ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Ann Thorac Surg 2009;87:1154-1160. doi:10.1016/j.athoracsur.2008.12.072
© 2009 The Society of Thoracic Surgeons
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
T. Sloane Guy
Elaine E. Tseng
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Azadani, A. N.
Right arrow Articles by Tseng, E. E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Azadani, A. N.
Right arrow Articles by Tseng, E. E.
Related Collections
Right arrow Great vessels
Right arrowRelated Article

Original Articles: Adult Cardiac

Mechanical Properties of Surgical Glues Used in Aortic Root Replacement

Ali N. Azadani, PhD, Peter B. Matthews, BS, Liang Ge, PhD, Ye Shen, BS, Choon-Sik Jhun, PhD, T. Sloane Guy, MD, Elaine E. Tseng, MD*

Department of Surgery, University of California at San Francisco Medical Center (UCSF) and San Francisco Veterans Affairs Medical Center (SFVAMC), San Francisco, California

Accepted for publication December 22, 2008.

* Address correspondence to Dr Tseng, Division of Cardiothoracic Surgery, UCSF Medical Center, 500 Parnassus Ave, Suite 405W, Box 0118, San Francisco, CA 94143-0118 (Email: elaine.tseng{at}ucsfmedctr.org).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 
Background: Surgical glues are used in mechanical, stentless bioprosthetic, and homograft aortic root replacements to seal and reinforce anastomotic suture lines. The aortic root normally undergoes substantial physiologic dilation and may be affected by the stiffness of applied sealants. We determined the material properties of four common commercial glues, comparing them with known properties of aortic root replacements.

Methods: Samples of BioGlue (CryoLife, Inc, Kennesaw, GA), CoSeal (Baxter Healthcare International, Palo Alto, CA), Tisseel (Baxter Healthcare Corp, Glendale, CA), and Crosseal (OMRIX Biopharmaceuticals, Inc, New York, NY) sealants underwent biaxial tensile testing. A Hookean strain energy function was fit to the stress-strain response of each sample, and the Young's modulus was obtained for comparison of material stiffness.

Results: Sealants demonstrate a relatively linear response to loading; mean elastic moduli for BioGlue (3,122.04 ± 1,639.68 kPa), CoSeal (100.02 ± 67.60 kPa), Tisseel (102.59 ± 41.13 kPa), and Crosseal (53.56 ± 32.59 kPa) varied greatly. CoSeal and Tisseel have no significant difference in stiffness (p = 0.897) while Crosseal is more compliant than Tisseel (p = 0.004) and CoSeal (p = 0.055). BioGlue is stiffer than CoSeal, Tisseel, and Crosseal (p < 0.001). Furthermore, BioGlue is much stiffer than cited properties of Dacron grafts, glutaraldehyde-fixed porcine roots, and human aortic tissue. However, CoSeal and Tisseel are much more compliant than the aortic root conduits.

Conclusions: BioGlue is much less compliant than the other sealants studied and materials available for aortic root replacement. A surgeon's choice of glue should be determined by stiffness as well as sealant efficacy. Sealants with greater stiffness than aortic root replacement material may restrict normal physiologic dilation and cause anastomotic strictures.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 Acknowledgments
 References
 
Surgical glues are used to seal suture lines for hemostasis and to strengthen and reinforce fragile tissues by tissue adherence. The use of surgical glues has been promoted to enhance coagulation and to create a mechanical barrier at the site of bleeding [1]. Based on their composition, surgical adhesives and hemostats can be categorized into fibrin sealants, cyanoacrylates, bovine collagen and thrombin, polyethylene glycol polymers, and albumin cross-linked with glutaraldehyde [2]. Four common commercial glues utilized in cardiovascular surgery are Tisseel (Baxter Healthcare Corp, Glendale, CA), Crosseal (OMRIX Biopharmaceuticals Inc, New York, NY), CoSeal (Baxter Healthcare International, Palo Alto, CA), and BioGlue (CryoLife Inc, Kennesaw, GA).

