic liver le-
MATERIALS AND METHODS
This retrospective study enrolled all patients who presented to
the emergency room with hemorrhagic liver lesions during a
two-year period and were treated by percutaneous transcath-
eter embolization with NBCA.
Eight consecutive patients were evaluated, and 13 lesions
were embolized exclusively with NBCA: eight pseudoaneu-
rysms and five active bleeds. All patients were treated suc-
cessfully using percutaneous transcatheter embolization with
NBCA without re-bleedings or major complications.
Percutaneous transcatheter embolization with NBCA is a safe
and effective method for treating hemorrhagic lesions.
Key words: • liver • hemorrhage • therapeutic embolization
• interventional radiology
Diagn Interv Radiol 2012; 18:403–409
Monsignore et al.
404 • July–August 2012 • Diagnostic and Interventional Radiology
All interventional procedures were
done via a femoral approach (11-cm-
long 5 F sheath introducer) with selec-
tive angiography of the celiac trunk,
common hepatic artery, and superior
mesentery artery, along with a delay
phase for splenoportography with a 5
F diagnostic angiography catheter. The
target areas were characterized as active
bleeding or pseudoaneurysm accord-
ing to the angiographic findings, and
each target area was classified accord-
ing to its location. When the common,
proper, right, or left hepatic artery was
involved, the targets were classified as
truncal or proximal lesions; when seg-
mental or subsegmental branches of
the right or left hepatic arteries were
involved, they were classified as distal.
All eight patients underwent an an-
giographic evaluation, and 13 lesions
were detected. Eight lesions were char-
acterized as pseudoaneurysms, and five
as active bleeding. All active bleeding
lesions were distal. Of the pseudoaneu-
rysms, two were truncal and six were
The target areas classified as truncal or
proximal and characterized as pseudoan-
eurysm were treated by selective embol-
ization of the false lumen, sparing the
affected artery (Fig. 1). A microcatheter
(Renegade 18, Boston Scientific, Natick,
intratumor bleeding, and multiple
spontaneous pseudoaneurysms were
the cause in one patient each. The
initial diagnosis of liver bleeding was
made with computed tomography in
five patients, scintigraphy in two, and
Doppler ultrasonography in one. Four
patients needed a transfusion after the
procedure: three patients with post-
traumatic etiology and one with spon-
taneous tumor bleeding.
All of the patients who presented
with active bleeding had an abnor-
mal platelet count or coagulogram
(prothrombin time/international nor-
malized ratio and activated partial
thromboplastin time ratio), as shown
in Table 1.
Table 1. Clinical findings of eight patients
Age (years)48 61213 5160 1557
GenderMale MaleMaleMale MaleFemale Male Male
Lowest serum hemoglobin level before embolization (g/dL)
7.7 8.65.1 7.9 4.58.4 5.56.3
Serum hemoglobin level at discharge (g/dL)
9.110.310.9 11.8 9.311.8 13.3 8.7
Platelet count (103 platelets/μL)
318541 79 532331550 12872
International normalized ratio
0.98 0.99 1.861.59 1.031.13 1.791.56
Activated partial thromboplastin time ratio
0.771.151.22 1.65 1.12 1.162.41 1.36
Blood tranfusion before embolization
YesYes YesYesYesYes Yes Yes
Blood transfusion after embolization
NoNo YesYesNo No YesYes
50% 50% 33% 50%50% 50%25%25%
Car vs. car
truck vs. car
Bicycle vs. car
Initial imaging method for diagnosis
Number of lesions14122111
LocalizationDistal DistalDistalDistalDistal / truncal TruncalDistalDistal
EtiologyIatrogenic SpontaneousTraumaticTraumaticTraumatic Iatrogenic TraumaticSpontaneous
NBCA, N-butyl cyanoacrylate.
Urgent percutaneous transcatheter embolization of hemorrhagic hepatic lesions with N-butyl cyanoacrylate • 405
Volume 18 • Issue 4
Figure 1. a–d. Truncal lesion embolization. The patient presented with melena two months after a motor vehicle collision. Selective
angiographic evaluation of the celiac trunk showed a pseudoaneurysm in the proper hepatic artery (a, white arrow). Microcatheterization of the
pseudoaneurysm (b), which resolved with angiographic control, sparing the proper hepatic artery (c). Cast of NBCA selectively injected inside
the pseudoaneurysm (d, black arrow).
