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Late Follow-Up of Cyanoacrylate Usage in Cardiothoracic Surgery

M Murat Demirta, MD, Serdar Cimen, MD, Bülend Ketenci, MD, Rafet Günay, MD, Murat Akçar, MD, Azmi Özler, MD

Siyami Ersek Thoracic & Cardiovascular Surgery Center Istanbul, Turkey

For reprint information contact: M Murat Demirta, MD Tel: 90 212 259 3569 Fax: 90 216 337 9719 email: mmuratdem{at}hotmail.com Ihlamurdere Cad. 149/5, Besiktas, Istanbul 80690, Turkey.

	Abstract

TOP Abstract Introduction Patients and Methods Results Discussion References

 
In cardiovascular and thoracic surgery, troublesome bleeding and sternal dehiscence can be life-threatening if not managed appropriately. We used commercially available cyanoacrylate adhesive 21 times in 20 sporadic patients for the management of 6 different problems: sternal gluing in 7 cases; anastomotic line reinforcement and bleeding control with a glued Teflon or pericardial patch in 6; right ventricular or superior vena caval patch repair in 5; and 1 case each of left ventricular apical glued Teflon felt, arterial wall reinforcement, and control of air leakage after lung surgery. The mean age of the patients was 55.7 ± 12.5 years, ranging from 34 to 71 years. Successful results were obtained in 18 patients and 17 were alive on follow-up at 7.7 ± 5.5 months (range, 2 to 16 months). We used two different commercial brands of adhesive but obtained good results with only one of these preparations. Although commercially available cyanoacrylate is a new adjunct to cardiac surgery with documented safety and lifesaving results at negligible cost, the appropriate polymer for best results needs to be defined.

	Introduction

TOP Abstract Introduction Patients and Methods Results Discussion References

 
Cyanoacrylate has been used as a surgical tissue adhesive in craniofacial plastic and reconstructive surgery, gynecology, esophagogastric intestinal surgery, and dentistry.^1–6 Cyanoacrylate derivatives have been widely applied in neurosurgery, ophthalmology, and urology.^7–10 The application of cyanoacrylate adhesive in critical cardiac injuries such as cardiac lacerations or ruptures has been reported by several authors.^11,12 We applied two different commercially available brands of cyanoacrylate glue in 20 patients for 6 different purposes. Our experiences are discussed with regard to published reports.

	Patients and Methods

TOP Abstract Introduction Patients and Methods Results Discussion References

 
Of the 20 patients in whom cyanoacrylate was used, 13 were male and 7 were female. The mean age was 55.7 ± 12.5 years, ranging from 34 to 71 years. Primary pathologies and technical features are given in Table 1. The indications for cyanoacrylate application were sternal detachment in 7 patients, bleeding from aortotomy or aortic anastomoses in 6, right ventricular free-wall perforation during dissection for redo sternotomy in 4, and one case each of superior vena caval laceration, bleeding from femoral arterial wall infiltrated by epidermoid carcinoma, bleeding after left apical ventriculotomy, and air leakage after surgery for hydatid cyst of the lung (Table 1).

Case 1
Our first patient was a 55-year-old male admitted in a preshock state. Chest radiography showed enlargement of the mediastinal shadow. Computed tomography of the thorax and abdomen revealed dissection of the ascending aorta, extending to the arcus. An intimal flap was seen arising just above the aortic valve. The patient underwent surgery 8 hours after admission. An acute ruptured ascending aortic dissection was found with an intimal tear a few centimetres above the aortic valve on the anterolateral wall of the aorta. A 28-mm woven double-velour vascular graft (Hemashield; Meadox Medicals Inc., Oakland, NJ, USA) was interposed above the coronary ostia to the aortic arch. Aortic hemiarch anastomosis was performed under deep-hypothermic total circulatory arrest without the use of Teflon felt strips. Abundant bleeding from the posterior part of the distal anastomotic line occurred and we could not control it with standard suturing techniques. As a last option, the anastomotic line was reinforced with commercially available cyanoacrylate adhesive; the peri-anastomotic tissues were approximated with cyanoacrylate glue by direct application over the suture line during an additional 5 minutes of total circulatory arrest. The patient was discharged on the 12th postoperative day and was quite well at 16 months after the operation, with no false lumen on magnetic resonance imaging.

Case 2
An iatrogenic right ventricular free-wall perforation occurred during dissection for redo mitral valve replace-ment in a 66-year-old female who had undergone a closed mitral valvotomy 16 years previously. A pericardial patch measuring 1.5 x 3 cm was glued over the epicardial surface of the ruptured right ventricle with a thin layer of cyanoacrylate. The rest of the procedure was uneventful and the patient was discharged on the 12th postoperative day.

Case 3
A 37-year-old female with an epidermoid carcinoma on the left groin was admitted to the hospital because of femoral bleeding. The common femoral artery was invaded by the carcinoma. Direct sutures were applied but as the arterial wall was very fragile, deep fascia and a femoral sheath were glued over the artery using cyanoacrylate. This patient was followed up for 2 months. Femoral artery patency was good and she was referred for further plastic surgical treatment.