Tisseel and Crosseal are fibrin sealants formed from concentrated fibrinogen and thrombin, whose biochemical reaction has been well-delineated [3]. They differ in their purification process and constituent antifibrinolytic agents [4]. Contrary to fibrin sealants, CoSeal and BioGlue are independent of the coagulation cascade and use cross-linking agents to covalently bind to tissue surfaces. Adhesion is based on the presence of a matrix and a cross-linking agent. The matrix is an inert synthetic polymer or a protein that subsequently becomes functionalized. CoSeal is a completely synthetic sealing agent consisting of two different tetrafunctional polyethylene glycol macromers, while BioGlue is a biologic protein matrix, consisting of 10% glutaraldehyde and a 45% bovine serum albumin solution [5, 6].

Although studies have evaluated adhesives with respect to hemostatic efficacy, biocompatibility, and safety, few have studied the mechanical properties of surgical glues [7, 8]. Mechanical properties play a significant role in cardiovascular applications when the sealant is subjected to cyclic loads, such as on the ventricle or arterial tree. When several materials work together they absorb the loads to which the structure is subjected. Each material differentially absorbs load based on its mechanical behavior, resulting in different internal stresses and deformations for each material. A mismatch of mechanical properties may result in shearing effects produced every cycle and generate excess stresses in the tissue. The goal of this study was to determine the mechanical properties of four common commercial glues utilized in cardiovascular surgery (Tisseel, Crosseal, CoSeal, and BioGlue) and compare the results to known properties of aortic root replacements.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 Acknowledgments
 References
 
Planar Biaxial Testing System
Samples of Tisseel (n = 12), Crosseal (n = 6), CoSeal (n = 10), and BioGlue (n = 12) were prepared according to the manufacturer's recommendations for surgical applications (Table 1). Glue was ejected onto a nonstick surface, and the largest sample of uniform thickness was cut into a square for testing at room temperature. A custom built planar biaxial stretcher was used to determine mechanical properties of the surgical glues (Fig 1). Details of the biaxial tensile testing methods and analyses have been previously described [9]. Briefly, three 5-0 silk sutures were anchored to each edge of the specimen using small, barbless fishhooks and they were attached to four linear arms of the stretcher. Five black ceramic markers (250 to 355 µm; MO-SCI Corp, Rolla, MO) were manually placed on the glue surface by visual inspection, creating a 3 mm x 3 mm grid in the center of the specimen (Fig 2). Load cells (1,000 gm; ± 0.1%, model 31/3672-02; Honeywell Sensotec Inc, Columbus, OH), located on two orthogonal arms, were zeroed and monitored while mounting the sample to ensure that a measurement of zero force corresponded to the resting specimen length. During extension, data from the load cells were amplified (0.01 V, model 13-4615-58, Gould 6 Universal Amplifier; Gould, Inc, Valley View, OH) and used to determine force on the sample.


View this table:
[in this window]
[in a new window]

  		Table 1 Dimension and Thickness of the Glue Samples
 

Figure 1
View larger version (20K):
[in this window]
[in a new window]

  		Fig 1. Custom built biaxial stretcher used in the experiments.

 

Figure 2
View larger version (107K):
[in this window]
[in a new window]

  		Fig 2. Image captured of a Tisseel sample at the zero strain state.

 
Real-time displacements of the marker beads on the surface were obtained using a noncontacting CCD camera placed over the sample surface (30 fps, model TM 9701; 0.1 pixels/mm; Pulnix Inc, Sunnyvale, CA). Images of the glue surface during deformation were digitized in MATLAB (v 7.0; The Mathworks, Natick, MA), and the markers were located based on their contrast to the surrounding surface. Coordinates of each marker were tracked through the loading cycle and their movement was used to calculate strain, a dimensionless measure of the magnitude of deformation relative to the original size, in the principle and shear directions.

Both BioGlue and CoSeal were applied as liquids that polymerize rapidly to hydrogel, which has high water content and readily releases water. The human body in general is a form of hydrogel, with an average water content of 70%. These two products will remain flexible and pliable while hydrated inside the human body. However, if they are left exposed to the environment (air) for a long period they will desiccate and harden, resulting in breakdown [10]. Therefore, all of the glue samples were kept hydrated and soaked in normal saline while in the stretcher.

