Beneficial Effect of BioGlue® Surgical Adhesive in Repair of Iatrogenic Aortic Dissection

Abstract

We report the benefits of using BioGlue® surgical adhesive to repair an iatrogenic aortic rupture and dissection that resulted from cannulation of the ascending aorta during open-heart surgery.

The incidence of acute aortic dissection varies between 0.03% and 0.35% during or soon after open-heart surgery. ¹ The dissection is generally discovered during surgery. We describe the case of a patient in whom iatrogenic aortic rupture and dissection during open-heart surgery required the use of BioGlue® surgical adhesive (CryoLife International®, Inc.; Kennesaw, Ga) to stop the bleeding.

Case Report

A 32-year-old man presented at our institution with a 7-year history of dyspnea and tachycardia. Initially, these symptoms had occurred only on exertion, but for the past month they had been occurring even when the patient was at rest. The patient also reported a history of acute rheumatic fever. The physical examination showed jugular venous distention, an arterial pressure of 90/60 mmHg, and a pulse rate of 75 beats/min. An apical systolic murmur was detected during cardiac auscultation. Pulmonary rales were audible at the bases of both lungs, and there was palpable hepatomegaly. Electrocardiography revealed atrial fibrillation and pulmonary hypertension. The cardiothoracic ratio was above normal, and the conus arteriosus was visible on the chest radiograph. Transthoracic echocardiography and cardiac catheterization showed severe mitral insufficiency, mitral stenosis (mean diastolic gradient, 10 mmHg), and pulmonary hypertension (50 mmHg).

At surgery, while cardiopulmonary bypass was being established, the cannula could not be passed into the ascending aorta; therefore, Hegar's dilators were used for dilatation of the ascending aorta, and then the cannula was placed. There was pulsatile backflow from the cannula. However, an expansive hematoma developed in the ascending aorta. Surgical exploration of the aorta for bleeding revealed 2 perforations on the posterior aortic wall; 1 was about 0.3 cm long and the other was about 0.5 cm long. The perforations were repaired by 3 polypropylene sutures each, with Teflon pledgets for support. Nonetheless, the bleeding continued, whereupon further exploration of the adventitia showed another perforation extending to the middle of the aortic arch. This perforation was repaired by plication with sutures supported by Teflon strips. Intraaortic echocardiography did not show any dissection.

A cross-clamp was placed on the intact proximal aorta to ensure cardiac arrest with the administration of anterograde cold crystalloid cardioplegia (St. Thomas II solution). The left atrium was incised, and the mitral apparatus was resected for replacement with a St. Jude Bileaflet mechanical prosthesis (No. 33). The cross-clamp was removed after the introduction of terminal retrograde warm blood cardioplegia. De-airing maneuvers were applied. Cardiopulmonary bypass was concluded without any further complication, and the aortic cannula was removed just after protamine administration.

Echocardiography at that time revealed a localized dissection flap beginning at the posterior aortic wall opposite from the aortic cannulation site and extending 2 to 3 cm distally. This dissection had not been seen earlier, most likely because the flap was hidden by the aortic cannula. Individual Teflon pledgeted sutures were used with guidance by intraaortic echocardiography, and aortic plication was performed to affix the flap to the aortic wall.

Despite these repairs and protamine administration, the bleeding through the suture lines did not cease. Therefore, 1 kit of BioGlue surgical adhesive was applied to the bleeding zones. The leaks stopped, and no bleeding recurred. The patient had an arterial systolic pressure of 90 mmHg within 30 minutes. We continued to observe the patient during the early postoperative hours for possible massive bleeding or cardiac tamponade. Transesophageal echocardiography was then performed in order to detect possible redissection. No such complications were found.

Extubation was performed 15 hours postoperatively. At 24 hours, the total thoracic and mediastinal drainage was 550 cc; therefore, the drains were removed. No dissection was identified by thoracic computed tomography on the 7th postoperative day, and the patient was discharged from the hospital the next day. When the patient returned for a follow-up visit at the end of 1st month, there was again no evidence of dissection on thoracic computed tomography.

Discussion

We treated a 35-year-old man for iatrogenic aortic dissection caused by problematic insertion of the aortic cannula during open-heart surgery. Such a complication is usually discovered during surgery. The 1st indication, as in our patient, is a bluish discoloration in the adventitia of the aorta. At this point, it is necessary to determine the size and extent of the dissection in the aortic wall. For this purpose, transesophageal echocardiography or intraaortic echocardiography is used for the examination. The plication technique can be used to treat a dissection of a small segment of the aortic wall (with an area less than 15% of the aortic diameter).

It is important to determine the relation of the tip of the aortic cannula to the dissection. If the tip penetrates the aortic wall, it may cause severe dissection at the beginning of cardiopulmonary bypass. Therefore, the cannula must be retracted if there is no backflow from the cannula or if echocardiography shows a relation between the cannula and the dissection. In our patient, the perforations opposite the entry hole of the aortic cannula likely occurred when the Hegar's dilators were 1st inserted, and then the dissection occurred when the dilator tips were directed toward the arch. The iatrogenic perforations on the posterior aortic wall were repaired 1st. However, because a large aortic hematoma extended toward the arch, another severe injury was suspected. Plication was performed to stop the bleeding in the incomplete aortic perforation line, but no flap was visible on the echocardiogram. At that stage, the flap was probably pinned to the aortic wall by the cannula. After the patient was weaned from cardiopulmonary bypass and the cannula was removed, a flap was seen on the echocardiogram. The severe bleeding probably began with the release of the flap. The dissected zone was, however, observed to be small and limited (3 cm) on echocardiography, and plication was again performed with interrupted pledgeted sutures.

There were severe leaks from the suture lines despite completion of protamine administration and compression to the aorta. For this reason, BioGlue surgical adhesive was used to seal the leaks in the zone weakened by the hematoma, particularly along the suture lines. BioGlue is an adhesive solution that has been approved by the Food and Drug Administration for use in the United States under the Humanitarian Device Exemption (HDE) regulations for the treatment of acute thoracic aortic dissections. The solution, composed of purified bovine serum albumin (45%) and glutaraldehyde (10%), is easy to prepare and apply. It begins to bond within 20 to 30 seconds and reaches its maximum bonding capability in 3 minutes.^* This adhesive solution can be used to attach the false lumen during repair of an aortic dissection and can be applied externally to guard against any possible leaks during repair. As in our patient, the adhesive solution strengthens the weak tissues and stops the bleeding. ² No leak occurred in our patient's posterior aortic wall after the application of BioGlue. Although this solution can cause allergic reactions, we observed no such reaction in our patient. Computed tomography also showed that the plication enabled repair of the dissection with BioGlue, with no newly developed pseudoaneurysm.

In conclusion, we suggest that the intraoperative application of BioGlue surgical adhesive is useful to stop leaks in weak suture lines during repair of small iatrogenic aortic dissections that are limited and localized.

Addendum

After this reported case, we used BioGlue® in another 3 patients to stop the leakage of blood from various cardiovascular tissues during open-heart operations.