Case 4
Cardiac tamponade developed on the 8th postoperative day after double valve replacement in a 42-year-old male. He underwent urgent reoperation. During chest closure, multiple bilateral transverse Hendrickson type III sternal fractures were seen. Sternal wires were applied in the standard fashion but as the sternum was severely fractured and osteoporotic, we applied cyanoacrylate adhesive to the sternal edges before the wires were tightened firmly. The sternum stabilized within a few minutes. The post-operative course was uneventful, without any sign of infection or sternal detachment. The patient was discharged after 8 days.

Case 5
A 46-year-old female who had undergone surgery for hepatic hydatid cysts 8 months previously, was admitted for left ventricular apicolateral echinococcal cyst extirpation. The ventriculotomy edges that were sutured with 2/0 polypropylene bled from a tear over the suture line; additional sutures failed. Two Teflon felt patches were treated with cyanoacrylate glue and applied to each side of the ventriculotomy. Her postoperative course was uneventful with total mediastinal drainage of 250 mL. During 13 months of follow-up, the patient had no complications.

Similar methods were used in a further 15 cases. In one of these (case no. 19), a hydatid cyst of the middle lobe of the right lung was enucleated and the cystic cavity was closed with sutures. Air leakage from the lung parenchyma was controlled by a pleural patch glued with cyanoacrylate.

Lely Turbo (cyanacrylacidethylester; Lely Turbo Yapistima Tek Ltd, Istanbul, Turkey) was used in 18 patients and Pattex Super Glue (methyl cyanoacrylate; Türk Henkel AS, Istanbul, Turkey) was applied in the other 2. Ethylene dioxide was used for external sterilization of the packages. In all cases, a sample of cyanoacrylate glue was inoculated into a soybean-casein digest broth (Bactec Plus Aerobic and Plus Anaerobic culture vials; Becton Dickinson Diagnostic Instrument Systems, Sparks, MD, USA), endo-agar (Dig-Media; Diomed AS, Istanbul, Turkey), and Sabouraud dextrose agar (Diomed AS, Istanbul, Turkey) for bacteriological control.

	Results

TOP Abstract Introduction Patients and Methods Results Discussion References

 
Cyanoacrylate application was successful in 18 cases. In case no. 6, the glue did not ensure stabilization of the sternum. In case no. 20, although Teflon felt and pericardial patches treated with cyanoacrylate were appropriately applied over the anastomotic lines, bleeding could not be controlled even temporarily, due to insufficient adhesion. In these two patients, Pattex Super Glue was used. Its gluing properties on biological surfaces were not sufficient to provide adequate firmness. For ethical reasons, this glue was not used again after these two unsuccessful experiences.

In the early postoperative period, no patient had problems related to cyanoacrylate application. All patients were followed up for 2 to 16 months (mean, 7.7 ± 5.5 months). One patient (no. 11) was lost on the 10th postoperative day due to bleeding related to mediastinitis, although his sternum was stable. The other patients were symptom-free and in New York Heart Association functional class I in the early postoperative period. In the late postoperative period, two patients died from chronic renal failure. However, this was not attributed to the use of cyano-acrylate. Bacteriological studies showed no growth in any of the cultured samples.

	Discussion

TOP Abstract Introduction Patients and Methods Results Discussion References

 
Cyanoacrylate derivates and polymer solutions have been successfully used previously in cardiovascular and pulmonary surgery. Horsley and Miller¹³ recently described the use of commercially available cyanoacrylate glue for managing air leaks in emphysematous lungs. Robicsek and colleagues¹⁴ reported 4 cases in which cyanoacrylate was successfully used to control hemorrhage in critical clinical situations. Repair of subacute cardiac rupture after myocardial infarction with pericardium or a Teflon patch glued over the myocardial tear has also been reported by before.^15,16 Jondeau and colleagues¹⁷ controlled a Swan-Ganz catheter-induced massive pulmonary hemorrhage by immediate therapeutic embolization of the segmental artery with cyanoacrylate.

Takenaka and colleagues¹⁸ reported sutureless anastomosis of blood vessels in an experimental study with a patency of 12 months with very little pannus and concluded that sutureless anastomosis with cyanoacrylate adhesive was a useful method of preventing anastomotic neointimal hyperplasia. Quinn and colleagues¹⁹ showed the in vitro antimicrobial efficacy of cyanoacrylate when standard disc sensitivity tests were used and bacteriological studies showed commercially available cyanoacrylate adhesive lacked bacterial contamination.²⁰ In our study, we also found no bacterial growth in cyanoacrylate cultures.

Comparative studies of biological glues showed that cyanoacrylate glue has the strongest adhesive power but it has poor biocompatibility and also has the disadvantage of becoming very stiff when applied.²¹ On the other hand, cyanoacrylate alone for wound closure has exhibited significantly less tensile strength than closure with traditional suture methods.²² This is in agreement with our clinical observations.

Our current indications for using cyanoacrylate glue in cardiac surgery are desperate situations that cannot be controlled by standard techniques, such as aortic bleeding, ventricular or vascular lacerations, and sternal detachment where it is considered that rewiring will not be sufficient to stabilize the sternum, especially in osteoporotic and diabetic patients.

Commercially available cyanoacrylate glue is the cheapest of all today's biological or biocompatible synthetic tissue adhesives and can be found easily in any market. It is a new adjunct in cardiac surgery with documented safety and lifesaving results. However, the appropriate type of polymer for best results needs to be defined.

	References

TOP Abstract Introduction Patients and Methods Results Discussion References

 

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