Data Collection and Analysis
Samples were tested using equibiaxial displacement controlled protocols; encoders located at the end of each linear arm of the stretcher recorded arm movement to ensure equal and simultaneous deformation. The same experimental protocol in the same order was repeated for each specimen. Specimens were stretched equibiaxially to a maximum strain of 10%. Glue samples that did not tear during the stretching protocol were analyzed: n = 8, Tisseel; n = 5, Crosseal; n = 8, CoSeal; n = 6, BioGlue. Analysis of stress, the average amount of force exerted per unit area, and strain assumes material incompressibility. The deformation gradient (F) was calculated for each recorded point of the loading cycle. The five markers within the strain region formed four nonoverlapping triangles (Fig 1). Green strain was calculated for each triangle independently to assess homogeneity of deformation and the data from the four triangles were subsequently averaged. Components of Green strain in the two directions were calculated using the following equations:


Formula 1A

(1a)


Formula 1B

(1b)
where {lambda}x and {lambda}y ({lambda}i = L i/L i0, i = x, y) are stretches in the x and y directions (Fig 1). Planar forces (fx, fy) during deformation were converted to Cauchy stresses in the principal directions and given by


Formula 2A

(2a)


Formula 2B

(2b)
where t is tissue thickness, whereas Lx and Ly are the length and the width of the samples in the x and y directions, respectively.

The stiffness of a material is its overall resistance to deformation under an applied load. This reflects the mechanical properties of the material as well as its shape, size, and loading conditions. In order to compare surgical glues we chose to evaluate the modulus of elasticity, or Young's modulus, a mathematic description of the material's tendency to deform when a force is applied. This measurement is defined as the slope of the stress-strain curve. The modulus of elasticity provides a normalized comparison of the four types of glue, accounting for variation in the size and thickness of individual samples. Stress-strain data were fit to a linear Hookean function, and Young's modulus was determined to reflect stiffness of the glues. One way analysis of variance was performed to test for differences between surgical glues. Reported values are quoted as mean ± standard deviation and statistical analyses were performed using MATLAB (v 7.0).

Material Properties of Aortic Root Replacement Conduits
Mechanical properties of Dacron grafts, glutaraldehyde-fixed porcine roots, and human aortic homografts have been obtained from literature. Mechanical properties of unused, woven, double-velour vascular graft (Boston Scientific, Medi-tech division, Natick, MA) was determined using a biaxial tensile system [11]. Stress-strain relationships in the circumferential and axial direction up to 30% strain were obtained. Comparison with our data was conducted using the maximum stiffness of Dacron samples by the largest slope of the stress-strain diagram. Zhou and colleagues [12] investigated mechanical properties of porcine roots fixed with 0.625% glutaraldehyde using ring specimens. A mathematical model for a flexible circular ring was used to determine the mean Young's modulus, which was used as comparison with our data. With regard to the human ascending aorta, Choudhury and colleagues [13] used a biaxial tensile tester system to evaluate the mechanical properties of the tissue. The average stress-strain curves demonstrated a nonlinear viscoelastic response and reported stiffness in both low and high stress regions; the high stress stiffness was used for comparison with our data.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 Acknowledgments
 References
 
The stress-strain data obtained from Tisseel samples are shown in Figure 3a. Data were fit to a linear Hookean function and a mean elastic modulus of 102.59 ± 41.13 KPa was obtained. The other studied fibrin sealant, Crosseal, also demonstrates a relatively linear behavior to loading, but it is significantly more compliant than Tisseel and has a mean modulus of elasticity of 53.56 ± 32.59 KPa (p= 0.004) (Fig 3b). In contrast to the fibrin sealants, Figure 3c shows the stress-strain data obtained from the cross-linking samples, CoSeal. The linear fit to the raw data has a slope of 100.02 ± 67.60 KPa, which indicates CoSeal is as compliant as Tisseel (p = 0.897).


