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Ann Thorac Surg 2001;72:638-640
© 2001 The Society of Thoracic Surgeons

How to do it

Use of "BioGlue" in aortic surgical repair

Ehud Raanani, MDa, David A. Latter, MDa, Lee E. Errett, MDa, Daniel B. Bonneau, MDa, Yves Leclerc, MDa, Gary C. Salasidis, MDa

a Division of Cardiovascular Surgery, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada

Accepted for publication March 22, 2001.

Address reprint requests to Dr Latter, 30 Bond St, Toronto, Ontario, Canada M4G 1A8
e-mail: latterd{at}smh.toronto.on.ca


   Abstract
Top
 Abstract
Introduction
 Technique
 Comment
 Acknowledgments
 References
 
A new bioadhesive (BioGlue, Cryolife Inc, Kennesaw, GA) was recently introduced for surgical use in thoracic aortic surgical repair. We describe our early experience and our suggested method of repair.


   Introduction
Top
 Abstract
 Introduction
Technique
 Comment
 Acknowledgments
 References
 
Tissue glues are used as surgical adjuncts in cardiac surgical procedures. Gelatin-resorcin-formalin (GRF) glue is the most widely used in surgical treatment of dissecting aortic aneurysms [1–3]. Recently a new biological glue (BioGlue, Cryolife Inc, Kennesaw, GA), has been developed and approved for surgical use in Canada by the Health Protection Branch.

BioGlue is composed of purified bovine serum albumin (45%) and glutaraldehyde (10%). Glutaraldehyde exposure causes lysine molecules of bovine serum albumin, extracellular matrix proteins, and cell surfaces to bind to each other creating a strong scaffold (Fig 1). The reaction is instantaneous and reaches maximum bonding strength in 2 to 3 minutes. In vivo bovine animal studies demonstrated that aortic bonding with BioGlue produced a tensile strength of 847 ± 127 g/cm and an ex vivo shear strength (lamina to media) of 256 ± 46 g/cm [4]. The delivery system includes a reusable delivery device, a prefilled solution cartridge, and fine pointed applicator tips (Fig 2). This report summarizes our initial experience with BioGlue and describes suggested methods of use.



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  		Fig 1. Reaction mechanism. Bovine serum albumin, extracellular matrix (ECM), and cell membrane proteins contain lysine molecules with an amine group side chain. Aldehyde links two amine groups.

 


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  		Fig 2. Delivery system. A prefilled cartridge automatically mixes the solution.

 

   Technique
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 Abstract
 Introduction
 Technique
Comment
 Acknowledgments
 References
 
Between August 1999 and March 2000, BioGlue was used as a surgical adjunct in 8 patients who underwent surgical repair of acute A aortic dissection and 10 patients who underwent repair of degenerative ascending or descending thoracic aortic aneurysm.

All operations for type A aortic dissection were performed using deep hypothermia and total circulatory arrest. At the distal anastomotic site, BioGlue is used to adhere the dissected layers and create stronger aortic tissue for sewing (Fig 3). Before applying the glue, all tissues surrounding the aortic arch are protected with wet sponges. The aortic arch is in close proximity to structures such as phrenic and vagus nerves, and caution should be taken to avoid exposing them to the toxic effect of the glutaraldehyde component. The glue is applied between the layers of the dissected aorta, to the two layers of the aortic wall, and to the adventitia of the aortic wall. Since no long-term follow-up information is available on the effect of BioGlue on arterial tissue, we limit its use to the local aortic tissue only. A simple end-to-end anastomosis between the Dacron (C. R. Bard, Haverhill, MA) graft and the treated aorta is then completed. Generally, we do not find it necessary to use any reinforcement sutures or Teflon (L. R. Bard, Tempe, AZ) felt strips to support the anastomosis.



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  		Fig 3. Distal repair using BioGlue. Wet sponges (A) protect surrounding tissues. BioGlue is applied between the layers of the aorta (B) and the adventitial surface of the aorta (C).

 
When the distal anastomosis is completed, cardiopulmonary bypass is reinstituted through a cannula in the ascending aortic Dacron graft, rewarming of the patient is started, and the proximal aorta is prepared for suturing. The glue is applied in the same manner as at the distal anastomosis with protection of the surrounding tissues (Fig 4). The glue is applied between the layers of the dissected aortic wall, to the two layers of the aortic wall, and to the adventitia of the proximal aortic wall. It is essential to protect the ostia of the coronary arteries from accidental spillage of glue. This can be accomplished by inserting a fine flexible plastic cannula into the ostia before applying the glue. After gluing the sinuses back to the aortic wall, the commissures of the aortic valve are further anchored to the aortic wall using three sutures supported with Teflon pledgets. Preservation of the aortic valve requires precise resuspension of the commissures, and may involve scalloping of the residual proximal aortic wall and complementary scalloping of the Dacron graft. The use of BioGlue and the avoidance of stiff Teflon felt strips make this precise reconstruction easier. The proximal anastomosis is then performed in a simple end-to-end anastomosis between the proximal aorta and Dacron graft.



