NBCA (n-butyl-2-cyanoacrylate) is a cyanoacrylate-based liquid adhesive used for endovascular interventions and has a major role in managing vascular abnormalities, bleeding, and many vascular diseases. NBCA reacts with ionic solutions such as blood or normal saline, and starts polymerization immediately causing vascular embolization. NBCA is typically used in combination with lipiodol for intravascular embolization to provide radiopacity and achieve an appropriate polymerization time. The embolic effect is permanent and has a strong embolic effect that does not depend on coagulation parameters, but it requires proficiency in handling due to the risk of serious ischemic complications and adherence to the catheter if not used properly. This article introduces the basics of NBCA such as its characteristics, precautions / preparations for use, mixing ratio, tips for injection, indications, contraindications, and possible complications, for safe use of NBCA.

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Endovascular therapy has been accepted as a less invasive and effective treatment for cerebrospinal and head and neck lesions, as well as other areas. Transcatheter embolization using n-butyl-2-cyanoacrylate (NBCA) can be used to treat various vascular lesions, including vascular malformations, hypervascular tumors, and arterial injuries. However, in this cerebrospinal and head and neck region, endovascular treatment has a risk of fatal outcomes due to ischemic or hemorrhagic complications affecting the cerebrospinal vasculature and cranial/spinal nerves. To obtain good results and avoid complications, knowledge of functional vascular anatomy, as well as of treatment techniques, is mandatory. This review summarizes the tips and tricks of endovascular treatment using NBCA for cerebrospinal vascular lesions and head and neck lesions.

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NBCA is now an essential embolic agent for embolization of hemorrhages in the pancreas and gastrointestinal tract. This article describes technical tips for NBCA embolization in this area with actual cases we have experienced.

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Interventional procedures for portal hypertension include transjugular intrahepatic portosystemic shunt (TIPS) to reduce portal hypertension, percutaneous transhepatic obliteration/sclerotherapy (PTO/S), transileocolic obliteration (TIO) and balloon-occluded retrograde transvenous obliteration (BRTO) to obliterate portosystemic shunt or varices, and partial splenic embolization (PSE) to improve hypersplenism. Segmental PSE using NBCA allows immediate occlusion and quantitative infarction ratios regardless of coagulopathy in hypersplenism as compared to metallic coils or gelatin sponges. For varices, ethanolamine oleate is usually used as a sclerosant in Japan during antegrade obliteration via PTO/S, TIO, and TIPS and retrograde obliteration (BRTO). NBCA after sclerotherapy shortens the overall procedure time by allowing immediate removal of the balloon catheter and reduces total costs compared to more expensive platinum coils. In percutaneous transhepatic portal embolization (PTPE) prior to major hepatectomy, immediate and more efficient hypertrophy can be obtained by embolization using NBCA than that using other embolic materials including gelatin sponges.

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Embolization using N-butyl cyanoacrylate (NBCA) for genitourinary diseases shows immediate and secure occlusion of targeted lesions when NBCA is selected in the optimal situation and appropriately used with optimal concentration, injection speed, and devices. NBCA will show the best performance in embolization for massive bleeding with large arterial injury due to genital tract injury, cesarian section, and uterine/renal arteriovenous malformation (AVM) with high-flow arteriovenous shunt. In embolization of high flow AVMs, flow control with balloon occlusion of the feeding artery and/or drainage vein may be appropriately introduced to prevent migration of embolic material and to control the extent of embolic material. Embolization using NBCA for atonic bleeding is controversial because there is a risk of proximal embolization which may lead to continuous bleeding through collateral arteries, or uterine necrosis with low concentration NBCA. Embolization using NBCA in combination with a coil or vascular plug for urinary leakage is effective and minimally invasive. Long-lasting occlusion of the ureter with this technique is demonstrated in previous reports.

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Histoacrylate, scientifically known as n-butyl-2-cyanoacrylate (NBCA), is a form of cyanoacrylate preparation with a long-standing history of utilization in embolization procedures. In March 2022, the NBCA was approved by the pharmaceutical affairs bodies, and in September of the same year was covered by insurance. This is particularly pertinent in cases of polytrauma where numerous points of hemorrhage often exist and the rate of exsanguination surpasses that in other types of hemorrhagic lesions. Due to its reactivity with anions and subsequent polymerization, NBCA is a significantly efficacious embolization agent in trauma IVR, facilitating hemostasis despite potential disruptions in the patient’s coagulation ability. In this article, we recapitulate essential details on trauma care and delineate the clinical implications of employing NBCA in trauma-induced intravascular resuscitation.

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N-butyl-2-cyanoacrylate (NBCA) is a liquid adhesive composed of monomers that polymerize into a solid after contact with anions in the blood. The strong adhesive properties of NBCA can result in adhesion to the catheter and vessel wall, and occlusion or clogging of the catheter, with unpredictable outcomes. A mixture of NBCA with lipiodol and ethanol (NLE) is a new liquid embolic material that is less adhesive than NBCA. The inflammatory change to the vascular wall caused by NLE is milder than that caused by NBCA. NLE forms a plug without adhering to the catheter or balloon. We mainly use NLE (1:4:1, 2:7:1, 3:6:1, or 2:2:1) in the following procedures: balloon-assisted embolization (b-NLE) for visceral aneurysm and arteriovenous malformation (AVM); prophylactic intraoperative AAA sac embolization during endovascular aneurysm repair (EVAR); balloon-occluded retrograde transvenous obliteration (BRTO) for gastric varices; transarterial embolization (TAE) or percutaneous direct sac embolization for endoleak; and preoperative percutaneous transhepatic portal embolization (PTPE), and preoperative TAE to reduce intraoperative bleeding. The optimum ratio of NLE varied according to the size of and flow speed within the target vessels. NLE (141), with a low concentration of NBCA, is suitable for embolization such as BRTO and PTPE, where it is necessary to fill the target vessel without anterograde blood flow under balloon occlusion. Although NLE (141) has the drawback of migration, it can be safely used under flow reduction using a balloon catheter or in combination with metallic coils. NLE (271, 361), with a moderate concentration of NBCA, is suitable for arterial embolization in situations such as endoleak cavities and AVM. NLE (221) with a high concentration of NBCA does not migrate, even after balloon deflation, and is suitable for balloon-assisted embolization of visceral aneurysms (b-NLE).

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Stent grafting for aortic aneurysms is becoming more prevalent, but post-treatment endoleaks, particularly in EVAR, pose a durability issue and have recently garnered significant attention. The treatment options for endoleaks range from open surgical repair (OSR) to embolization, although the majority of endoleaks suitable for embolization are type 2 endoleaks. There are two primary approaches to embolization: transarterial and direct percutaneous puncture, each with its own advantages and disadvantages. This paper presents the embolization technique using NBCA and introduces actual cases based on the aforementioned characteristics.

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