Ann Thorac Surg 2005;79:1793-1794
© 2005 The Society of Thoracic Surgeons
How to do it
Effective Use of Fibrin Glue for Acute Aortic Dissection
Takayuki Nakajima, MDa,*,
Kohei Kawazoe, MDa,
Hiroshi Izumoto, MDa,
Tsuyoshi Kataoka, MDa,
Toshinobu Kazui, MDa
a Department of Cardiovascular Surgery, Iwate Medical University Memorial Heart Center, Iwate Medical University, Morioka, Japan
Accepted for publication December 22, 2003.
* Address reprint requests to Dr Nakajima, Department of Cardiovascular Surgery, Iwate Medical University Memorial Heart Center, Iwate Medical University, 1-2-1 Chuodori, Morioka, Japan 020-8505
t_nakajima{at}imu.ncvc.go.jp
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Abstract
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The use of gelatin-resorcine-formalin (GRF) glue for reconstruction of the vascular wall in the context of acute aortic dissection has become more common. However, anecdotal evidence suggests that use of the GRF glue results in higher rates of postoperative redissection. We describe an alternative method of reinforcing the dissected aorta with fibrin glue that may avoid this complication. A fabric sheet is presoaked in fibrinogen solution and then placed within the false lumen. Thrombin solution is then applied to the fabric sheet. That results in obliteration of the false lumen and effective reinforcement of the dissected wall.
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Introduction
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A critical component of surgical correction of acute aortic dissection is the reinforcement of the fragile vascular wall. Several reports describe the use of gelatin-resorcine-formalin (GRF) glue as an effective method of reconstruction that yields higher patient survival rates. However, recent studies demonstrated the development of postoperative midterm redissection after use of GRF glue for treatment of acute type A aortic dissection [1, 2]. In 1999, the use of GRF glue was discontinued in our institution because of similar experiences regarding redissection of the aortic root. Since 2000, a method that we had employed to reconstructed dissected aorta until 1995 was again adopted. The method involved insertion of a fabric sheet into the false lumen, with subsequent mixing of fibrinogen and thrombin solution upon the sheet. While postoperative midterm redissection did not occur after this procedure, the procedure generated an adhesive strength that was still relatively weak. Over the past year, we have further modified this protocol to correct this deficiency.
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Technique
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After the establishment of the cardiopulmonary bypass, the patient is cooled to deep hypothermia. During cooling, the fibrin glue (Beriplast, Centeon, Germany) and the 0.61-mm thick knitted polyester fabric (Bard Sauvage Fabric, Tempe, AZ) are prepared as usual. The fabric sheet is cut to a suitable size and placed in a Petri dish. Next, the fibrinogen solution of the fibrin glue set is dropped on the sheet (Fig 1) and allowed to soaked the sheet (1 mL of fibrinogen solution is required to soak a 5-cm2 area of the sheet).
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Fig 1. The fibrinogen solution of fibrin glue set is dropped onto the fabric sheet in a Petri dish and allowed to soak the sheet.
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The patient is cooled to a rectal temperature of 20°C, after which the systemic circulation is arrested, and the aorta is opened. Cold-crystalloid cardioplegia is infused directly into the coronary ostia. The dissected aorta with the primary intimal tear is resected, and the fibrinogen-soaked sheet is inserted and unfolded within the false lumen of the distal aorta. Any surplus sheet that extrudes from the false lumen is excised. Next, the thrombin solution of the fibrin glue set is dropped onto the inside and outside of the fibrinogen-soaked sheet (2 to 3 drops per 1 cm2; Fig 2), and the layers of the dissected wall are compressed with surgical forceps for 1 to 2 minutes. A Hemashield graft (Boston Scientific, Natick, MA) is anastomosed using 4-0 polypropylene, and Teflon felt is placed on the outer surface of the aorta. After distal anastomosis, the proximal portion of the graft is clamped, and antegrade systemic perfusion from the side graft of the main graft is restarted.
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Fig 2. The fibrinogen-soaked sheet is inserted and unfolded within the false lumen of distal aorta. The thrombin solution of fibrin glue set is dropped onto the inside and outside of the fibrinogen-soaked sheet.