Figure 3
View larger version (26K):
[in this window]
[in a new window]

  		Fig 3. Equibiaxial stretch data from the glue samples. (a) Tisseel samples (n = 8), (b) Crosseal samples (n = 5), (c) CoSeal samples (n = 8), and (d) BioGlue samples (n = 6). Stress-strain data are collected in two axes for each sample; each shape represents the data collected from one sample in the two directions.

 
On the other hand, BioGlue, another cross-linking agent, has a significantly stiffer response to loading than all the other glues (p < 0.001). The mean Young's modulus of BioGlue obtained was 3,122.04 ± 1,639.68 KPa, which is almost 60 times greater than Crosseal and 30 times greater than Tisseel and CoSeal (Fig 3d). Due to its high stiffness, BioGlue samples were only stretched up to 5% deformation. In some cases, particularly for BioGlue, attempts to stretch samples more than 5% failed due to tearing at the hook sites. Data from successful trials were averaged, and the mean Young's modulus was used to compare the four glues (Fig 4).


Figure 4
View larger version (14K):
[in this window]
[in a new window]

  		Fig 4. Comparison of the mean modulus of elasticity of the surgical glues.

 
Current literature indicates that the maximum stiffness of unused Dacron graft is 1,100 KPa in the circumferential and 500 KPa in the axial direction, stiffer than Tisseel, Crosseal, and CoSeal, but less stiff than BioGlue [11]. Glutaraldehyde-fixed porcine roots have a reported mean Young's modulus of 1,320 KPa in the circumferential direction, similarly stiffer than all glues except BioGlue [12]. The modulus of elasticity of human aortic tissue is larger in the circumferential direction than the axial direction. The high-stress elastic modulus in the circumferential direction was reported as 450 KPa, much more compliant than Dacron or fixed porcine tissue [13]. Overall Tisseel, Crosseal, and CoSeal are more compliant than any of the aortic root replacement materials. However, BioGlue is significantly stiffer than the other surgical glues as well as the aortic root conduits.


   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
Acknowledgments
 References
 
Mechanical properties play a significant role in the effectiveness of surgical glues and a surgeon's choice of glue should be determined by stiffness as well as other factors [3]. A mismatch between the mechanical properties of surgical glues and the adjacent materials could result in excess stress in the tissue, particularly in high pressure arterial vessels undergoing repetitive cyclic loads. In this paper we demonstrated that all the studied glues have a linear elastic response to tensile stress. BioGlue is significantly stiffer than Tisseel, CoSeal, and Crosseal. Furthermore, Tisseel and CoSeal had a similar stiffness and Crosseal was more compliant than Tisseel. Crosseal was also more compliant than CoSeal, though not statistically significant. In comparison with the mechanical properties of aortic root replacement materials, BioGlue is a much stiffer material. On the other hand, Tisseel, CoSeal, and Crosseal are over an order of magnitude more compliant than Dacron grafts and fixed porcine roots, and approximately 4 to 9 times more compliant than human homografts.

Hemostatic Efficacy
Surgical glues are commonly used as standard adjuncts in cardiovascular surgery. Substantial evidence has shown that adhesives have a positive impact on surgical results by shortening operative time and reducing perioperative bleeding [14–16]. Selection of a particular glue depends on hemostatic efficacy, availability, cost, ease of use and preparation, tissue cellular response, effects on wound healing, and likelihood of transmission of blood-borne diseases [17]. Tisseel and Crosseal are fibrin agents utilized to seal vascular anastomoses in both arterial and venous blood vessels. CoSeal is used in vascular reconstructions to achieve adjunctive hemostasis by mechanically sealing areas of leakage, especially suture lines. BioGlue is utilized as an adjunct to standard methods to achieve hemostasis in adult patients in open surgical repairs of large vessels. Applications of BioGlue in cardiovascular surgery include acute type A dissections, aortic root reconstruction, and left ventricular apical cannulation [18].

