Ann Thorac Surg 1997;64:1186-1187
© 1997 The Society of Thoracic Surgeons
How To Do It
Surgical Clip for Compression of the Aortic Wall During Gluing
Tohru Sakamoto, MD,
Hirokuni Arai, MD,
Makoto Sunamori, MD
Department of Cardiothoracic Surgery, School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
Accepted for publication April 23, 1997.
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Abstract
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An acrylic clip was developed to compress the dissected aortic wall during gluing. These small instruments have a concave-convex contact face adjusted to the most common graft size. There are several advantages to this method of treatment of acute aortic dissection.
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Introduction
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Adhesive glues have been used to repair the dissected aortic wall, with marked improvements in the operative results [1, 2]. Different instruments have been employed to apply pressure to the dissected aortic wall during gluing [2]. When the outer layer of the aorta is accessible, compression clamps are used. However, the arms of clamps are large and necessitate exposure of plenty of room opposite to the glued aorta.
We developed small acrylic clips to compress the dissected aortic layers during gluing.
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Technique
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The Clip
A small acrylic clip (Fig 1
) was designed based on a common device used to clasp papers.* The contact faces of the plates of the clip are concave-convex. The inside of the outer plate exhibits a concavity, and the outside of the inner plate exhibits a convexity. The extent of the curvature on the contact surface was adjusted to the curve of the most commonly implanted graft (26 mm in diameter) in Japan. The thickness of the glued aortic wall was estimated to be about 4 mm at its greatest. The distance between the two curved faces is kept parallel when the clip holds a 4-mm thickness. The elastic power of the spring was adjusted to hold the aortic wall at 20 newtons/cm2, which is the optimal compression pressure for sealing [3]. Because many surgeons stitch the aorta 6 mm from its edge, a shallow groove was placed inside the clip, approximately 6 mm from the tip of the outer plate. Excess glue accumulates within this groove, reinforcing the suture line. The clip is 4.5 cm in length. While in place, the clip occupies an additional 2 cm of the operative field. The outer plate is larger than the inner plate, and the inner contact face has a different curvature. To prevent misplacement, colored plastic is used for the inner plate and clear plastic is used for the outer plate. This allows inspection of the aorta during gluing. The inner plate is thin enough to provide room in the lumen of the aorta for the placement of a flexible suction catheter.
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Fig 1. . Schematic representation of the acrylic clip. One black star indicates the shallow groove to allow a thick bead of glue to reinforce the suture line, and two black stars note the concave-convex faces of the plates used to hold the circular aorta.
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Use of the Clip
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In 7 patients with type A acute aortic dissection, this clip was used to compress the aortic layers after gluing. Depending on the length of the dissection, 10 to 12 clips were used (Fig 2). It took approximately 15 seconds to clip the entire aortic circumference. A suction catheter was placed in the aorta via the "tube of clips." Cardiopulmonary bypass was resumed using femoral arterial perfusion without disturbing the glued wall. Because the clips were small, it was possible to place them simultaneously on two different sites in 3 patients who underwent total aortic arch replacement. The remaining 4 patients underwent replacement of the ascending aorta after the aortic stumps were reinforced with gelatin-resorcin-formalin glue. One patient died 3 months postoperatively of intestinal infarction due to acute occlusion of the superior mesenteric artery, and another 6 patients were in good condition at the time of this report.
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Fig 2. . Nine clips were placed on the descending aorta in a patient with a Stanford type A acute aortic dissection. A flexible suction catheter was placed within the aorta.
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Comment
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A variety of methods have been used to compress the glued aortic layers, depending on the accessibility of the outer layer of the dissected aorta. Indwelling balloon catheters and Hegar dilators are used when there is no access to the outer aortic layer [2]. A clamp with curved shovel-like jaws is used when there is an accessible outer aortic wall [2]. The curved clamp and Hegar dilator have long bodies, disturbing the progress of other procedures during gluing.
The famous German circular cake "Baumkuchen" inspired us to develop the clip to hold circularly the glued aorta. Cutting the Baumkuchen into several equal pieces reveals trapezoids with circular tops and bottoms. If the pieces are divided into upper and lower segments along the growth ring within the cake, the faces exhibit concave-convex curvatures. This shape can compress the glued aorta without deforming it. The size of the face was tailored to the most commonly used aortic arch graft (26 mm in diameter) and to the estimated thickness of the glued aorta (4 mm in thickness). Different aortic sizes are accommodated by changing the number of clips placed. We have also used these clips when employing the glue to reinforce the outside of the aorta with a strip of bovine pericardium in patients who have undergone total aortic arch replacement for sclerotic aneurysms. This approach results in better hemostasis than the use of Teflon felt.
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Footnotes
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Address reprint requests to Dr Sakamoto, Department of Cardiothoracic Surgery, School of Medicine, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113, Japan.
* This clip is manufactured and commercially available through Senko Medical Instrument Mfg Co Ltd, 3-23-13, Hongo, Bunkyo-ku, Tokyo, 113, Japan. 
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References
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- Bachet J, Gigou F, Laurian C, Bical O, Goudot B, Guilmet D. Four-year clinical experience with the gelatin-resorcine-formol biological glue in acute aortic dissection. J Thorac Cardiovasc Surg 1982;83:212–7.[Medline]
- Borst HG, Laas J, Buhner B. Efficient tissue gluing in aortic dissection. Eur J Cardiothorac Surg 1994;8:160–1.[Abstract]
- Albes JM, Krettek C, Hausen B, Rohde R, Haverich A, Borst HG. Biophysical properties of the gelatin-resorcin-formaldehyde/glutaraldehyde adhesive. Ann Thorac Surg 1993;56:910–5.[Abstract]
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[Abstract]
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Abstract
Introduction