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The procedure for the proximal aorta is performed during the subsequent rewarming. The root is transected above the level of the commissures and inspected. The aortic root is reinforced with the fibrinogen-soaked sheet and thrombin solution in the same manner described above.
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Results
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From January to September 2003, 12 consecutive patients with acute aortic dissection underwent aortic replacement using the method described above. One patient died of heart failure caused by preoperative acute myocardial infarction. Computed tomography, performed in the remaining 11 patients within the first postoperative month, revealed no dissection in the aorta near the proximal anastomosis or distal anastomosis. There were no reoperations after discharge. Follow-up computed tomography of the 11 surviving patients was performed 3 to 9 months (mean, 6.3 ± 2.3) after aortic replacement. Computed tomography findings revealed no redissection or no further dissection in all patients.
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Comment
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The conventional method using fibrin glue and the fabric sheet was used in our institution as early as in 1994. The fabric sheet is inserted into the false lumen to promote adhesion between the media and the adventitia, as the smooth surface of the media and the adventitia alone is an insufficient base for the fibrin glue and would yield a low adhesive strength. The fabric sheet also provides physical reinforcement to the dissected wall and prevents further damage to the fragile media from the suture line.
While this conventional method was useful, the adhesive strength to obliterate the false lumen was relatively weak. That is likely because the reaction between the two solutions was initiated before the fabric was adequately saturated. In the modified protocol described in the present study, fibrinogen solution was allowed to soak the fabric before initiation of the glue reaction, thereby increasing the adhesive strength of fabric-fibrin glue complex. Morikawa and coworkers [3] have reported that the new method using the fibrinogen-soaked absorbable mesh and the thrombin solution showed a sixfold enhancement of the adhesive properties as compared with the conventional layer method without absorbable mesh in lung surgery. We adopted not the absorbable mesh but the fabric sheet because the fabric sheet seemed to be superior to absorbable mesh in reinforcement of dissected wall.
The method using a fibrinogen-soaked sheet seems to yield some benefits as compared with the method using GRF glue. Firstly, while application of GRF glue has been associated with histologic alterations of the tissue in previous studies [1, 2, 4, 5], there have not been any reports of toxic events when using the fibrin glue. Secondly, GRF glue often runs into distal false lumen, and thrombotic complications possibly occur with the escape of GRF glue through reentry [6]. This complication does not occur with the use of the fibrinogen-soaked fabric.
Postoperative redissection caused by the use of the biological glue should be avoided as much as possible. Careful observation of the clinical course of the patients in whom we performed the aortic repair with the fibrinogen-soaked fabric will be necessary. We believe that this method leads to a favorable outcome.
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References
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- Bingley JA, Gardner MA, Stafford EG, et al. Late complications of tissue glues in aortic surgery. Ann Thorac Surg. 2000;69:1764–1768[Abstract/Free Full Text]
- Kazui T, Washiyama N, Bashar AHM, et al. Role of biologic glue repair of proximal aortic dissection in the development of early and midterm redissection of the aortc root. Ann Thorac Surg. 2001;72:509–514[Abstract/Free Full Text]
- Morikawa T, Katoh H. Improved techniques of applying fibrin glue in lung surgery. Eur Surg Res. 1999;31:180–186[Medline]
- Ennker J, Ennker IC, Schoon D, et al. The impact of gelatin-resorcinol glue on aortic tissue: a histomorphologic evaluation. J Vasc Surg. 1994;20:34–43[Medline]
- Walker JD, Kratz JM, Basler CG, et al. Fate of gelatin-resorcinol-formaldehyde/glutaraldehyde adhesive on femoral vessel morphology. J Surg Res. 1997;71:73–78[Medline]
- Carrel T, Maurer M, Tkebuchava T, Niederhäuser U, Schneider J, Turina MI. Embolization of biologic glue during repair of aortic dissection. Ann Thorac Surg. 1995;60:1118–1120[Abstract/Free Full Text]
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Abstract
Introduction
