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Page 6 of 8 Tumscitz et al. Vessel Plus 2019;3:20 I http://dx.doi.org/10.20517/2574-1209.2018.71

A B

C D

E F

Figure 2. Second case presented. A: CTO of the RCA (Antegrade injection); B: Guidewire in the PL branch after crossing the CTO lesion; C:
Evidence of extravasal bleeding at the level of the PL branch; D: persistence of extravasal bleeding at the distal edge of the covered stent; E:
(NBCA-MS)-based glue injection; F: Final result. CTO: chronic total occlusion

DISCUSSION
Coil embolization for the treatment of small vessel Ellis type III perforations is considered the gold standard
for emergent sealing. CTO operators always keep a set of different coils ready in the catheterization
laboratory and should know the compatibility of the coils with different microcatheters used for CTO PCI .
[32]
Ideally, coils should be delivered in every CTO microcatheter but this is not always true. Moreover, sealing
perforations with coils can be time-consuming and significantly costly when multiple coils are needed. On
the other hand, auxiliary embolization material such as subcutaneous fat tissue or clots or trombin, are
troublesome and inconvenient to prepare and are not adequately precise and reliable to deliver. For these
reasons we believe that (NBCA-MS)-based glue should be an effective and inexpensive tool to keep in every
catheterization laboratory as an alternative to the embolization coils.

On the other hand, the use of (NBCA-MS)-based glue compared with coils requires some experience to be
delivered in a precise and safe manner. The adverse events described after glue embolization are basically
divided in three main categories: inadvertent vascular embolization, suboptimal agent polymerization time,
and catheter retention . Both the suboptimal agent polymerization time and the catheter retention are
[33]
related to the operator’s inexperience. Correct proportion of the mixture (NBCA-MS)-based glue/ethiodized
oil and use of small boluses or sandwich technique make the procedure safer and keep such complications
infrequent.