The risk of thromboembolism in aortic surgery is omnipresent but is
typically surrounding the use of adjunctive cerebral perfusion and
surgical manipulation of the diseased aorta. It is important to
highlight that BioGlue, despite being broken down by proteolysis after
application, still poses a risk of embolism.21 Carrel
et al. suggest that surgical adhesive embolization usually occurs via
one of three routes: inadvertent spillage into the true lumen (TL),
leakage through a distal re-entry tear into the TL, or leakage through
anastomotic needle holes into the TL.21 The last has
been proven by LeMaire et al. in 2005, who further concluded that
intramural adhesive particles dislodge and embolise
easily.22 All three routes are real risks when priming
E-Vita Open NEO with BioGlue – embolization to the coronary arteries,
pulmonary circulation, brain, and limbs have all been reported in
literature.22 Particles of polymerised surgical glue,
for example, have been identified in cerebral vessels during post-mortem
of a patient who had undergone FET for TAAD but did not show clinical
evidence of stroke.21 LeMaire notes that BioGlue leaks
through suture tracts in up to 10% of anastomoses, and that this may
occur in spite of proper administration technique.22BioGule leaks through prosthetic grafts, such as E-Vita Open NEO, have
also been shown to form discrete, round, adhesive particles with a
propensity for dislodging and embolising.22 Gillham
and Tousignant described a case of aortic mechanical valve occlusion
caused by GRF glue that had entered the aortic TL via aortotomy suture
lines.23 Miller et al. reported extracting large
BioGlue ‘bullets’ from thoracoabdominal aortas in patients that had
previously undergone proximal aortic repair, and Mahmood et al. reported
a fatal myocardial infarct resulting from embolization of BioGlue to the
coronary arteries following proximal aortic
repair.24,25 Crucially, given the significant
morbidity associated with major aortocardiac procedures, postoperative
stroke and end-organ dysfunction are common complications; these tend
not to raise suspicions over adhesive embolization and are usually
attributed to factors such as hypothermic circulatory arrest or
atherosclerotic thromboembolism.22 Indeed, because
postmortem microscopy studies are not routine in such patients either,
it is challenging to accurately ascertain the true extent of adhesive
embolic damage, and how this may be augmented by BioGlue priming of the
FET prosthesis.20