Ann Thorac Surg 2006;82:1922-1923
© 2006 The Society of Thoracic Surgeons
How To Do It
Cyanoacrylate Adhesive Coating for the Treatment of Serous Leaks From Modified Blalock-Taussig Gore-Tex Shunts
Ben Davies, MRCS(Eng)*,
Yves d'Udekem, MD, PhD,
Christian P. Brizard, MD, MS
Cardiac Surgical Unit, Royal Children's Hospital, Parkville, Australia
Accepted for publication January 10, 2006.
* Address correspondence to Dr Davies, Cardiac Surgical Unit, Royal Children's Hospital, Flemington Rd, Parkville, VIC 3052 Australia. (Email: ben.davies{at}mcri.edu.au).
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Abstract
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Serous leakage and intrathoracic collections from expanded polytetrafluoroethylene (ePTFE) conduits used for modified Blalock-Taussig shunts are an uncommon but challenging clinical problem. We describe a simple technique using an externally applied cyanoacrylate adhesive with an ePTFE wrap leading to rapid and safe resolution without contamination of the mediastinum and facilitating later reoperation.
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Introduction
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Modified Blalock-Taussig shunts, as described by Gazzaniga and colleagues [1], allow the creation of controlled systemic-to-pulmonary artery shunts with high early patency, while avoiding the risks of ipsilateral arm malperfusion associated with the original Blalock-Taussig shunt [2].
Expanded polytetrafluoroethylene (ePTFE) is preferred owing to superior handling qualities, but serous leakage through the fabric of the graft occurs in as many as 10% to 15% of patients [3]. This unpredictable complication may result in excessive or prolonged chest drainage, cardiac tamponade, and compression of other major structures by the development of a semi-solid seroma.
The precise mechanism of such leakage is unclear, but probably relates to transudative movement of fluid through micropores intrinsic to the fabric before sufficient thrombin deposition and endothelialization of the interior of the shunt can occur. Such leaks have previously been treated using topical fibrin preparations [4] or intravascular fibrinogen [5].
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Technique
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Since 2000, we have performed 114 modified Blalock-Taussig shunts with serous leaks occurring in 4 children (3.5%). Of these, two occurred in patients with pulmonary atresia and intact ventricular septum (1 with a complex anatomy and 1 in a neonate with tetralogy of Fallot with pulmonary atresia). Initial access was by sternotomy and thoracotomy in two cases each. Fibrin glue was applied empirically to the suture lines of the original shunts in 2 of these patients. Patients presented at varying intervals (range, 2 to 16 postoperative days) with pericardial effusion and cardiac tamponade (n = 2), serous discharge through the sternal wound (n = 1), and pleural effusion with compression of lung parenchyma (n = 1). In one case, drain losses were in excess of 300 mL/day. Serum fibrinogen levels were normal in all patients without administration of blood products.
All underwent reoperation using the following technique without revision of the original shunt or the use of cardiopulmonary bypass. Serous losses ceased immediately in all cases upon application of the adhesive. There were no postoperative complications including phrenic nerve paralysis.
All serous fluid within pleural and pericardial cavities together with any other loculated mediastinal collections is removed. The shunt is located, carefully assessed, and the exterior surface dried using surgical gauze. A rectangular patch of Gore-Tex Preclude pericardial membrane (W. L. Gore & Associates, Flagstaff, AZ) is fashioned and placed beneath the shunt so that a cylindrical wrap can be loosely created to surround the shunt once the adhesive has been applied (Fig 1).
A single vial of sterile 2-octyl cyanoacrylate adhesive (Dermabond [Ethicon, Somerville, NJ]) is used to lightly coat all aspects of the shunt (Fig 2). Once curing is started and excess adhesive is removed with suction, the edges of the wrap are opposed with interrupted 5-0 polypropylene sutures. ePTFE pericardial membrane is routinely placed prior to sternal closure. Chest drains are removed once drainage has ceased according to the protocols of our unit.
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Comment
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ePTFE is by design a partially porous material formed by the paste extrusion of a fluorocarbon polymer and used to manufacture synthetic, nontextile vascular grafts favored for their handling characteristics and conformability [6]. The smooth, inert surface combined with their highly electronegative and hydrophobic properties may delay luminal interactions with potentially already depleted blood components usually involved in the prompt deposition of fibrinogen and platelets with later pseudointima formation. This, in combination with the smaller sizes of these thin walled, microcrimped, fibrillary structured grafts used in congenital cardiac surgery may explain the production of a chronic, serous ultrafiltrate.
Cyanoacrylate adhesives are solvent-free, liquid monomers that polymerise in the presence of a weak base such as water to create a strong, flexible, impermeable bond. Their use in civilian practice was initially restricted owing to concerns relating to vigorous curing reactions and degradation products, but contemporary formulations such as 2-octyl cyanoacrylate are now widely used in surgery and interventional radiology. Their use as an adjunct for hemostasis in the peripheral arteriovenous ePTFE shunts of renal dialysis patients has recently been reported [7]. The presence of any trace amounts of surface water on the graft only serves to accelerate the curing reaction and consequently seal any micropores.
Since 2000, 114 patients have undergone surgery for the creation of modified Blalock-Taussig shunts in our institution. Four of these patients developed serous leaks from the body of the graft, causing significant hemodynamic compromise in 2. Serum fibrinogen levels were within the normal range in all patients; hence we elected not to administer blood products. Resolution after application of the adhesive is almost instant, and we now use this technique selectively if the body of the graft gives us grounds for concern.
We have used the above described technique to economically, quickly, and successfully seal leaking, microporous prosthetic grafts without recurrence, and we found the Gore-Tex wrap to facilitate dissection and shunt take down at reoperation.
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References
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- Gazzaniga A, Elliott M, Sperling D, et al. Microporous expanded polytetrafluoroethylene arterial prosthesis for construction of aortopulmonary shunts: experimental and clinical results Ann Thorac Surg 1976;21:322.[Abstract/Free Full Text]
- Blalock A, Taussig H. The surgical treatment of malformations of the heart in which there is pulmonary stenosis or pulmonary atresia JAMA 1945;128:189.[Abstract/Free Full Text]
- LeBlanc J, Albus R, Williams WG, et al. Serous fluid leakage: a complication following the modified Blalock-Taussig shunt J Thorac Cardiovasc Surg 1984;88:259-262.[Abstract]
- Noyez L, Daenen W. The modified polytetrafluoroethylene Blalock-Taussig shunt: case report of an unusual complication J Thorac Cardiovasc Surg 1987;94:634-635.[Abstract]
- Hiramatsu Y, Atsumi N, Sasaki A, Mitsui T. A successful treatment of serous leakage from a polytetrafluoroethylene Blalock-Taussig shunt with intravenous fibrinogen administration J Thorac Cardiovasc Surg 1999;117:1230-1231.[Free Full Text]
- Rossbach M, Beard J. Vascular grafts, sutures and anastomosesIn: Beard J, Gaines P, editors. A companion to specialist surgical practice: vascular and endovascular surgery. 2nd ed.. London: WB Saunders; 2001. pp. 377-383.
- Schenk 3rd WG, Spotnitz WD, Burks SG, Lin PH, Bush RL, Lumsden AB. Absorbable cyanoacrylate as a vascular hemostatic sealant: a preliminary trial Am Surg 2005;71:658-661.[Medline]
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Abstract
Introduction