The adhesive strength of the four surgical glues has not been studied specifically in aortic root replacement. However, Cortes and colleagues [19] studied adhesive strength of the surgical glues using ex vivo human fetal membranes. Tisseel, CoSeal, and BioGlue were placed on punctured fetal membranes fastened to a pressure-controlled pump. Leak pressure of the membrane was measured and compared with a two-layer membrane system without sealant as control. Tisseel provided some sealing capabilities compared with control (46 ± 10 vs 27 ± 3 cm H2O). However, CoSeal and BioGlue achieved statistically significant higher average leak pressures compared with controls (CoSeal, 85 ± 11 cm H2O; and BioGlue, 78 ± 9 cm H2O; p < 0.05 for both). The leak pressures obtained suggested an inherent weak adhesive strength of fibrin glues, but a high adherence of CoSeal and BioGlue.

Clinical effectiveness of BioGlue as a surgical adjunct in cardiac and vascular surgical repairs was evaluated in a prospective, multicenter, randomized, controlled trial involving 151 patients [20]. Patients were randomized to receive standard surgical repair with BioGlue applied to the anastomotic site prior to clamp removal or standard surgical anastomotic repair alone, including use of pledgets, make-up stitches, hemostatic devices, thrombin glues, fibrin glues, and antifibrinolytic agents. Surgical procedures in this trial included cardiac, aortic, and peripheral vascular operations. Immediate anastomotic hemostasis was found to be superior with BioGlue compared with standard surgery controls (81% vs 57%; p < 0.003). Overall, BioGlue demonstrates hemostatic efficacy and adhesive strength, but is significantly stiffer than other glues and aortic root conduits.

In another study [21], hemostatic efficacy of CoSeal was examined in a prospective, randomized, controlled multicenter trial with 148 patients. Half of the patients were treated with CoSeal and the other half with a control of absorbable gelatin sponge and thrombin hemostat. The most common surgical procedures involved were infrainguinal revascularization and dialysis access shunts. Overall, subjects treated with CoSeal achieved immediate sealing at more than twice the rate of subjects treated with Gelfoam (Pharmacia & Upjohn Company. Division of Pfizer Inc, NY, NY)/thrombin (47% vs 20%; p < 0.001). Unlike BioGlue, CoSeal not only demonstrates hemostatic efficacy and adhesive strength but also is much more compliant than aortic root replacement materials.

BioGlue-Associated Complications
Sealants with greater stiffness than aortic root replacement materials may restrict normal physiologic dilation and cause anastomotic strictures [22]. In a study applying BioGlue to aortic anastomoses in 4-week-old piglets [22], BioGlue animals developed a 34% stenosis of aortic lumen area after 7 weeks of growth. Given the hemostatic efficacy and adhesive properties of BioGlue, the amount of glue applied should be minimized while achieving adequate results. BioGlue is commonly used in acute type A aortic dissections to reinforce the sinus segment and obliterate the false lumen [23]. Use of BioGlue in the aortic sinus significantly stiffens the repaired aortic root and alters wall stresses within the sinuses, which may have secondary effects on the leaflet stresses and durability [24].

Fibrin sealants have also been described for reconstruction of the aortic sinus in acute type A aortic dissection [25–28]. Because fibrin sealants and human aortic tissue have comparable stiffness, use of fibrin sealants instead of BioGlue may not restrict the normal physiologic dilation. However, fibrin glue alone may yield low adhesive strength. Due to this concern, an alternative method was proposed to reinforce the dissected aorta using fibrin glue and a neomedia fabric sheet [25]. The effect of fibrin glue and neomedia fabric on the composite material property of the dissected aortic root is unknown. Low early and late mortality, as well as low reoperation rate, has been reported for this technique [26].

BioGlue has also been associated with pseudoaneurysm development [20, 29]. When large quantities of BioGlue have been used, the surrounding tissue has been noted to be soft and friable [30]. Histology revealed retardation of normal healing, a local inflammatory process, and occasionally necrosis up to 2 years of BioGlue application [30]. BioGlue toxicity has been implicated in these changes in structural integrity [31]. However, the high stiffness of BioGlue as demonstrated in this study may result in an elevated wall stress, which could additionally weaken the tissue and predispose to late pseudoaneurysm formation.

