Super glue. What can’t it do?
Fix a broken flower vase? Check.
Hold together a Halloween costume? Check.
Allow surgeons to safely remove tangled clumps of extra veins that are otherwise tricky and dangerous to treat? Check.
That’s right. A team from Seattle Children’s has pioneered a safer method to remove venous malformations in the head and neck by first injecting them with n-butyl cyanoacrylate (n-BCA) glue, a medical variation of the familiar household super-adhesive.
The team published a report of their novel technique last month in the journal Otolaryngology Head and Neck Surgery.
A new approach to a challenging procedure
Venous malformations are spaghetti-like, blood-filled clusters of unnecessary veins. They are usually present at birth and grow slowly, if at all, as a child grows. When they’re close to the skin, venous malformations look like a purplish mass.
But removing venous malformations is tough, explains Jonathan Perkins, DO, clinical chief of the Vascular Anomalies Program at Children’s. Although they are usually not dangerous, these vein clusters can be disfiguring and painful – and if one is accidentally bumped or cut, it can bleed profusely.
“These things are like water balloons filled with tiny tubes of liquid,” he says. “If we puncture one while we’re trying to remove it, it decompresses and there’s nothing left to remove.” When the puncture heals, the tube fills again with blood and the purplish mass can return.
Overcoming that obstacle by using glue was the brainchild of Basavaraj Ghodke, MB, BS, an interventional radiologist on the vascular anomalies team.
“Filling the veins with glue before operating seemed like a great solution,” recalls Perkins, who notes that n-BCA was designed to prevent strokes by treating leaking aneurysms in the brain. “You can inject it slowly and control where it goes, and it hardens up in about 20 minutes,” he says. “I thought, ‘why not try it?’”
When the glue is hard, the surgeon can clearly identify the boundaries of the malformation and cleanly remove it.
Puffy purple problem
Seven-year-old Kaleb Klempel of Eltopia, Wash. (a farm community four hours east of Seattle), was born with a venous malformation at the corner of his mouth.
“It looked like a big, puffy purple spot on the one side of his mouth,” says his dad, Reuel. “When he cried or got worked up, it would double or triple in size. We were concerned that if he fell or cut it somehow, that thing would really bleed.”
The Klempels, who have 12 children, knew and trusted Children’s (as a baby, Kaleb had orthopedic surgery here on his foot).When Kaleb was six, his parents were worried enough about the purple patch to travel here to have it checked out.
“When Dr. Perkins explained the super glue concept, it sounded to me like it might work,” says Reuel. “I knew doctors were using it in place of stitches because one of our other sons had a head wound treated with super glue at a hospital back east.”
The Klempels said “yes” to the experimental procedure.
Before: Choosing between imperfect options
Before they hit upon the glue concept, Perkins’ team was dissatisfied with the conventional treatments for venous malformations.
One option, sclerotherapy, involves injecting the veins with a substance that makes them shrink. “But this has to be done repeatedly, and each time under general anesthesia,” says Perkins. Recovery can be painful, and the substance can damage a patient’s skin or mucous membrane.
Even more troubling, the most effective sclerotherapy substance is absolute alcohol, which can potentially travel through the veins. “If the dose is big enough, it can stop the patient’s heart and even cause death,” he says. “That’s a big risk, and one we’re uncomfortable taking.”
A second option, he says, is “cooking” the malformed veins from the inside using a laser fiber. This, too, requires repeated procedures under general anesthesia and recovery is painful.
One procedure, three hours, less risk
Kaleb’s surgery started in the radiology suite, where an interventional radiologist injected the glue. By the time it set, the team had moved Kaleb to the operating room, where a surgeon removed the hardened chunk of glue – along with the rogue veins.
The entire procedure took about three hours, says Perkins.
To date, more than 20 Children’s patients with venous malformations in their mouths, heads, necks and cheeks have been treated with the glue procedure. When necessary, Perkins maps the facial nerve in ink on a patient’s skin to avoid damaging it during surgery.
The team has reviewed their patient cases dating to 2000, and they estimate that about half the patients Children’s treated for venous malformations since then would have benefited from the glue procedure, had it been available.
New standard of care
Kaleb spent one night in the hospital after his surgery. When his mouth healed there was no sign of the purplish mass, says Reuel. It has not returned in the year since his surgery.
The super glue procedure has already become the standard of care at Children’s for certain types of venous malformations in the head and neck, says Perkins. He hopes the paper in Otolaryngology Head and Neck Surgery will help spread the word of this ingenious procedure to peers at other institutions.
“It’s the first technique we’ve hit on that allows us to remove localized venous malformations in one shot – and with minimal risk of recurrence,” says Perkins.
If you’d like to arrange an interview with the Klempels or Drs. Perkins and Ghodke, please contact Children’s PR team at 206-987-4500 or at press@seattlechildrens.org.