Massachusetts, USA) with an inner lu-
men diameter of 0.021” and a 0.014”
Scientific) were navigated coaxially into
the 5 F catheter until they reached the
lumen of the pseudoaneurysm.
The tip of the microcatheter was
placed inside the pseudoaneurysm
and close to its visible limits. Then,
the microcatheter was flushed exhaus-
tively with 5% dextrose solution; this
was followed by injecting a mixture
of NBCA and iodized oil (Lipiodol,
Laboratoire André Guerbet, Aulnay-
sous-Bois, France) in a 1:1 ratio (50%
NBCA) until the pseudoaneurysm was
obstructed completely; this spared the
feeding artery. We avoided injections
lasting more than 1 min. After the
injection, the microcatheter was re-
moved quickly under aspiration to pre-
vent potential non-target embolization
and was discarded. Then, the 5 F an-
giographic catheter was aspirated and
flushed, and postembolization angiog-
raphy was performed.
Target areas that were classified as
distal, both pseudoaneurysms (Fig.
2) and active bleeding (Fig. 3), were
treated by embolizing the lesion, to-
gether with the affected artery, proxi-
mal and distal to the lesion. A micro-
catheter and a micro-guidewire were
navigated coaxially into the 5 F cath-
eter until they reached the segmental
or subsegmental hepatic artery that
was responsible for the bleeding or
that supplied the pseudoaneurysm.
The microcatheter was flushed with
5% dextrose solution; this was fol-
lowed by the injection of a mixture
of NBCA and iodized oil in a 1:1 to
1:3 ratio (50%–25% NBCA), depend-
ing on the velocity of blood flow, un-
til the lesion and affected artery were
obstructed completely. For patients
with more than one target area, dif-
ferent microcatheters were used and
then discarded, repeating the steps
All patients were hospitalized for
clinical and laboratorial evaluations
and discharged after an average of 16.6
days (range, 6–47 days). The longest
Monsignore et al.
406 • July–August 2012 • Diagnostic and Interventional Radiology
stays were for patients with a traumatic
etiology, as other organs were affected
or there were surgical complications.
The mean hemoglobin at discharge
was 10.6±1.6 g/dL.
Technical success using percutane-
ous transcatheter embolization with
NBCA was achieved in all patients for
both techniques, which included com-
plete exclusion of the pseudoaneurysm
from the circulation. Complete clini-
cal success was also achieved for all
patients: no clinical recurrence was
observed during the hospital stay or
follow-up, with progressive recovery
of the hemoglobin level following the
intervention (Table 1). Non-target em-
bolization, inside or outside the liver,
was not observed in this series.
In a patient who had two pseudoan-
eurysms, a truncal pseudoaneurysm
in the right hepatic artery and a distal
pseudoaneurysm in a segmental right
hepatic artery, the latter was perforat-
ed during microcatheterization. The
treatment proceeded with an NBCA
injection to obstruct the pseudoaneu-
rysm and the affected artery so that
the bleeding was resolved. This patient
was awake during the procedure and
did not develop new symptoms or a
decrease in hemoglobin.
No major complications were ob-
served during the hospital stay or in
the follow-up in our patient series.
One patient developed a large asymp-
tomatic peritoneal pseudocyst, which
was seen on the one-month magnetic
resonance imaging follow-up, but the
pseudocyst had resolved spontaneous-
ly by the three-month follow-up and
was believed to be secondary to previ-
ous intra-abdominal bleeding.
