Abstract
Surgical outcomes of acute Stanford type A aortic dissection (ATAAD) have significantly improved in recent decades due to advances in surgical techniques and adhesives such as BioGlue (Cryolife, Kennesaw, GA, USA). However, this convenient material can sometimes cause complications such as thrombotic embolism and pseudoaneurysm. Herein, we present the case of a 61-year-old man with ATAAD who successfully underwent total arch replacement. Five days after surgery, he collapsed due to right-sided hemiplegia. We immediately performed cerebral thrombectomy to remove thrombotic embolism caused by BioGlue, which was used to obliterate the false lumen of the dissected aorta during ATAAD repair.
Learning objective
Thanks to surgical techniques and adhesives such as BioGlue, surgical outcomes of acute Stanford type A aortic dissection have significantly improved recently. However, thromboembolic events due to adhesives such as BioGlue use can happen not only during surgery, but also a few days after it.
Keywords: Aortic dissection, BioGlue, Stroke
Introduction
On account of a variety of hemostatic agents, adhesives, and sealants, surgical outcomes of acute Stanford type A aortic dissection (ATAAD) repair have improved greatly. BioGlue (Cryolife, Kennesaw, GA, USA) is an adhesive (independent of the coagulation cascade) that has hemostatic properties. Moreover, it also strengthens and holds tissues together at sites of complex anastomoses [1]. There have been some reports of complications associated with the use of BioGlue, such as acute cerebral embolism, myocardial infarction, and pseudoaneurysm [1], [2], [3]. Herein, we report the rare case of a patient with embolism associated with BioGlue use after ATAAD repair. He was successfully treated with cerebral thrombectomy.
Case report
A previously healthy 61-year-old male was referred to our hospital for sudden chest pain. Chest computed tomography (CT) revealed ATAAD. We performed emergency total arch replacement for ATAAD using the frozen elephant trunk technique. This was performed under hypothermic circulatory arrest in combination with ante-grade selective cerebral perfusion (cardiopulmonary bypass time: 193 min, lower body circulatory arrest time: 54 min, core temperature during hypothermic circulatory arrest: 25 °C) (Fig. 1a and b). We used BioGlue to reinforce the suture line outside felt strip of the distal anastomosis. To reconstruct the proximal stump, we injected BioGlue into the false lumen of the Valsalva sinus. Small covered wet gauze was placed into the true lumen of the Valsalva sinus to prevent overflow of BioGlue into the Valsalva sinus wall or annulus of the aortic valve. We used the felt sandwich technique to repair the Valsalva sinus. We individually reconstructed three neck vessels without using BioGlue. The patient was extubated on postoperative day 1 and started rehabilitation. He had no post-operative paroxysmal atrial fibrillation.
Fig. 1.
Chest computed tomography (CT) shows (a) acute Stanford type A aortic dissection (ATAAD). (b) Three-dimensional CT of ATAAD.
However, he collapsed with right-sided hemiplegia on postoperative day 5. Immediately, we performed three-dimensional cerebral computed tomography (CT) that revealed occlusion in the left anterior cerebral artery (Fig. 2a and b). Cerebral thrombectomy was performed by cerebral interventionalists within a few hours after onset of right-sided hemiplegia (Fig. 2c and d). Moreover, we used not only BioGlue, but also factor XIII with fibrinogen and gelatin for hemostasis outside the vessels during surgery. However, pathological examination revealed a yellowish material collected with the freshly removed thrombus and was found to be consistent with BioGlue (Fig. 3a and b), which was structureless material with scarce cellular components that stained uniformly pink with hematoxylin and eosin stain (Fig. 3c).
Fig. 2.
(a, b) Brain three-dimensional computed tomography shows patency in the right anterior cerebral artery (ACA) (red arrow) and occlusion in the left ACA (black arrow). (c) Cerebral angiography shows patency in the right ACA (red arrow) and occlusion in the left ACA (black arrow) before thrombectomy, and (d) patency both in the right (red arrow) and left ACA (black arrow) after thrombectomy.
Fig. 3.
(a, b) BioGlue collected during cerebral thrombectomy (yellow arrow). (c) Pathological image revealed structureless material with scarce cellular components that stained uniformly pink with hematoxylin and eosin stain.
Discussion
Advances in surgical techniques and development of medical institutions improved surgical outcomes of ATAAD [4]. However, it remains a life-threatening medical emergency procedure associated with high morbidity and mortality. Exploring ways is essential to reduce postoperative cerebral events after ATAAD repair that are usually associated with poor early outcomes [5]. A few possible mechanisms of postoperative cerebral events after ATAAD repair have been suggested. They include partial or complete occlusion in the arch vessels by the intimal-medial flap (cerebral malperfusion), hypoxic encephalopathy secondary to shock or tamponade, and/or brain embolism due to developing thrombus in the false lumen [6], [7]. Currently, on observing partial thrombosis in the false lumen of the ascending aorta in patients with ATAAD, we perform direct cannulation of the malperfused carotid artery. In addition, we select the subclavian artery as cannulation site, to avoid perioperative cerebral events after ATAAD repair. In our case, since we did not observe any thromboses in the false lumen, we performed true lumen cannulation of the ascending aorta using the Seldinger technique. Although our patient woke without any neurological dysfunction on postoperative day 1, he collapsed with right-sided hemiplegia due to thrombotic embolism associated with BioGlue a few days after surgery.
There have been some reports of complications associated with the use of BioGlue, such as stroke, coronary embolism, and pseudoaneurysm formation [1], [2], [3]. Carrel et al. reported three possible mechanisms by which surgical adhesives such as BioGlue could cause thrombotic embolism [8]: (i) direct spillage of glue into the true lumen (despite precautions); (ii) escape of glue through distal reentry sites into the true lumen; and (iii) secondary mobilization of glue particles through suture-line needle holes. Regarding the first mechanism, we suggest that we have taken enough precautions to avoid direct spillage of glue into the true lumen. However, a thromboembolic event could have happened during surgery. Regarding the second mechanism, it could not have occurred a few days after surgery because we performed total arch replacement, and reentry could not exist at the proximal site of three neck vessels. Concerning the third mechanism, we cannot avoid embolic events even with careful application of BioGlue. Since the embolic event in our case occurred a few days after surgery, we suggest that the third mechanism may have played a role, which cannot be currently proved. By contrast, we cannot deny the possibility of the mechanism that excess volume of BioGlue in the false lumen was pushed out into the lumen during proximal anastomosis after felt sandwich technique in spite of careful BioGlue use. Usually, thromboembolic events due to BioGlue use can occur during surgery. However, it is difficult to prove that BioGlue use was related to cerebral stroke event during surgery because there was no indication for cerebral thrombectomy after the total arch replacement procedure. Therefore, our findings might indicate that cerebral embolic stroke due to using BioGlue could occur more frequently in clinical practice. In addition, our case proved that thromboembolic events due to BioGlue use can happen not only during surgery, but also a few days after it.
Regarding the prevention of BioGlue embolism, we think that we have to use the BioGlue as the false lumen is kept dry, avoid the use of excess volume of BioGlue in the false lumen, and wash out the BioGlue carefully before anastomosis.
Author contribution
All authors discussed the results and commented on the manuscript.
Funding
None declared.
Informed consent
We obtained the patient's informed consent.
IRB approval, consent statement and clinical trial registration: N/A.
Declaration of competing interest
None declared.
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