Biodegradability
Biodegradability is critical to the long-term effects of surgical glues. Tisseel and Crosseal are biodegradable and adsorb in the body between 3 and 4 weeks after usage [32]. Long-term effects of fibrin sealants and their metabolites are minimal and there are no recent reports of significant fibrosis or tissue reaction using these materials. BioGlue and CoSeal are also both degradable after implantation; however, their degradation rates and mechanisms are different. CoSeal is resorbed by hydrolysis and reportedly degraded within less than 30 days of implantation. It could not be discerned grossly or histologically at 30 days [33]. However, BioGlue is resorbed slowly in the body by proteolysis and histologically the material was detectable after 1 year in a goat model [34]. For aortic root replacements, enhanced biodegradability would be considered a favorable aspect for surgical glues.

Study Limitations
Mechanical properties of aortic root replacement materials were not directly assessed in our experimental system. Instead, cited values of stiffness of Dacron grafts, glutaraldehyde-fixed porcine roots, and human aortic tissue were used for comparison [11–13]. Because the Young's modulus was used to reflect material stiffness, a comparison between the cited values and our results is valid.

We report a large standard deviation in the mean modulus of elasticity, indicating considerable variability in glue stiffness. This finding is mainly due to an inability to completely remove air traps in the samples during preparation. Although significant care was taken to avoid air trapping, this inhomogeneity is certainly present during surgical application as well. Therefore, the data reflect the variability of mechanical properties seen clinically. Air bubbles may result in an anisotropic behavior of the glue samples and lower the stiffness and bonding capabilities of the adhesives.

Conclusions and Future Research
A surgeon's choice of glue should be determined by stiffness in addition to other factors. We demonstrated that all the studied glues have a linear elastic response to tensile stress. BioGlue is significantly stiffer than CoSeal and the fibrin sealants. Furthermore, BioGlue is a much stiffer material than aortic root replacement conduits. Unlike BioGlue, CoSeal and Tisseel have similar elastic moduli, are more compliant than human aortic homografts, and are significantly more compliant than the fixed porcine roots and Dacron grafts.

Use of surgical glues as a substitute for sutures in aortic root replacements requires long-term stability and is not yet advocated. Properties required by appropriate glues for applications of sutureless anastomoses include adequate tensile strength and mechanical stability over time. The current bonding strength of available glues is likely not sufficient. However, the elastic behavior of surgical glues is in harmony with that of soft tissue and encourages further research to provide greater elasticity, not present in sutured tissue.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
References
 
