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.
References
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7. Geirsson A, Szeto WY, Pochettino A, et al. Significance of malperfusion syndromes prior to contemporary surgical repair for acute type A dissection: outcomes and need for additional revascularizations.Eur J Cardiothorac Surg . 2007; 32(2): 255-262.
8. Carrel T, Maurer M, Tkebuchava T, Niederhäuser U, Schneider J, Turina MI. Embolization of biologic glue during repair of aortic dissection.Ann Thorac Surg. 1995;60(4):1118-1120.