Asian Cardiovasc Thorac Ann 2006;14:e91-e92
© 2006 Asia Publishing EXchange Ltd
Early Failure of Surgical Angioplasty with Tissue Glue: a Word of Caution
Asif Malik, MBChB,
Mehmet Oc, MD,
George Doukas, MD,
Christos Alexiou, MD,
Tomas J Spyt, MD
Department of Cardiac Surgery, Glenfield Hospital, Leicester, United Kingdom
For reprint information contact: Tomas J Spyt, MD Tel: 44 147 640 1009 Fax: 44 116 232 2511 Email: Malaak25{at}Yahoo.com, Department of Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester, Leicester, England, United Kingdom.
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ABSTRACT
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A 43-year-old woman with critical stenosis of the left main stem was managed with saphenous vein angioplasty using BioGlue. She developed severe myocardial ischemia postoperatively, probably due to external compression exerted on the patch by the adhesive material, and required emergency coronary artery bypass grafting.
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CASE REPORT
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A 43-year-old woman presented with an 18-month history of severe angina. An exercise test was strongly positive and a coronary artery angiogram showed 90% ostial stenosis of the left main coronary artery (LMCA), normal left anterior descending and circumflex arteries, and good left ventricular function. At surgery, the aortotomy was extended to the LMCA, crossing the stenosis, using the posterior approach described by Hitchcock and colleagues.1 The incision was closed with an onlay patch of the long saphenous vein. The venous patch appeared to lie satisfactorily in a concave position. Although the suture line did not demonstrate leaks, it was prophylactically reinforced with BioGlue (CryoLife, Inc., Kennesaw, GA, USA) before the aortic clamp was removed. On completion of the operation, transesophageal echocardiography showed good left ventricular function and an easily identifiable origin of the LMCA. The patient was transferred to the intensive care unit in a stable condition with a normal electrocardiogram. Six hours later, she developed persistent ventricular fibrillation. Following successful resuscitation and insertion of an intra-aortic balloon pump, she underwent emergency coronary angiography that revealed poor blood flow into the left coronary system. She was returned immediately to the operating room for re-operation. On the table, transesophageal echocardiography could no longer identify the origin of the LMCA and showed regional wall motion abnormalities affecting the septum, anterior septum, and the apex. On inspection, the saphenous vein angioplasty patch was covered by the glue material and appeared set in a convex position. The left anterior descending artery was grafted with a segment of the long saphenous vein, and the patient was weaned off cardiopulmonary bypass on inotropics and intra-aortic balloon pump support. She was extubated after 48 hours and was discharged home 12 days later.
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DISCUSSION
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In 1989, Dion and colleagues2 described surgical angioplasty of left main stem ostial stenosis with saphenous vein or pericardium as an alternative to conventional bypass surgery. BioGlue is a preparation of bovine albumin and glutaraldehyde, with adhesive properties. Studies have demonstrated the safe use of BioGlue as an adjunct to conventional repair methods.3 It is recognized that application of BioGlue reinforces the suture lines, reducing intraoperative and postoperative anastomotic site bleeding and the need for pledgets.3,4 Indeed, hemostatic sutureless coronary artery bypass graft surgery with BioGlue anastomoses has been described recently.5 Despite its well-documented hemostatic advantages, the use of BioGlue is not without problems. Clinical and experimental studies have described an association between BioGlue and aneurysmal dilatation and necrosis of the aortic wall.6 Moreover, LeMaire and colleagues7 provided evidence linking the circumferential application of BioGlue around an aorto-aortic anastomosis with the development of anastomotic strictures. Economopoulos and colleagues8 recently reported superior vena caval stenosis due to extrinsic compression following local application of BioGlue.
The cause of early stenosis of the LMCA angioplasty in our case cannot be identified with certainty. Although surgical imperfection is possible, the senior author (TJS) had previously performed 17 successful osteoplasties using identical techniques but without utilizing adhesive material. As shown by transesophageal echocardiography, the LMCA on completion of the operation was patent and apparently remained so for 6 hours until ventricular fibrillation occurred. We believe that the most likely cause of LMCA obstruction was the generous use of BioGlue around the patch whilst the aorta was clamped and not pressurized. It would appear that once solidified, the glue constricted and distorted the patch, eventually occluding the LMCA. On the basis of our experience, we raise a word of caution and recommend that the use of BioGlue in LMCA angioplasty, and indeed other anastomoses, be avoided. If the suture line does not demonstrate any leaks, then prophylactic reinforcement with BioGlue is not required.
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REFERENCES
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- Hitchcock JF, Robles de Medina EO, Jambroes G. Angioplasty of the left main coronary artery for isolated left main coronary artery disease. J Thorac Cardiovasc Surg 1983;85:880–4.[Abstract]
- Dion R, Verhelst R, Schoevaerdts JC, Col J, Rennotte MT, Chalant CH. Surgical plasty of the left main coronary artery. Ann Chir 1989;43:85–9.[Medline]
- 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;197:243–53.[Medline]
- Hewitt CW, Marra SW, Kann BR, Tran HS, Puc MM, Chrzanowski FA Jr, et al. BioGlue surgical adhesive for thoracic aortic repair during coagulopathy: efficacy and histopathology. Ann Thorac Surg 2001;71:1609–12.[Abstract/Free Full Text]
- Van Nooten G, Van Belleghem Y, Foubert L, Francois K, Caes F, Van Overbeke H, et al. An experimental model of coronary anastomosis without suturing. Cardiovasc Surg 2003;11:80–4,[Medline]
- Kirsch M, Ginat M, Lecerf L, Houel R, Loisance D. Aortic wall alterations after use of gelatin-resorcinol-formalin glue. Ann Thorac Surg 2002;73:642–4.[Abstract/Free Full Text]
- LeMaire SA, Schmittling ZC, Coselli JS, Undar A, Deady BA, Clubb FJ Jr, et al. BioGlue surgical adhesive impairs aortic growth and causes anastomotic strictures. Ann Thorac Surg 2002;73:1500–6.[Abstract/Free Full Text]
- Economopoulos GC, Dimitrakakis GK, Brountzos E, Kelekis DA. Superior vena cava stenosis: a delayed BioGlue complication. J Thorac Cardiovasc Surg 2004;127:1819–21.[Free Full Text]
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