| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Baylor College of Medicine and The Texas Heart Institute at St. Luke's Episcopal Hospital, One Baylor Plaza, BCM 390, Houston, TX 77030
(Email: slemaire{at}bcm.edu).
During the past decade, there has been a substantial increase in the number of surgical adhesives and sealants available for use in cardiovascular operations. As new products and new information about benefits and risks become available, surgeons constantly need to adjust their algorithms for deciding when to use each agent. Key considerations in these algorithms include the agent's effectiveness, safety, and cost. In this report, Azadani and colleagues [1] describe important quantitative differences in the stiffness and elasticity of several adhesives and sealants, and the authors make the case that the mechanical properties of a product should also be considered when adhesives and sealants are selected.
Although the authors have chosen to discuss their results in the context of aortic root replacement, their findings have implications for many types of cardiovascular and thoracic operations. Both Tisseel (Baxter, Deerfield, IL) and BioGlue (CryoLife Inc, Kennesaw, GA) are widely used in aortic dissection repair to glue the inner dissecting membrane to the outer aortic wall, thereby obliterating the false lumen. This technique, which effectively sandwiches the adhesive between layers of aortic tissue, can profoundly alter the mechanical properties of the aorta. These agents are marketed for use not only in aortic repairs but also in peripheral vascular, pulmonary, and esophageal procedures; in all of these areas, a mismatch between adhesive and tissue compliance can lead to complications. For example, sealants and adhesives are used on the surface of the lung to reduce postoperative air leaks, but if an agent is unable to expand and contract with the lung throughout the respiratory cycle, it is unlikely to maintain an effective seal.
The authors' objective findings about the differing mechanical properties of these agents corroborate the subjective differences observed by surgeons who have used them. Of particular concern are the findings that the stiffness of BioGlue was at least 30 times greater than that of the other products tested, and its elasticity was significantly less than that of aortic tissue or commonly used aortic replacement conduits. In considering the clinical implications of their findings, the authors suggest that, "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."
Several reports have described pseudoaneurysms and redissections that occurred after BioGlue was used for ascending aortic repair. Ngaage and colleagues [2], for example, recently reported nearly circumferential disruption of both the proximal and distal anastomoses after ascending aortic dissection repair. Although the role of the glue in the anastomotic failure was primarily attributed to the intense local inflammatory process the glue caused, the strain placed on the anastomosis as the relatively compliant aortic wall and prosthetic graft pulsated against a noncompliant ring of adhesive may also have been a factor.
Although adhesives and sealants can be extremely useful tools in the surgical armamentarium, Weissberg's words of caution remain salient: "Tissue adhesives are not innocuous when applied to the arterial wall. This ... mitigates against [their] indiscriminate use" [3]. By examining the mechanical limitations of existing products and discussing their potential clinical implications, Azadani and colleagues remind us of the importance of ongoing efforts to develop better surgical adhesives and sealants.
 |
References |
|---|
 Top References |
|---|
Related 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 |
