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Ann Thorac Surg 2001;72:509-514
© 2001 The Society of Thoracic Surgeons
a First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
Accepted for publication April 17, 2001.
Address reprint requests to Dr Kazui, First Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, Japan, 431-3192
e-mail: tkazui{at}hama-med.ac.jp
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Abstract |
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Methods. From January 1983 to September 2000, 130 patients had emergency operation for acute type A aortic dissection. Of them, 57 patients underwent root reconstruction using biologic glues and 4 patients (7.0%) developed redissection of the aortic root associated with moderate to severe aortic regurgitation 5 to 27 months after the initial operation. In all patients, the proximal false lumen was obliterated with infusion of gelatin-resorcinol-formaldehyde (GRF) glue or BioGlue and the aorta was reinforced with Teflon felt strip or Surgicel placed on its outside wall.
Results. During reoperation, the noncoronary aortic sinus was found to be redissected in all patients with the dissection extending retrogradely to the aortic annulus. This resulted in aortic regurgitation with prolapse of the noncoronary cusp because the proximal suture line dehisced. Histopathology showed disappearance of the nuclei of the medial smooth muscle cells, suggesting tissue necrosis at the site of GRF glue application. The lesions were treated successfully with full root replacement using a freestyle heterograft bioprosthesis or a composite graft prosthesis.
Conclusions. The use of biologic glues for reapproximating the layers of the dissected aortic root is associated with a certain amount of risk of aortic wall necrosis. Therefore, care should be taken to ensure proper use of these glues. Full root replacement could be a preferable technique for treating redissection of the aortic root.
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The present study involved a review of these 57 patients who had aortic root reconstruction using the biologic glues. There were 38 men and 19 women with a mean age of 63±11.7 years. Two patients (3.5%) had typical Marfan syndrome. Two patients had undergone previous cardiac operation: 1 had coronary artery bypass grafting (CABG) and aortic valve replacement and the other had CABG only. Three patients had undergone previous aortic operation: 2 had abdominal aortic replacement and the other had axillofemoral bypass grafting. Preoperative risk factors included hypoperfusion (shock) in 15 patients (26.3%), cardiac tamponade in 16 (28.1%), myocardial ischemia in 6 (10.5%), renal/mesenteric ischemia in 1 (1.8%), leg ischemia in 3 (5.3%), cerebral ischemia in 6 (10.5%), and renal dysfunction in 2 (3.5%) with 1 requiring hemodialysis.
Operative technique
All operations were performed within 14 days from the onset of acute aortic dissection. The techniques of reinforcing the dissected aortic layers using biologic glues were as follows.
For proximal aortic reconstruction, the ascending aorta was transected immediately above the aortic commissure. Aortic regurgitation caused by commissural detachment during the dissection process was mostly repaired with resuspension of the aortic commissures using mainly 4-0 polypropylene sutures with Teflon pledgets placed on both the inner and outer side of the aorta. Then GRF glue was infused into the proximal false lumen after drying the lumen by removing blood and clots. The layers of the aortic wall were then compressed with a special clamp [15] for 5 minutes to allow polymerization of the glue. Teflon felt strips were placed on the outer surface of the aorta for reinforcement using 4-0 polypropylene running sutures.
BioGlue was used in an essentially similar fashion except that the dissected aortic wall was not clamped for compression, and the external aortic wall was reinforced with Surgicel (Ethicon Inc, Somerville, NJ) instead of Teflon felt strip. Having completed the proximal aortic reconstruction, systemic circulatory arrest was induced and distal aortic reconstruction was performed. For the latter, an essentially similar technique was used to reapproximate the dissected aortic layers in the case of ascending aorta replacement or hemiarch replacement, whereas a different technique was used in the case of concomitant total arch replacement (TAR). The detail of our TAR techniques has been described previously [16]. Briefly, the technique used in concomitant TAR cases was as follows: The descending aorta distal to the origin of the left subclavian artery was completely transected. Running 5-0 polypropylene suture was placed circumferentially on the descending aorta 1 cm below the aortic stump to prevent dislodgment of biologic glue. Then biologic glue was infused into the false lumen. After reinforcing the outer side of the aorta with a Teflon felt strip, the false lumen was obliterated in a sandwich-like fashion. After the distal aortic reconstruction was completed, a Hemashield graft (Boston Scientific, Natick, MA) was anastomosed to the distal aortic stump, antegrade systemic perfusion from the side arm of the main graft was started, and then the proximal side of the graft was anastomosed to the proximal aortic stump in the same way as the distal anastomosis. GRF glue was used to reinforce the dissected aortic layers of both proximal and distal anastomotic sites in 47 patients, and only the distal anastomotic site in 6 patients. BioGlue was used to reinforce the dissected aortic layers of both the proximal and distal anastomotic sites in the most recent 4 patients. Aortic valve resuspension was performed in 22 patients (38.6%) with AR caused by commissural detachment, and composite graft replacement in 6 patients (10.5%) with annuloaortic ectasia. The extent of distal aortic replacement was ascending only in 4 patients (7%), ascending and proximal portion of the aortic arch in 10 (17.5%), and the whole aortic arch in 43 (75.4%). Indications for TAR in this series were intimal tear in the aortic arch, intimal tear in the descending aorta, rupture or massive false lumen of the aortic arch, compromised arch vessels, coexistent arch aneurysm, and young age, particularly in patients who had Marfan syndrome without serious preoperative complications. Total arch replacement was performed using antegrade selective cerebral perfusion as the cerebral protection technique, the details of which were described previously [16]. Concomitant procedures included CABG in 2 patients (3.5%), mitral annuloplasty in 1 (1.8%), and Doty’s extended aortoplasty for supravalvular aortic stenosis in 1 (1.8%).