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  		Fig 4. Proximal repair using the glue. (A) A soft cannula protects coronary ostia. (B) Commissures are resuspended. (C) BioGlue is applied between dissected layers.

 
BioGlue is also used in operations for atherosclerotic aortic aneurysm repair to increase the strength of the aortic tissue at the site of the aorta-to-Dacron-graft anastomosis. It is applied to the aorta at the intended site of anastomosis taking care to protect the adjacent tissues in the same manner as described earlier.

Hospital mortality was 17% (3 of 18). One patient undergoing aortic dissection died in the operating room from cardiogenic shock. Another such patient did well from a cardiovascular point of view but suffered a perioperative stroke and died 120 days postoperatively. One patient undergoing atherosclerotic aortic aneurysm repair died in the operating room from a combination of bleeding and cardiogenic shock. Mean postoperative chest tube blood loss in the first 24 hours was 702 ± 457 mL. Median postoperative intensive care unit stay was 96 hours (range, 24 to 740 hours). Median hospital stay was 10 days (range, 6 to 120 days). Seven of the eight type A aortic dissections were associated with significant preoperative aortic insufficiency. With the aid of BioGlue, 6 of 7 patients had successful resuspension of their aortic valve. During short-term follow-up (5 to 12 months; mean follow-up, 9.2 months) no patients required reoperation for redissection, delayed rupture, or aortic insufficiency.


   Comment
Top
 Abstract
 Introduction
 Technique
 Comment
Acknowledgments
 References
 
Recently, concern has been raised regarding the late effects of tissue glues. Bingley and colleagues [5] found a high reoperation rate, mostly due to redissection in the proximal portion of the aorta causing aortic insufficiency, in patients in whom GRF glue was used in the repair of acute aortic dissection associated with aortic valve regurgitation. Failure of GRF glue may be due partly to the relatively high concentrations of formaldehyde (37%) and limitations of the delivery system. In contrast, BioGlue contains a lower concentration of glutaraldehyde (10%) and a precise delivery system. Gundry and coworkers [6] showed in animals that BioGlue produces a strong enough tissue bond that it can be used to create a sutureless coronary anastomosis. We believe that BioGlue, the newest of the biological glues, has a stronger glue effect than older surgical glues such as GFR glue, and will likely prove to have superior long-term results in aortic dissections. Longer-term follow-up of patients treated with BioGlue is necessary.


   Acknowledgments
Top
 Abstract
 Introduction
 Technique
 Comment
 Acknowledgments
References
 
We thank Mr Zahir Young for drawing the illustrations.


   References
Top
 Abstract
 Introduction
 Technique
 Comment
 Acknowledgments
 References
 

  1. Bachet A., Goudot B., Dreyfus G., et al. The proper use of glue: a 20-year experience with the GRF glue in acute aortic dissection. J Cardiac Surg 1997;12(Suppl 2):243-253.[Medline]
  2. Fukunaga S., Karck M., Harringer W., Cremer J., Rhein C., Haverich A. The use of gelatin-resorcin-formalin glue in acute aortic dissection type A. Eur J Cardiothorac Surg 1999;15:564-570.[Abstract/Free Full Text]
  3. Neri E., Massetti M., Capannini G., Carone E., Sassi C. Glue containment and the anastomosis reinforcement in repair of aortic dissection. Ann Thorac Surg 1999;67:1510-1511.[Abstract/Free Full Text]
  4. Yuksel U, Peacock L, Thomas H, et al. Characteristics of an experimental bioadhesive. Presented at the XVIth Congress of the International Society on Thrombosis and Haemostasis (ISTH), Florence, Italy, June 1997.
  5. Bingley A., Gardner M.A.H., Stafford E.G., et al. Late complications of tissue glues in aortic surgery. Ann Thorac Surg 2000;69:1764-1768.[Abstract/Free Full Text]
  6. Gundry R., Black K., Izutani H. Sutureless coronary artery bypass with biologic glued anastomosis: preliminary in vivo and in vitro results. J Thorac Cardiovasc Surg 2000;120:473-477.[Abstract/Free Full Text]



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This Article
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