This work was supported by the American Heart Association Beginning Grant-in-Aid 0565148Y and the Northern California Institute for Research and Education. We gratefully acknowledge the technical assistance of Namrata Gundiah.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Spotnitz WD, Burks S. Hemostats, sealants, and adhesives: components of the surgical toolbox Transfusion 2008;48:1502-1516.[Medline]
  2. Spotnitz WD. Surgical tissue adhesives: new additions to the surgical armamentarium J Long Term Eff Med Implants 2003;13:385-387.[Medline]
  3. Sierra DH. Fibrin sealant adhesive systems: a review of their chemistry, material properties and clinical applications J Biomater Appl 1993;7:309-352.[Abstract/Free Full Text]
  4. Pipan CM, Glasheen WP, Matthew TL, et al. Effects of antifibrinolytic agents on the life span of fibrin sealant J Surg Res 1992;53:402-407.[Medline]
  5. Wallace DG, Cruise GM, Rhee WM, et al. A tissue sealant based on reactive multifunctional polyethylene glycol J Biomed Mater Res 2001;58:545-555.[Medline]
  6. Chao HH, Torchiana DF. BioGlue: albumin/glutaraldehyde sealant in cardiac surgery J Card Surg 2003;18:500-503.[Medline]
  7. Berchane NS, Andrews MJ, Kerr S, Slater NK, Jebrail FF. On the mechanical properties of bovine serum albumin (BSA) adhesives J Mater Sci Mater Med 2008;19:1831-1838.[Medline]
  8. García Páez JM, Jorge Herrero E, Rocha A, et al. Comparative study of the mechanical behaviour of a cyanoacrylate and a bioadhesive J Mater Sci Mater Med 2004;15:109-115.[Medline]
  9. Gundiah N, Kam K, Matthews PB, et al. Asymmetric mechanical properties of porcine aortic sinuses Ann Thorac Surg 2008;85:1631-1638.[Abstract/Free Full Text]
  10. Sen A, Green KM, Khan MI, Saeed SR, Ramsden RT. Cerebrospinal fluid leak rate after the use of BioGlue in translabyrinthine vestibular schwannoma surgery: a prospective study Otol Neurotol 2006;27:102-105.[Medline]
  11. Nagano N, Cartier R, Zigras T, Mongrain R, Leask RL. Mechanical properties and microscopic findings of a Dacron graft explanted 27 years after coarctation repair J Thorac Cardiovasc Surg 2007;134:1577-1578.[Free Full Text]
  12. Zhou J, Quintero LJ, Helmus MN, Lee C, Kafesjian R. Porcine aortic wall flexibility. Fresh vs Denacol fixed vs glutaraldehyde fixed. ASAIO J 1997;43:M470-M475.[Medline]
  13. Choudhury N, Bouchot O, Rouleau L, et al. Local mechanical and structural properties of healthy and diseased human ascending aorta tissue Cardiovasc Pathol 2008Mar 3 [Epub ahead of print].
  14. Fink D, Klein JJ, Kang H, Ergin MA. Application of biological glue in repair of intracardiac structural defects Ann Thorac Surg 2004;77:506-511.[Abstract/Free Full Text]
  15. Kjaergard HK, Fairbrother JE. Controlled clinical studies of fibrin sealant in cardiothoracic surgery–a review Eur J Cardiothorac Surg 1996;10:727-733.[Abstract/Free Full Text]
  16. Raanani E, Latter DA, Errett LE, Bonneau DB, Leclerc Y, Salasidis GC. Use of "BioGlue" in aortic surgical repair Ann Thorac Surg 2001;72:638-640.[Abstract/Free Full Text]
  17. Basu S, Marini CP, Bauman FG, et al. Comparative study of biological glues: cryoprecipitate glue, two-component fibrin sealant, and "French" glue Ann Thorac Surg 1995;60:1255-1262.[Abstract/Free Full Text]
  18. Zehr KJ. Use of bovine albumin-glutaraldehyde glue in cardiovascular surgery Ann Thorac Surg 2007;84:1048-1052.[Abstract/Free Full Text]
  19. Cortes RA, Wagner AJ, Lee H, et al. Pre-emptive placement of a presealant for amniotic access Am J Obstet Gynecol 2005;193(3 Pt 2):1197-1203.[Medline]
  20. Coselli JS, Bavaria JE, Fehrenbacher J, Stowe CL, Macheers SK, Gundry SR. Prospective randomized study of a protein-based tissue adhesive used as a hemostatic and structural adjunct in cardiac and vascular anastomotic repair procedures J Am Coll Surg 2003;197:243-253.[Medline]
  21. Glickman M, Gheissari A, Money S, Martin J, Ballard JL, CoSeal Multicenter Vascular Surgery Study Group A polymeric sealant inhibits anastomotic suture hole bleeding more rapidly than gelfoam/thrombin: results of a randomized controlled trial Arch Surg 2002;137:326-332.[Medline]
  22. LeMaire SA, Schmittling ZC, Coselli JS, et al. BioGlue surgical adhesive impairs aortic growth and causes anastomotic strictures Ann Thorac Surg 2002;73:1500-1506.[Abstract/Free Full Text]
  23. Bavaria JE, Brinster DR, Gorman RC, Woo YJ, Gleason T, Pochettino A. Advances in the treatment of acute type A dissection: an integrated approach Ann Thorac Surg 2002;74:S1848-S1863.[Abstract/Free Full Text]
  24. Robicsek F, Thubrikar MJ, Fokin AA. Cause of degenerative disease of the trileaflet aortic valve: review of subject and presentation of a new theory Ann Thorac Surg 2002;73:1346-1354.[Abstract/Free Full Text]
  25. Nakajima T, Kawazoe K, Izumoto H, Kataoka T, Kazui T. Effective use of fibrin glue for acute aortic dissection Ann Thorac Surg 2005;79:1793-1794.[Abstract/Free Full Text]
  26. Nakajima T, Kawazoe K, Kataoka T, et al. Midterm results of aortic repair using a fabric neomedia and fibrin glue for type A acute aortic dissection Ann Thorac Surg 2007;83:1615-1620.[Abstract/Free Full Text]
  27. Séguin JR, Picard E, Frapier JM, Chaptal PA. Aortic valve repair with fibrin glue for type A acute aortic dissection Ann Thorac Surg 1994;58:304-307.[Abstract/Free Full Text]
  28. Séguin JR, Picard E, Frapier JM, Chaptal PA. Repair of the aortic arch with fibrin glue in type A aortic dissection J Card Surg 1994;9:734-739.[Medline]
  29. Kazui T, Washiyama N, Bashar AH, et al. Role of biologic glue repair of proximal aortic dissection in the development of early and midterm redissection of the aortic root Ann Thorac Surg 2001;72:509-514.[Abstract/Free Full Text]
  30. Ngaage DL, Edwards WD, Bell MR, Sundt TM. A cautionary note regarding long-term sequelae of biologic glue J Thorac Cardiovasc Surg 2005;129:937-938.[Free Full Text]
  31. Fürst W, Banerjee A. Release of glutaraldehyde from an albumin-glutaraldehyde tissue adhesive causes significant in vitro and in vivo toxicity Ann Thorac Surg 2005;79:1522-1529.[Abstract/Free Full Text]
  32. Spotnitz WD. Commercial fibrin sealants in surgical care Am J Surg 2001;182(suppl 2):8S-14S.[Medline]
  33. Hill A, Estridge TD, Maroney M, et al. Treatment of suture line bleeding with a novel synthetic surgical sealant in a canine iliac PTFE graft model J Biomed Mater Res 2001;58:308-312.[Medline]
  34. Gundry SR, Black K, Izutani H. Sutureless coronary artery bypass with biologic glued anastomoses: preliminary in vivo and in vitro results J Thorac Cardiovasc Surg 2000;120:473-477.[Abstract/Free Full Text]

