Non-thrombotic Pulmonary Embolism Following Cyanoacrylate Injection for Gastric Varices: A Case Series of Six Patients

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Background: Endoscopic injection of cyanoacrylate is a standard therapeutic approach for managing bleeding gastric varices in patients with portal hypertension. While generally effective, the procedure carries a risk of non-thrombotic pulmonary embolism (NTPE) resulting from the systemic migration of the biological glue. Aim: This study describes the clinical, radiological, and therapeutic characteristics of NTPE occurring after cyanoacrylate injection for gastric varices. Methods: A retrospective observational study was conducted at the Ibn Rochd University Hospital (Casablanca, Morocco) between January 2015 and December 2022. The study included patients who received biological glue injections for bleeding gastric varices and subsequently developed pulmonary embolism confirmed by chest radiography or computed tomography (CT) angiography. Results: Among 46 patients treated with a Glubran® 2 and Lipiodol® mixture during the study period, 6 patients (13%) developed NTPE. The mean patient age was 49 years. Clinical onset was primarily characterized by acute dyspnea and oxygen desaturation. Chest CT angiography confirmed the presence of hyperdense embolic material within the pulmonary arteries in all affected patients. Therapeutic management was predominantly supportive, relying heavily on oxygen therapy. Clinical outcomes were favorable with symptomatic treatment in three patients; however, one patient required transient mechanical ventilation, and one death occurred. Conclusion: NTPE is a rare but potentially severe complication of gastric variceal obturation. The risk highlights the need for meticulous injection techniques and close post-procedural respiratory monitoring, particularly in patients with large varices or those requiring higher injection volumes.

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