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Ann Thorac Surg 2004;77:2181-2182
© 2004 The Society of Thoracic Surgeons

New technology

Invited commentary

Ernst Wolner, MD, Marek P. Ehrlich, MD

Department of Cardiothoracic Surgery, University of Vienna, Waehringer Guertel 18-20 Wien 1090, Austria

e-mail: ernst.wolner{at}akh-wien.ac.at

In 1968, Gottlob and Blümel [1] described a method for anastomosing small vessels with a diameter of 2 mm or less with the aid of adhesive rings. Both ends of the vessels were everted over a small plastic ring, fixed with cyanoacrilate glue, and then linked with a "Quick Connector."

At that time, we attempted this procedure in a canine model with the use of left heart bypass, to make a mammary coronary end-to-end anastomosis with this device. It failed because cyanoacrilate was too toxic for the thin vessel wall; this resulted in necrosis of the wall with subsequent thrombosis of the anastomosis.

A few years later, fibrin glue was introduced to cardiovascular surgery [2]. Microvascular surgery was also introduced during this time, particularly in the fields of plastic, reconstructive, and coronary surgery. As a result, there was a demand to perform microanastomoses not only with conventional sutures, but also with the use of a glue. Indeed, Matras attempted anastomoses with the fibrin glue, but his success rate was limited [3].

Since that time, several glue have products entered the market. All of them have been tested for usage in vessel anastomoses. Basically, there are three different types of tissue glues:

  1. Those that are produced from biological material exclusively. This list includes fibrin glue and all its variations.
  2. Glues which are produced partially from biologic and chemical materials, like Bioglue, which is composed of bovine albumin and glutaraldehyde.
  3. Glues which are produced exclusively from chemical materials, such as the first developed methyl-2-cyanoacrilatglue and so-called "French-glue" gelatine-resorcinol formaldehyde.

Basically, chemical glues are more resistant to tearing but have much higher tissue toxicity, while biological glues are more tissue friendly but more prone to tearing. For these reasons, no technique exists where vessel anastomoses can be performed using glues that yield the same high quality results as compared with conventional sutures. There is a high dehiscence rate when biological glues are used for anastomoses; with chemical glues there is a high tendency of thrombosis due to vessel necrosis.

This paper by Van Belleghem and colleagues confirms this experience. One of the eight animals died due to massive bleeding from the anstomoses. Of the remaining 14 anastomoses, three were totally occluded and two had major reduced flow after six weeks. In angiographic control animals, the results were even worse after twelve weeks. If one considers, that these were basically primarily healthy vessels with large diameters, the results do not compare favorable to the suture techniques.

This study confirms previous experiences with adhesive devices for vessel anastomoses. The histological data has some new and interesting aspects. Therefore, it remains at this time that glues only have an important role in closing small dehiscences, especially in patients with coagulopathies. In addition, dissected aortas are helpful to join dissected wall layers. In this latter application, the results are good; however, for vessel anastomoses, the suture technique remains the method of choice.

References

  1. Gottlob R., Bluemel G. Anastomoses of small arteries and veins by means of bushings and adhesive. J Cardiovasc Surg 1968;9:337-341.[Medline]
  2. Spängler H.P., Braun F., Holle J., Moritz E., Wolner E. The local application of fibrinogen and collagen for haemastosis in heart surgery. Wien Klin Wschr 1976;126:86-89.
  3. Matras H., Kletter G., Dinges H.P. Partial glueing of extra-intracranial microvascular anastomoses. Wien Klin Wschr 1978;90:450-452.




This Article
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Right arrow Peripheral vascular

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