Cyanoacrylate Glue in Gastric Variceal Bleeding

Objectives For more than 15 years, the tissue glue cyanoacrylate (n-butyl-2-cyanoacrylate) has been successfully used in Europe and many other countries, but not in the United States, for the treatment of bleeding gastric varices. The use of cyanoacrylate for the treatment of esophageal and gastric varices via the percutaneous transhepatic route, was first described by Lundequist et al. [ 1 ]. Endoscopic injection of the tissue glue for gastric variceal bleeding was first reported in 1986 [ 2 ]. Due to its excellent efficacy [ 3 ] [ 4 ] [ 5 ] [ 6 ] [ 7 ] [ 8 ] [ 9 ] [ 10 ] [ 11 ] [ 12 ] [ 13 ] [ 14 ] cyanoacrylate is considered to be the optimal initial therapy for gastric variceal bleeding by many clinicians worldwide, with the exception of the US. In Europe, cyanoacrylate has recently been approved for endoscopic use (Glubran®; GEM, Viareggio, Italy). Despite its widespread use, there are still some controversies in the literature concerning technique, safety, and long-term results [ 15 ] [ 16 ] [ 17 ]. Embolization of the glue is a potential risk and a cause for concern, as evidenced in recent reports [ 18 ] [ 19 ] [ 20 ]. High rebleeding rates are related to incomplete obliteration of the varices. A rare and less severe complication is pyrexia. Instrument-related complications due to incorrect preparation include adhesion to the endoscope, sticking of the needle to the varix and obstruction of the injection catheter [ 21 ]. This article deals with the practical details of cyanoacrylate injection of bleeding gastric varices, including equipment, preparation, injection technique and follow-up. Close attention to and implementation of these technical recommendations will result in a safer and successful use of the tissue glue.