Abstract
Ascending aortic dissection is a life threatening surgical emergency and carries high peri-operative mortality. Various biological adhesive materials are commonly used in such a surgery to enhance strengthening of separated layers of aortic wall. Despite of extensive use, embolization of the glue material remains a feared complication. Here we are describing a case where BioGlue embolized down the left main stem and resulted in refractory ventricular arrhythmia and hemodynamic instability.
1
Introduction
Ascending aortic dissection is a life threatening emergency, requiring emergency aortic root repair/replacement, with or without aortic valve repair/replacement and carries high peri-operative mortality and morbidity. If the patient survives the early period the operation carries good long-term prognosis. Recent data suggest that, early and long term survival after surgical repair has improved .
Biological adhesive materials have been used for more than 3 decades. The most commonly used in cardiovascular operations are gelatine-resorcin-formalin (GRF) glue and BioGlue. BioGlue surgical adhesive (CryoLife Inc, Kennesaw, Georgia) was recently been approved by US Food and Drug Administration (US FDA) , and is accepted widely to reinforce suture lines in surgical procedures such as type A ascending aortic repair. Due to its characteristic as a less tissue toxic agent compared to GRF , and added efficacy as a haemostatic agent with better tensile strength, it has become the best available agent .
BioGlue is a two-component protein matrix consisting of 45% bovine albumin and 10% glutaraldehyde. Both components get mixed in the delivery tip at the time of application. Glutaraldehyde reacts with amine group of albumin and native tissue resulting in rapid polymerization time and reaches bonding strength within 2–3 minutes .
Despite extensive usage, life-threatening complications are uncommon with the use of biological glue. Reported complications include; prosthetic valve dysfunction , aortic wall necrosis/aortic wall growth impairment , cerebral , pulmonary , coronary and peripheral embolization as well as its ability to injure exposed nerves . Most of these were noted from the intra-operative period to a few months after the operation and in some cases at the time of post-mortem examination.
2
Case report
A 76 years old lady was transferred to our cardiac centre with ascending aortic dissection involving the aortic valve, resulting in severe aortic regurgitation (AR). She underwent emergency aortic dissection repair by two interposition grafts using biological glue, re-suspension of aortic valve as well as grafting of left internal memory artery (LIMA) on to left anterior descending (LAD) artery. Patient required surgi-cell packing in the mediastinum due to extensive bleeding during the operation. Thirty-six hours post-procedure, surgi-cell packing was removed, and within 2–3 minutes she started having intractable ventricular fibrillation (VF), requiring recurrent direct current (DC) cardioversion. In view of recurrent episodes of VF, we decided to take her to the cardiac catheter laboratory for diagnostic coronary angiography.
In the catheter laboratory, we inserted intra-aortic balloon pump (IABP) to offer circulatory support (as she was in cardiogenic shock) prior to performing angiography through right femoral artery. We proceeded with right radial arterial access, using 6 F sheath to perform diagnostic coronary angiography, which demonstrated a significantly large filling defect with clearly sharp edge demarcation, extending from left main stem (LMS) in to the proximal part of left circumflex (LCx) and also into proximal left anterior descending (LAD) artery ( Image 1 ). The LAD had competitive filling from the left internal memory artery (LIMA). The Right coronary artery (RCA) demonstrated mild to moderate diffuse disease, but no flow-limiting lesion was noted. Even though the appearance was not suggestive of thrombus, it could not be ruled out, so we decided to perform aspiration first. We changed from diagnostic catheter to extra back-up (EBU) 3.5 F guide (Launcher® coronary guide catheters, Medtronic, Minneapolis, USA) and wired only the LCx with balanced medium weight (BMS) wire (Abbott vascular®) as a 6 F size catheter does not allow passage of an aspiration catheter in the presence of a second wire. Furthermore, the LAD was protected with a LIMA graft. Despite of repeated attempts, we failed to aspirate any material through aspiration catheter, so we tried to aspirate through the catheter, by deeply engaging it into the LMS, but without success. The angiographic appearance of the vessel did not improve; rather the “obstructing material” was nudged further down the vessel. The patient continued to have intermittent episodes of VF. We felt we had very little options other than to stent the vessel to restore flow.
After wiring the LAD, we ballooned from LMS into LCx using 3.0 × 15 mm balloon, followed by stenting with 4.0 × 20 mm bare metal stent (BMS), which was deployed at 16 atmospheres (atm). After stent deployment, we used the wire from LCx to cross over into LAD through struts, and the jailed LAD wire was passed into LCx. We used 2.5 mm balloon to dilate the struts of the stent and then deployed another 4.0 × 16 mm DES, followed by final kissing balloon inflation to complete the procedure. Satisfactory final angiographic result was obtained ( Image 2 ). As this procedure was performed in an emergency situation and patient was very unstable, we did not perform any invasive imaging to assess stent deployment and apposition with the vessel wall as we would have done in any other case.
Hemodynamic parameters improved very quickly, and patient did not experience any further episodes of VF. She made uneventful recovery and was discharged from hospital and remains asymptomatic from cardiac point of view.
2
Case report
A 76 years old lady was transferred to our cardiac centre with ascending aortic dissection involving the aortic valve, resulting in severe aortic regurgitation (AR). She underwent emergency aortic dissection repair by two interposition grafts using biological glue, re-suspension of aortic valve as well as grafting of left internal memory artery (LIMA) on to left anterior descending (LAD) artery. Patient required surgi-cell packing in the mediastinum due to extensive bleeding during the operation. Thirty-six hours post-procedure, surgi-cell packing was removed, and within 2–3 minutes she started having intractable ventricular fibrillation (VF), requiring recurrent direct current (DC) cardioversion. In view of recurrent episodes of VF, we decided to take her to the cardiac catheter laboratory for diagnostic coronary angiography.
In the catheter laboratory, we inserted intra-aortic balloon pump (IABP) to offer circulatory support (as she was in cardiogenic shock) prior to performing angiography through right femoral artery. We proceeded with right radial arterial access, using 6 F sheath to perform diagnostic coronary angiography, which demonstrated a significantly large filling defect with clearly sharp edge demarcation, extending from left main stem (LMS) in to the proximal part of left circumflex (LCx) and also into proximal left anterior descending (LAD) artery ( Image 1 ). The LAD had competitive filling from the left internal memory artery (LIMA). The Right coronary artery (RCA) demonstrated mild to moderate diffuse disease, but no flow-limiting lesion was noted. Even though the appearance was not suggestive of thrombus, it could not be ruled out, so we decided to perform aspiration first. We changed from diagnostic catheter to extra back-up (EBU) 3.5 F guide (Launcher® coronary guide catheters, Medtronic, Minneapolis, USA) and wired only the LCx with balanced medium weight (BMS) wire (Abbott vascular®) as a 6 F size catheter does not allow passage of an aspiration catheter in the presence of a second wire. Furthermore, the LAD was protected with a LIMA graft. Despite of repeated attempts, we failed to aspirate any material through aspiration catheter, so we tried to aspirate through the catheter, by deeply engaging it into the LMS, but without success. The angiographic appearance of the vessel did not improve; rather the “obstructing material” was nudged further down the vessel. The patient continued to have intermittent episodes of VF. We felt we had very little options other than to stent the vessel to restore flow.
