Use of “BioGlue” in Aortic Surgical Repair

Ehud Raanani, MD, David A. Latter, MD, Lee E. Errett, MD, Daniel B. Bonneau, MD,
Yves Leclerc, MD, and Gary C. Salasidis, MD
Division of Cardiovascular Surgery, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada

A new bioadhesive (BioGlue, Cryolife Inc, Kennesaw, of the glutaraldehyde component. The glue is applied
GA) was recently introduced for surgical use in thoracic between the layers of the dissected aorta, to the two
aortic surgical repair. We describe our early experience layers of the aortic wall, and to the adventitia of the aortic
and our suggested method of repair. wall. Since no long-term follow-up information is avail-
(Ann Thorac Surg 2001;72:638 – 40) able on the effect of BioGlue on arterial tissue, we limit its
© 2001 by The Society of Thoracic Surgeons use to the local aortic tissue only. A simple end-to-end
anastomosis between the Dacron (C. R. Bard, Haverhill,
MA) graft and the treated aorta is then completed.
Generally, we do not find it necessary to use any rein-
T issue glues are used as surgical adjuncts in cardiac
surgical procedures. Gelatin-resorcin-formalin
(GRF) glue is the most widely used in surgical treatment
forcement sutures or Teflon (L. R. Bard, Tempe, AZ) felt
strips to support the anastomosis.
of dissecting aortic aneurysms [1–3]. Recently a new When the distal anastomosis is completed, cardiopul-
biological glue (BioGlue, Cryolife Inc, Kennesaw, GA), monary bypass is reinstituted through a cannula in the
has been developed and approved for surgical use in ascending aortic Dacron graft, rewarming of the patient
Canada by the Health Protection Branch. is started, and the proximal aorta is prepared for sutur-
BioGlue is composed of purified bovine serum albu- ing. The glue is applied in the same manner as at the
min (45%) and glutaraldehyde (10%). Glutaraldehyde distal anastomosis with protection of the surrounding
exposure causes lysine molecules of bovine serum albu- tissues (Fig 4). The glue is applied between the layers of
min, extracellular matrix proteins, and cell surfaces to the dissected aortic wall, to the two layers of the aortic
bind to each other creating a strong scaffold (Fig 1). The wall, and to the adventitia of the proximal aortic wall. It is
reaction is instantaneous and reaches maximum bonding essential to protect the ostia of the coronary arteries from
strength in 2 to 3 minutes. In vivo bovine animal studies accidental spillage of glue. This can be accomplished by
demonstrated that aortic bonding with BioGlue pro- inserting a fine flexible plastic cannula into the ostia
duced a tensile strength of 847 ⫾ 127 g/cm and an ex vivo before applying the glue. After gluing the sinuses back to
shear strength (lamina to media) of 256 ⫾ 46 g/cm [4]. The the aortic wall, the commissures of the aortic valve are
delivery system includes a reusable delivery device, a further anchored to the aortic wall using three sutures
prefilled solution cartridge, and fine pointed applicator supported with Teflon pledgets. Preservation of the aor-
tips (Fig 2). This report summarizes our initial experience tic valve requires precise resuspension of the commis-
with BioGlue and describes suggested methods of use. sures, and may involve scalloping of the residual proxi-
mal aortic wall and complementary scalloping of the
Technique Dacron graft. The use of BioGlue and the avoidance of
stiff Teflon felt strips make this precise reconstruction
Between August 1999 and March 2000, BioGlue was used
easier. The proximal anastomosis is then performed in a
as a surgical adjunct in 8 patients who underwent surgi-
simple end-to-end anastomosis between the proximal
cal repair of acute A aortic dissection and 10 patients who
aorta and Dacron graft.
underwent repair of degenerative ascending or descend-
BioGlue is also used in operations for atherosclerotic
ing thoracic aortic aneurysm.
All operations for type A aortic dissection were per- aortic aneurysm repair to increase the strength of the
formed using deep hypothermia and total circulatory aortic tissue at the site of the aorta-to-Dacron-graft anas-
arrest. At the distal anastomotic site, BioGlue is used to tomosis. It is applied to the aorta at the intended site of
adhere the dissected layers and create stronger aortic anastomosis taking care to protect the adjacent tissues in
tissue for sewing (Fig 3). Before applying the glue, all the same manner as described earlier.
tissues surrounding the aortic arch are protected with Hospital mortality was 17% (3 of 18). One patient
wet sponges. The aortic arch is in close proximity to undergoing aortic dissection died in the operating room
structures such as phrenic and vagus nerves, and caution from cardiogenic shock. Another such patient did well
should be taken to avoid exposing them to the toxic effect from a cardiovascular point of view but suffered a peri-
operative stroke and died 120 days postoperatively. One
Accepted for publication March 22, 2001. patient undergoing atherosclerotic aortic aneurysm re-
Address reprint requests to Dr Latter, 30 Bond St, Toronto, Ontario, pair died in the operating room from a combination of
Canada M4G 1A8; e-mail: latterd@smh.toronto.on.ca. bleeding and cardiogenic shock. Mean postoperative

© 2001 by The Society of Thoracic Surgeons 0003-4975/01/$20.00

Published by Elsevier Science Inc PII S0003-4975(01)02663-7
Ann Thorac Surg HOW TO DO IT RAANANI ET AL 639
2001;72:638 – 40 “BIOGLUE” IN AORTIC SURGICAL REPAIR

Fig 1. Reaction mechanism. Bovine se-

rum albumin, extracellular matrix
(ECM), and cell membrane proteins
contain lysine molecules with an amine
group side chain. Aldehyde links two
amine groups.

Fig 2. Delivery system. A prefilled car-

tridge automatically mixes the solution.

chest tube blood loss in the first 24 hours was 702 ⫾

457 mL. Median postoperative intensive care unit stay
was 96 hours (range, 24 to 740 hours). Median hospital
stay was 10 days (range, 6 to 120 days). Seven of the eight
type A aortic dissections were associated with significant
preoperative aortic insufficiency. With the aid of BioGlue,
6 of 7 patients had successful resuspension of their aortic
valve. During short-term follow-up (5 to 12 months;
mean follow-up, 9.2 months) no patients required reop-
eration for redissection, delayed rupture, or aortic
insufficiency.

Comment
Recently, concern has been raised regarding the late
effects of tissue glues. Bingley and colleagues [5] found a
high reoperation rate, mostly due to redissection in the
proximal portion of the aorta causing aortic insufficiency,
in patients in whom GRF glue was used in the repair of
acute aortic dissection associated with aortic valve regur-
gitation. Failure of GRF glue may be due partly to the
relatively high concentrations of formaldehyde (37%) and
limitations of the delivery system. In contrast, BioGlue Fig 3. Distal repair using BioGlue. Wet sponges (A) protect sur-
contains a lower concentration of glutaraldehyde (10%) rounding tissues. BioGlue is applied between the layers of the aorta
and a precise delivery system. Gundry and coworkers [6] (B) and the adventitial surface of the aorta (C).
640 HOW TO DO IT RAANANI ET AL Ann Thorac Surg
“BIOGLUE” IN AORTIC SURGICAL REPAIR 2001;72:638 – 40

Glue, the newest of the biological glues, has a stronger

glue effect than older surgical glues such as GFR glue,
and will likely prove to have superior long-term results in
aortic dissections. Longer-term follow-up of patients
treated with BioGlue is necessary.

We thank Mr Zahir Young for drawing the illustrations.

References
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Fig 4. Proximal repair using the glue. (A) A soft cannula protects experimental bioadhesive. Presented at the XVIth Congress
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