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Ann Thorac Surg 2000;69:1768
© 2000 The Society of Thoracic Surgeons

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Invited commentary

Invited commentary

^a Department of Cardiovascular Surgery, University Hospital Berne,, CH-3010 Berne, Switzerland

e-mail: thierry.carrel{at}insel.ch

One of the main technical difficulties encountered during repair of aortic dissection consists in construction of satisfactory anastomoses between the delicate injured aortic wall and the prosthetic graft. After many technical modifications (eg, using external or internal wall reinforcement or sutureless prosthetic replacement), refixation of the dissected aortic layers with gelatin-resorcin-formalin—the so-called "biologic glue"—has been widely accepted as a most reliable, expedient method achieving increased tissue solidity and improving hemostasis while the blood flow is restituted into the true lumen, at least at the level of the distal anastomosis.

Bingley and colleagues report on a series of complications observed in patients in whom different tissue adhesives have been used—mainly during aortic repair. The objective of this article is obviously to draw the attention of the surgical community on those complications and to warn the readership about the hazardous use of those adjuncts. For many reasons, the article itself and the arguments supporting the authors’ opinion are indeed largely opened to criticism.

1. The authors infer that the complications observed in different groups of patients were related to these adhesive adjuncts and that there is a direct causative link: this represent a subjective opinion not supported by any evidence.
   
2. Late reoperation for aortic valve regurgitation in patients having had valve resuspension during surgery for acute aortic dissection is a commonly observed situation whatever technique is used. The data reported in the present article are similar to those found in the literature with or without the use of adhesive adjuncts.
   
3. The authors hold the glues responsible for complications that might have occurred due to the misuse of the product rather than the product itself. This is obvious at least in the 3 pediatric patients and in those adult patients who received composite graft or homograft repair because of annulo-aortic ectasia or aortic root abscess.
   
4. The use of the GRF glue has never been proposed to enhance topical hemostasis—like in the arterial switch procedure—where only fibrin sealant is recommended.
   

Several authors who have described the properties of GRF glue suggested that its use also provided long term aortic wall stability [1,2] without adverse effects. However, early mortality following repair of aortic dissection has not significantly changed whether or not the glue was used. Furthermore, long-term results suggest that the use of GRF glue does not have any impact on the incidence of reoperation but a increased risk of proximal redissection was observed [3]

To obtain the best possible effect on tissue consistency, the adhesive—inclusive the activator—should be healed to 40°C. The glue is then injected between the dissected layers, with special care directed to not contaminate the LV cavity, the aortic valve leaflets and the coronary ostia. The activator is then added—a few drops only—to the glue using a cannula tipped syringe. Thereafter the layers of the aorta should be compressed together to improve the polymerization process.

Several precautions have been recommended when biologic GRF-glue has been used because beside toxicity of formalin, glue may escape into the true channel during the sealing process through one or several small re-entries located just distally to the anastomosis or secondary mobilization of glue particles may occur through the stitch channels, especially if the aortic lumen is not completely controlled during the sealing process or when the letter is performed in a wet surgical field [4].

In conclusion, GRF glue has demonstrated efficacy during repair of aortic dissection only. Neglecting this unique indication will unnecessarily lead to the harmful sequelae demonstrated in the present article.

References

1. Laas J., Jurmann M., Heinemann M., Borst H.G. Advances in aortic surgery. Ann Thorac Surg 1992;53:227-232.[Abstract]
2. Westaby S., Katsumata T., Freitas E. Aortic valve conservation in acute type A dissection. Ann Thorac Surg 1997;64:1108-1112.[Abstract/Free Full Text]
3. Fukunaga S., Karck M., Harringer W., Cremer J., Rhein C., Haverich A. The use of gelatin-resorcin-formalin glue in acute aortic dissection type A. Eur J Cardiothorac Surg 1999;15:564-570.[Abstract/Free Full Text]
4. Carrel T., Maurer M., Tkebuchava T., et al. Embolization of biologic glue during repair of aortic dissection. Ann Thorac Surg 1995;60:1118-1120.[Abstract/Free Full Text]

This article has been cited by other articles:

				S. A. LeMaire, S. A. Carter, T. Won, X. Wang, L. D. Conklin, and J. S. Coselli The Threat of Adhesive Embolization: BioGlue Leaks Through Needle Holes in Aortic Tissue and Prosthetic Grafts Ann. Thorac. Surg., July 1, 2005; 80(1): 106 - 111. [Abstract] [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Thierry P. Carrel Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Carrel, T. P. Search for Related Content PubMed Articles by Carrel, T. P. Related Collections Related Article