The hepatic artery or its branches
can hemorrhage due to a number of
etiologies, including traumatic, iatro-
genic, or spontaneous. Trauma is the
most common etiology and accounts
for approximately 85% of cases; this
includes active bleeding from a liver
Figure 2. a–c. Multiple distal pseudoaneurysm embolization. The patient
presented with abdominal pain and hypotension after spontaneous rupture of
intrahepatic pseudoaneurysms. Selective angiography of the proper hepatic
artery showed four lesions in the intrahepatic branches of the right hepatic
artery consistent with pseudoaneurysms (a, white arrows). Superselective
microcatheterization of each pseudoaneurysm was performed with
microcatheters (b, white arrow). At angiography after the NBCA treatment,
the pseudoaneurysms are no longer seen (c).
Urgent percutaneous transcatheter embolization of hemorrhagic hepatic lesions with N-butyl cyanoacrylate • 407
Volume 18 • Issue 4
laceration, usually after blunt trauma,
or a liver contusion with pseudoan-
eurysm formation (2). Iatrogenic le-
sions to the hepatic artery can occur
during surgical (e.g., cholecystectomy,
duodenopancreatectomy, and liver
transplantation) or percutaneous (e.g.,
biliary drainage and liver biopsy) pro-
cedures (3, 4). Spontaneous hepatic
artery bleeding is uncommon and in-
cludes aneurysm and pseudoaneurysm
ruptures, tumors, pre-eclampsia, and
other rare causes.
Endovascular embolization is cur-
rently the treatment of choice for a
life-threatening liver hemorrhage of
any etiology (5, 6, 10–13). The report-
ed success rates of embolization of liver
bleeding are from 53% to 92% (2, 14,
15), depending on the site of the bleed
and which embolic material was used
(Table 2). A wide range of materials has
been used for treatment, including coils
(4–6), absorbable gelatins (2–4), PVA
particles (2), stent grafting (16), and
NBCA (4–7), either exclusively or in
combination. Coils are considered the
best embolic material for active bleed-
ing from pseudoaneurysms. However,
coils are inconvenient because superse-
lective catheterization is always re-
quired, and the proximal occlusion of
a vessel may not successfully treat the
bleeding lesion due to the presence of
collateral vessels (6) or in patients with
coagulopathy. Absorbable gelatin and
PVA particles are often used in com-
bination with coils, but they have a
high rate of technical failure, especially
when used alone.
NBCA is a non-absorbable liquid
ester that polymerizes rapidly in the
presence of ionic substances like blood
and saline. When mixed with Lipiodol,
NBCA becomes radiopaque, and its po-
lymerization is retarded to a timescale
of seconds; the polymerization time is
inversely proportional to the amount
of Lipiodol in the mixture (17). It has
been used in interventional radiology
for more than three decades and pri-
marily for neuro-interventional pro-
cedures, e.g., cerebral and medullar
arteriovenous malformations (AVMs)
Figure 3. a–d. Post-traumatic active bleeding embolization. Following an automobile collision, the patient presented with blunt abdominal
trauma with free abdominal fluid at ultrasonography and hypovolemic shock. Two different spots of active bleeding were seen in the right liver
lobe from distal branches of the right hepatic artery (a, white arrows). NBCA injection after microcatheterization (b) and postembolization
angiography (c) are seen. Cast of NBCA is inside the distal branches of the right hepatic artery (d, black arrow).
Monsignore et al.
408 • July–August 2012 • Diagnostic and Interventional Radiology
(18, 19) or head and neck tumors (20).
Recently, its use outside the central
nervous system was approved; case re-
ports and series have been published
on the treatment of gastrointestinal
bleeding (21–23), varicoceles (24),
peripheral arteriovenous fistulas and
AVMs (25), tumor lesions (26), and por-
tal vein embolization (27) with NBCA
alone or with other embolic material.
