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Tumscitz et al. Vessel Plus 2019;3:20 I http://dx.doi.org/10.20517/2574-1209.2018.71 Page 3 of 8

Table 1. Ellis classification of coronary artery perforations
ELLIS classification
Types Ellis 1 Ellis 2 Ellis 3a Ellis 3b
Details Extraluminal Epicardial fat or Extravasation Perforations with contrast spilling
crater without myocardial blush through frank directly into either the left ventricle,
extravasation without contrast (> 1 mm) coronary sinus or other anatomic
jet extravasation perforation circulatory chamber
Mortality 5.8% 5.2% 16.6% 0%

various materials, such as autologous clots or fat [12,13] , gel foam , fibrin glue , microcoils and polyvinyl
[16]
[14]
[15]
alcohol form [17-23] can be embolized to the site in order to provide haemostasis and bleeding cessation.
When percutaneous treatment of CAP is not effective, surgical repair rapresent the bail out strategy. Efficacy
of surgical repair however is not very high, as reported by a register from Al-Lamee et al. , where the rate
[9]
of success was just 44.4%.

In this case report we used (NBCA-MS)-based glue embolization (GLUBRAN2, GEM s.r.l. ITALY) in order
to seal the perforation of small vessels during retrograde and antegrade revascularization of two cases of
CTO-PCI.

Sterile glue is available for medical use either as pure synthetic glue (Histoacryl), or as dual component
fibrin glue (fibrin plus thrombin). Sterile glue has been described as an effective embolization material for
neurointerventional indications [24,25] , closure of oesophageal varices , femoral pseudoaneurysms , septal
[26]
[27]
ablation in Hypertrophic Obstructive Cardiomyopathy and as a surgical adjunctive tool to stick a patch
[28]
over the myocardial wall after an acute myocardial infarction complicated with cardiac rupture [29,30] . The use
of sterile glue has already been described for the embolization of the right coronary artery’s distal portion .
[31]
The (NBCA-MS)-based glue can be injected pure or pre-mixed with Ethiodized oil (Lipiodol/Ethiodol). The
mechanism of the (NBCA-MS)-based glue is related to his reaction to Na ions of tissue fluids. When (NBCA-
MS)-based glue comes into contact with Na ions the glue solidifies in a variable amount of time which varies
from a few seconds to one minute depending on the proportion of Ethiodized oil you pre-mix with [Table 2].
Ethiodized oil also works as a Contrast agent which produces radiopacity in the mixture and helps the physician
to confirm the site of embolization. Na ions are also present in Heparin and in Contrast media therefore both
sterile cup and the syringes used for mixing the components shouldn’t have been in contact with blood and
Heparin. Furthermore, the microcatheter should be carefully flushed with dextrose solution just before the
injection of the (NBCA-MS)-based (pure or mixture) in order to clean the inner surface from blood or heparin
residues. This flushing avoids the premature start of the glue polymerization process into the microcatheter,
which could occlude it totally or partially and make the microcatheter useless for multiple injections.

The injection can be done in a “single shot” fashion or with multiple “sandwich” injections when the mixture
is alternated with dextrose boluses.

Choosing the best proportion of ethiodized oil and the right amount of mixture is of paramount importance
to achieve the best results. The proportion of (NBCA-MS)-based with ethiodized oil component in very
small leakage of distal perforations can be 1:1 or 2:1 with a “single shot” 0.5-1 mL bolus. This strategy allows
fast and effective sealing with the same microcatheter already in place. In case of a bigger leak when the
perforation is more proximal or if there are other branches very close to the perforation site the multiple
“sandwich” technique with (NBCA-MS)-based/ethiodized oil proportion of 1:2 to 1:4 with small boluses
of 0.3-0.5 mL allows more precise embolization with smaller risk of back flow of the mixture which could
cause side branch occlusion or thrombosis. After last embolization it is always advisable to perform a rapid