Comment
Advances in surgical techniques and the development of medical
organizations has enabled improvements in the outcome of surgeries for
ATAAD4. However, it remains a life-threatening medical
emergency associated with high morbidity and mortality. It is essential
to explore ways to reduce perioperative cerebral events after ATAAD
repair as they are associated with poor early
outcomes5. A few possible mechanisms of perioperative
cerebral events after ATAAD repair include partial or complete occlusion
of the arch vessels by the intimal-medial flap (cerebral malperfusion),
hypoxic encephalopathy secondary to shock or tamponade, and/or brain
embolism from thrombus in the false lumen6.7.
Currently, on observing partial thrombosis in the false lumen of the
ascending aorta of a patient with ATAAD, we perform direct cannulation
of the malperfused carotid artery and select the subclavian artery as
cannulation site, to avoid perioperative cerebral events after ATAAD
repair. In our case, we performed true lumen cannulation of the
ascending aorta using the Seldinger technique as we did not observe any
thromboses in the false lumen. Although our patient woke without any
neurological dysfunction on postoperative day 1, he collapsed with right
hemiplegia due to thrombotic embolism associated with BioGlue a few days
after the surgery.
There have been some reports on
the complications associated with the use of BioGlue, such as stroke,
coronary embolism, and pseudoaneurysm formation1-3.
Carrel et al. reported three possible mechanisms by which surgical
adhesives such as BioGlue can cause thrombotic
embolism8 : (1) direct spillage of glue into the true
lumen (despite precautions); (2) escape of glue through distal reentry
sites into the true lumen; and (3) secondary mobilization of glue
particles through suture-line needle holes. With the third mechanism, we
cannot avoid embolic events even with careful application of BioGlue.
Considering that the embolic event in our case occurred a few days after
surgery, we believe that the third mechanism may have played a role,
though we cannot prove it. Cerebral thrombectomy is not usually
indicated for embolic events during surgery. Therefore, we believe our
case indicates that cerebral embolic stroke due to use of BioGlue may
occur more frequently in clinical practice.
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