The use of N-butyl cyanoacrylate for embolization of bleeding patients must be demystified regardless of the operator experience

I read with great interest the article by Grange et al. recently published in Quantitative Imaging in Medicine and Surgery and evaluating the safety, efficacy and impact of operator’s experience of N-butyl cyanoacrylate (NBCA) as an embolic agent in emergency transcatheter arterial embolization (TAE) (1).

I have several comments. First of all, I would like to congratulate the authors for their work which represents the only study available to date assessing the role of interventional radiologist’s (IR) expertise in using NBCA glue in such a setting.

TAE has gained widespread acceptance in clinical practice as a first-line therapy for emergency arterial bleedings over time, regardless of the anatomical territory and the cause of bleeding (2-4). Mixed embolic agents such as coils or particles have emerged as the currently preferred embolic agents for this purpose (2,3). NBCA has been used increasingly as well over the last decade for bleeding patients (4-6). It is particularly interesting in hemodynamically unstable patients and in cases of underlying coagulopathy, because it usually provides faster and better hemostasis than other embolic agents, which is very beneficial on an emergency basis (7,8). However, historically, glue had a very bad reputation in the IR community, with a common belief that its use is quite difficult and should be reserved for trained and skilled operators. Although conclusions from the present study must be drawn with caution because of its retrospective nature, the authors demonstrated that the clinical success, mortality during follow-up, 30-day mortality, complications and recurrence of bleeding were not significantly different based on the operators’ experience (P>0.05), with a threshold of 3 years. As reported here, this finding challenges the common belief about the difficulties of using this embolic agent, regarding non-target embolization. I am in line with the authors on that feature.

First, in our experience, glue has no more risk of complications than any other embolic agents if properly used (4,6,7). Second, the few events of non-target embolization which may happen in visceral interventions have no serious clinical consequences in the majority of cases, and then this should not be a hindrance to its use. Third, NBCA has many well-known advantages from a technical point of view in terms of navigability, visibility, versatility, efficacy and duration of vessel occlusion (8,9). It is especially true in patients with compromised spontaneous thrombosis since polymerization and vessel occlusion do not depend on coagulation parameters, making it an embolic agent of choice in case of coagulopathy, as previously reported (7). These technical advantages can even translate into better clinical outcomes, not only for bleeding patients, as reported in many situations (7-11). For these reasons, in our institution, TAE using glue as the only embolic agent has become the salvage treatment of choice in bleeding patients. It is then of utmost importance to highlight that NBCA usage must be demystified and democratized within the entire IR community, especially among the young generation of IRs, in the interest of patients. Based on the current findings, the use of NBCA by young operators may be actively recommended. On the other hand, the present study demonstrated that the learning curve for operators in using NBCA properly in emergent situations is quite short if well supervised (1). Fourth, overall outcomes were particularly good, with a clinical success, early rebleeding, major complications, and 1-month mortality rates of 82.3%, 4.4%, 0%, and 13.3%, respectively. These good outcomes were reported despite a high proportion of patients with active bleeding (68.1%) and hemodynamically unstable (43.4%), meaning with more severe condition and at higher risk of rebleeding. We can then assume that the absence of glue use in this population could have led to worse outcomes than expected with other embolic agents, reflecting the fact that glue TAE was finally of utmost importance in these selected patients (1). Last, I was surprised by the 1/1 NBCA/Lipidiol^® ratio used in the majority (45.1%) of patients, the trend being to use a more diluted mixture such as 1/3 or 1/4 ratio in most of arterial bleeders in order to obtain a more distal embolization (4,11).

In conclusion, like the authors, our experience suggests that TAE using cyanoacrylates alone or in combination with other embolic agents, is generally very effective, fast and safe in controlling acute arterial bleeding, regardless of the anatomical territory. Additionally, I fully agree that operator experience should no longer be considered as a key factor for outcomes.

Appendix 1: Response to “The use of N-butyl cyanoacrylate for embolization of bleeding patients must be demystified regardless of the operator experience”.

Acknowledgments

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Footnote

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1830/coif). The author has no conflicts of interest to declare.

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References

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