Acute pulmonary embolism following N-butyl-cyanoacrylate endoscopic injection sclerotherapy

Nikolaos E. Papiamonis^a, Erminia Matrella^a, Emmanuel G. Blevrakis^b, Elias A. Kouroumalis^a

University Hospital of Heraklion, Heraklion, Crete, Greece

^a Department of Gastroenterology, (Nikolaos E. Papiamonis, Erminia Matrella, Elias A. Kouroumalis);
^bDepartment of Radiology (Emmanuel G. Blevrakis),
University Hospital of Heraklion, Crete, Greece

Conflict of Interest: None

Correspondence to: Nikolaos E. Papiamonis, MD,
Department of Gastroenterology, University Hospital of Heraklion,
P.O. BOX 1352, 71110 Heraklion, Crete, Greece,
Tel: +30 2810392356, Fax: +30 2810542085,
e-mail: nikospapiamonis@hotmail.com

Received 1 March 2012; accepted 12 March 2012

Endoscopic injection of N-butyl-2-cyanoacrylate (Histoacryl) is widely used for the control of gastric variceal bleeding with initial hemostasis rates of 87-100% [1,2]. However, Histoacryl injection has been associated with major complications, including embolism, sepsis, fistula and adherence of the needle within the varix [3,4].

We report a 32-year-old male patient with chronic hepatitis B infection, who presented to our emergency department with loss of consciousness following hematemesis and melena. Due to torrential bleeding, the patient was incubated and underwent upper gastrointestinal endoscopy in the operating theater. An acutely bleeding isolated fundic varix was found, which was obliterated with 2 cc of a 1:1 mixture of Histoacryl (B. Braun, Germany) with Lipiodol (Guerbert, France). Despite successful hemostasis, the patient immediately exhibited ventricular tachycardia, hypoxia (O₂ saturation of 89%), and hypotension (systolic blood pressure of 70 mmHg). The arrhythmia was treated with i.v. infusion of amiodaron (Angoron, Sanofi-Aventis, France) and circulation instability was reversed. A chest radiograph revealed multiple bilateral pulmonary emboli of the Histoacryl/lipiodol mixture (Fig. 1). Pulmonary embolism was confirmed by computed tomography (CT), which showed no evidence of lung infarcts (Fig. 2). The patient remained hemodynamically stable, and hypoxia was reversed within 48 h. Our patient illustrates the risk of pulmonary embolization following sclerotherapy with even small volumes of Histoacryl/lipiodol. Despite eventual recovery of normal lung function, pulmonary embolism with Histoacryl/lipiodol can cause life threatening cardiovascular complications such as ventricular tachycardia that require appropriate monitoring and treatment settings for their management.

References

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