Follow-up
The patients were followed up until December 2000 at the outpatient clinic or were contacted by telephone or letter. The follow-up was 100% complete. The mean follow-up duration was 36.3 ± 24.1 months.
Statistical analysis
Continuous data are expressed as mean ± standard deviation. Fisher’s exact test was used to compare in-hospital mortality between patients receiving aortic root reconstruction with glue and those without glue. Actuarial patient survival and freedom from reoperation were estimated by Kaplan–Meier method.
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Reoperations
A total of 12 reoperative procedures were performed in 10 patients for proximal and distal aortic lesions. In 5 of these patients, reoperation was done for proximal aortic lesions, 4 (GRF glue in 3 patients and BioGlue in 1) for redissection of the aortic root associated with moderate to severe AR, and 1 (BioGlue) for pseudoaneurysm formation in the proximal graft anastomotic site. None of these patients had Marfan syndrome. Table 1 shows the profile of patients who developed redissection of the aortic root. In these patients, AR caused by commissural detachment was either absent or only occasionally present in a mild form and there was no dilated aortic root at the initial operation. All these patients underwent reconstruction of the aortic root using biologic glues and supracommissural ascending aortic replacement with TAR or partial arch replacement at the initial operation and had an uneventful postoperative course. Digital subtraction angiography and computed tomography scan taken 1 month postoperatively confirmed satisfactory reconstruction of aortic root, ascending aorta, and aortic arch in all patients. However, they developed redissection of the aortic root with AR and required reoperation 5 to 27 months after the initial operation (Fig 1).
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Histopathology of the inner wall of the redissected aortic root at the site of the GRF glue application showed almost a complete disappearance of the nuclei of the medial smooth muscle cells and hemosiderin deposition on the false lumenal side of the media on hematoxylin and eosin staining (Fig 2). The medial elastic lamellae at the false lumenal side appeared disrupted on Elastica van Gieson staining. Focal disruption of the elastic lamellae was also observed on the inner side of the wall. However, neither cystic degeneration nor inflammatory change was found there.
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Another 5 patients underwent reoperation for aneurysm formation of the false lumen in the descending aorta. In these patients and in 3 others who had previous elephant trunk procedure, unusual macroscopic and microscopic findings like those at the proximal anastomotic site were not found at the distal anastomotic site.
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Comment |
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Conventionally, the aortic root is reconstructed by aortic valve resuspension in 70% to 80% cases of AR in acute dissection [2, 3, 7, 10], and obliteration of the proximal false lumen mostly reinforced with Teflon felt if the aortic root is not dilated and the aortic valve is normal. However, about 20% of the patients who received this aortic root repair required aortic valve replacement 10 years postoperatively [1, 2, 10].
In 1977, Guilmet and colleagues [19] first applied GRF glue in aortic root reconstruction to reinforce the aorta rendered fragile by the acute dissection and to strengthen the aortic anastomosis. Since then, GRF glue, sometimes referred to as the "French glue," has been widely used in the treatment of acute aortic dissection, and its usefulness has been validated [4, 6–9].
