Transcatheter embolization of aortopulmonary collaterals using the Trufill® n-Butylcyanoacrylate (n-BCA) liquid embolic system; A single-center experience

Background

Aortopulmonary collaterals (APCs) are commonly found in patients with cyanotic heart disease. These APCs compete with normal pulmonary blood flow in patients who have undergone Glenn or Fontan surgery. APCs are also seen in patients with cystic fibrosis (CF), where they are known to cause hemoptysis. Transcatheter occlusion of APCs has previously been described using coils, vascular plugs, and polyvinyl alcohol (PVA) particles. We present a series of patients in which the APCs were embolized using Trufill n-BCA liquid.

Objectives

This study aims to evaluate the safety and effectiveness of Trufill® N-Butylcyanoacrylate (n-BCA) for transcatheter embolization of aortopulmonary collateral vessels in patients with congenital heart disease and cystic fibrosis, particularly in cases where traditional embolization methods are limited or in patients with significant hemoptysis.

Methods

From 2009 to 2012, a total of 18 catheterization procedures were performed (in 15 patients), in which APCs were embolized using n-BCA. The mean age was 8.5 years (range: 4 months to 21 years), with a mean weight of 29 kg (range: 7–72 kg). Three patients had cystic fibrosis (CF) and presented with hemoptysis. The remaining patients had cyanotic congenital heart disease and had undergone Bidirectional Glenn or Fontan procedures. One of the congenital heart disease patients had two catheterization procedures (2.5 years apart) for hemoptysis.

Results

n-BCA embolization of APCs was technically successful in all patients. The three patients with cystic fibrosis who presented with hemoptysis had symptomatic improvement and have not needed repeat catheterization. One patient with cyanotic congenital heart disease and hemoptysis had acute improvement; however, 2.5 years later, she had recurrent hemoptysis and required additional APCs to be embolized. A complication attributable to n-BCA use also occurred in this patient. Following occlusion of an APC arising from the left lateral thoracic artery, she developed erythema of the overlying skin, followed a few days later by the formation of a small ulcer (presumably due to ischemia of the soft tissue/skin). The ulcer resolved without any specific treatment.

The only other complication occurred when n-BCA unintentionally embolized to the ulnar artery during APC embolization, causing partial occlusion in a patient with a previously occluded radial artery. Vascular surgery successfully removed the material, and the patient had no lasting effects. There were no other major n-BCA-related complications such as cerebrovascular accident, pulmonary embolism, or catheter adhesion.

Conclusion

n-BCA is a liquid embolic agent that is FDA-approved for the embolization of cerebral arteriovenous malformations. PVA particles, previously used for cerebral AVMs, have a high recanalization rate and have therefore been replaced by Trufill n-BCA or Onyx liquid embolic systems.

APCs have been embolized using coils, vascular plugs, and PVA particles—all of which are associated with varying rates of recanalization. We believe that n-BCA provides a more permanent form of APC occlusion with a decreased incidence of recanalization.

However, caution should be exercised, especially when embolizing arteries or APCs that may have branches extending to subcutaneous tissue, as n-BCA may be less forgiving compared to other occlusion methods.