As a liquid embolic material, NBCA
has the advantage of promoting the
occlusion of an entire vessel and the
bleeding lesion or being extremely se-
lective inside a truncal pseudoaneu-
rysm of the hepatic artery, depending
on its dilution with Lipiodol. It is pre-
pared and delivered quickly, relative to
absorbable gelatin and PVA particles,
resolving the bleeding rapidly. As the
vessel occlusion does not depend on
the patient’s coagulation state, it can be
used safely in cases of severe coagulopa-
thy. Although non-target embolization
can occur, NBCA is considered safe
and effective for treating hemorrhagic
liver lesions because of the dual blood
supply to the liver and the low rate
of hepatic necrosis when there is nor-
mal portal venous flow (8, 28). Onyx
a permanent nonadhesive liquid em-
bolic agent with behavior comparable
to acrylic glue. Some authors have
used Onyx to treat acute bleeding with
good results (29). We feel that Onyx is
indicated for situations in which long
injections of material are needed to
achieve better filling of the lesion, usu-
ally for intracranial (30, 31) and periph-
eral (32) vascular malformations. With
active bleeding, although Onyx can be
used, we consider NBCA superior due
to the ability to alter its concentration
and hence the polymerization time. In
summary, the indications for the use
of NBCA and Onyx differ; we consider
NBCA more controllable when the oc-
clusion of a vessel is needed.
The presence of anatomical variation
in the arterial supply of the liver and
gallbladder and physiological anasto-
moses to adjacent organs (33) can lead
to undesirable and potentially danger-
ous non-target embolization outside of
avoid the use of liquid embolic agents
because they consider their delivery
difficult to control. The main techni-
cal limitation of the use of NBCA is
its management. Its polymerization
characteristics, dilution with Lipiodol,
velocity of delivery, reflux control,
and anatomical familiarity are im-
portant aspects linked to its use, and
the clinician must know these well to
perform safe, successful procedures.
Interventional radiologists must be at-
tentive to some physiological anasto-
moses, called dangerous anastomoses,
during the use of NBCA in specific lo-
cations, such as external carotid artery-
ophthalmic artery-internal carotid ar-
tery in the treatment of epistaxis (34)
and bronchial artery-anterior spinal
artery in the treatment of hemoptysis
(35), due to the possibility of neuro-
Our study has several limitations.
First, it was a retrospective study exam-
ining preliminary results and included
a small number of patients, which pre-
vents additional statistical analysis.
Second, all of the procedures were per-
formed by two experienced interven-
tional radiologists in a single center,
which may bias the results. A multi-
center study with more patients must
be performed to confirm our findings.
In conclusion, this preliminary
study demonstrated that endovascular
embolization with NBCA as a single
embolic agent is a feasible and effec-
tive method for treating hemorrhagic
liver lesions. NBCA occludes the em-
bolized artery or the pseudoaneurysm
definitively, without recurrent bleed-
ing during follow-up. Interventional
Table 2. Embolization of liver hemorrhagic lesions in the literature
re-bleeding, and death)
Hidalgo et al. 1995
12 Iatrogenic trauma (n=7),
blunt external trauma (n=3),
septic emboli (n=1), and
lupus vasculitis (n=1)
gelatin sponge (n=8),
7/12 (58%)Ischemic necrosis of the
liver failure (n=1),
biliary sepsis (n=1),
Görich et al. 1999
26Hemobilia following percutaneous
biliary drainage (n=12) or
biliary stenting (n=3),
vascular tumor bleedings (n=3),
iatrogenic trauma post biopsy or
cumarin therapy (n=1),
hepatic aneurysm (n=1), or
gelatin sponge (n=1)
24/26 (92%)Hepatic abscess (n=1),
gallbladder necrosis (n=1)
Srivastava et al. 2006
32Iatrogenic trauma (n=6),
car accident (n=13),
vascular malformation (n=2),
hepatobiliary tumors (n=5)
gelatin sponge (n=15),
17/32 (53%)Septicemia with
multiorgan failure (n=1),
NBCA, N-butyl cyanoacrylate.
Urgent percutaneous transcatheter embolization of hemorrhagic hepatic lesions with N-butyl cyanoacrylate • 409
Volume 18 • Issue 4
radiologists must become familiar with
the use of NBCA in lesions outside
the central nervous system. In trained
hands, NBCA can be used as the prima-
ry or sole embolic agent in many situ-
ations, particularly for hemodynami-
cally unstable patients who require
fast, effective resolution of bleeding,
truncal pseudoaneurysms of the he-
patic artery to spare the affected artery,
and patients with severe coagulopathy
in whom other embolic procedures are
Conflict of interest disclosure
The authors declared no conflicts of interest.
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