In 1994, we started using GRF glue to reconstruct the aortic stump in cases of acute aortic dissection. Despite some practical difficulties in comparing the surgical outcome of different patient cohorts reported in the literature, we noticed an improvement in the survival rate of these patients when compared with that of those who had Teflon repair. In-hospital mortality in patients who received aortic root reconstruction without biologic glue was 23% compared with only 10.5% in those who had glue reconstruction. However, no significant difference was noted in terms of reoperation event-free rate for proximal and distal aortic lesions in the late postoperative period between these two groups. It has been reported that 10% to 40% of patients who were treated with aortic root reconstruction using GRF glue developed recurrence of AR and required reoperation in the late postoperative period [3, 7, 10–12].
Recently, Fukunaga and colleagues [12] reported that 9 of 148 patients treated with GRF glue required reoperation and 7 patients had aortic root redissection related to GRF glue. Macroscopically, the tissue treated with GRF glue appeared necrotic; microscopically, medial degeneration was found in 2 patients. They speculated that complications associated with the GRF glue are likely to be caused by the toxic effect of its formalin component. In our series, macroscopic findings were similar and microscopically, nuclei of the medial smooth muscle cells had mostly disappeared, suggesting necrosis of these cells.
It is necessary to use appropriate surgical and glue application techniques to obtain the desired effect of the glue. Measures such as warming (45°C) the gelatin-resorcin mixture, drying the tissue surface, applying pressure, allowing time for polymerization, and avoiding formalin overdose [8] have been recommended [20]. While using the GRF glue, we have paid special attention to these points.
There are multiple causes for reoperation after aortic root reconstruction. Casselman and coworkers [14] reported that risk factors for reoperation were the use of fibrinous glue and the presence of a dilated aortic annulus (larger than 27 mm), whereas Pessotto and coworkers [13] found preoperative moderate to severe AR to be a factor of increased risk for recurrent AR. Judging from the clinical and pathologic findings, we speculate that the aortic root redissection in the present series was due to formalin overdose or inadequate mixing of the glue components. A similar redissection in the downstream aorta was not seen in this series. Reasons might have been a lesser hemodynamic stress on the distal aorta or obliteration and reinforcement of the distal false lumen with our modified elephant trunk technique.
More recently, BioGlue made from bovine serum albumin and less toxic glutaraldehyde has been used in clinical trials in Japan. Earlier, it was reported that Bioglue was useful in repairing acute aortic dissection in a sheep model [21]. We have used BioGlue as an alternative to GRF glue to strengthen the aortic stump. As with GRF glue application, care should be taken to ensure the tissue surface is dry and bloodless. Moreover, pressure should not be applied using surgical forceps because it may cause this less sticky substance to spill out from the false lumen and produce a less effective adhesion. Although glutaraldehyde is less toxic to human tissue than formalin, its overdose may still cause tissue necrosis.
Aortic root replacement using composite graft prosthesis has been described as a radical treatment for acute type A dissection associated with annuloaortic ectasia [22]. However, this technique is not suitable when the aortic annulus is of an average size. More recently, favorable midterm results of valve-sparing aortic root replacement for acute type A aortic dissection have been reported [17, 18]. Although these procedures seem to be offering a more radical treatment, they are more technically demanding than the conventional aortic root reconstruction, particularly in critically ill patients. Moreover, further follow-up will be necessary to assess the recurrence of AR.
If the dissection process mainly involves the noncoronary sinus, our current approach is to obliterate the false lumen on either side of the noncoronary sinus with glue and then resect the sinus, leaving a rim of about 5 mm above the valve leaflet, and transect the ascending aorta horizontally above the right and left coronary sinuses. A woven Dacron (Boston Scientific, Natick, MA) graft tailored in a scallop-shaped configuration to match the noncoronary sinus is then anastomosed to the proximal aortic stump [23]. This partial remodeling technique is much easier than usual remodeling or reimplantation of the aortic root because coronary reimplantation is not necessary.
Indications of reoperation for aortic root redissection in our series included marked dilation of aortic root and relatively prompt progression from moderate to severe AR. The operative technique used for aortic root redissection was aortic root replacement with coronary reimplantation. Freestyle aortic root bioprosthesis, which has recently become available as a conduit for aortic root replacement [24], was used in patients older than 70 years of age or in elderly patients who will require total thoracoabdominal aortic replacement because no anticoagulation is necessary and its hemodynamic function is superior.
In conclusion, aortic root reconstruction using biologic glue for treating acute type A aortic dissection is associated with a certain amount of risk of aortic wall necrosis and subsequent redissection of the aortic root. Although these complications can usually be treated by available surgical means, further improvements in the quality of glues and their application technique will be necessary to prevent problems in the first place.
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