4.2.4: BioGlue Embolism
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