Related Article

Invited Commentary
Scott A. LeMaire
Ann. Thorac. Surg. 2009 87: 1160. [Extract] [Full Text] [PDF]



This article has been cited by other articles:


Home page
 J. Clin. Pathol.Home page
A. Luk, T. E. David, and J. Butany
Complications of Bioglue postsurgery for aortic dissections and aortic valve replacement
J. Clin. Pathol., November 1, 2012; 65(11): 1008 - 1012.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
T. B. Pedersen, J. L. Honge, H. K. Pilegaard, and J. M. Hasenkam
Comparative Study of Lung Sealants in a Porcine Ex Vivo Model
Ann. Thorac. Surg., July 1, 2012; 94(1): 234 - 240.
[Abstract] [Full Text] [PDF]

Home page
 CLIN APPL THROMB HEMOSTHome page
W. D. Spotnitz and S. Burks
State-of-the-Art Review: Hemostats, Sealants, and Adhesives II: Update As Well As How and When to Use the Components of the Surgical Toolbox
Clinical and Applied Thrombosis/Hemostasis, October 1, 2010; 16(5): 497 - 514.
[Abstract] [PDF]

Home page
 Ann. Thorac. Surg.Home page
S. A. LeMaire
Invited Commentary
Ann. Thorac. Surg., April 1, 2009; 87(4): 1160 - 1160.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
T. Sloane Guy
Elaine E. Tseng
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Azadani, A. N.
Right arrow Articles by Tseng, E. E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Azadani, A. N.
Right arrow Articles by Tseng, E. E.
Related Collections
Right arrow Great vessels
Right arrowRelated Article

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS