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J Thorac Cardiovasc Surg 2004;127:593-595
© 2004 The American Association for Thoracic Surgery

Brief communication

Pathologic findings of aortic redissection after glue repair of proximal aorta

^a Division of Cardiovascular Surgery, National Kure Medical Center, Hiroshima, Japan
^b Department of Pathophysiological and Experimental Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan

Received for publication August 18, 2003; accepted for publication September 15, 2003.

^* Address for reprints: Masao Yoshitatsu, Division of Cardiovascular Surgery, National Kure Medical Center, 3-1, Aoyama, Kure, Hiroshima 737-0023, Japan
yoshitatsu{at}kure-nh.go.jp

Gelatin-resorcinol-formaldehyde (GRF) glue (Cardial, Technopole, Sainte-Etienne, France) has become the standard choice in the repair of type A dissections.¹ Several authors have reported the incidence of redissection of the aortic wall just proximal to the anastomosis. The causes remain controversial and some investigators reported that redissection might be caused by necrosis of the aortic wall caused by GRF glue.^2-4 We present our clinical experience with redissection of the aortic root late after repair of type A aortic dissection.

Clinical summary

A 62-year-old male patient had total aortic arch replacement because of aortic dissection (Stanford type A) in December 1999. The distal lumen was fixed with GRF glue and the proximal aortic stump was reinforced with a 1-cm glued Xenomedica strip (Baxter Healthcare Co, Deerfield, Ill) outside and 0.5 cm of 2-mm polytetrafluoroethylene sheet (Gore-Tex; W. L. Gore & Associates, Inc, Flagstaff, Ariz) inside with mattress sutures from inside to outside, and a 28-mm straight Hemashield graft (Meadox Medicals, Oakland, NJ) was anastomosed. The patient's hospital course was unremarkable, without any complications, and he was discharged from the hospital 5 weeks after the operation.

During the 3 years after operation, contrast-enhanced chest computed tomographic (CT) scans were performed once or twice a year and redissection was not detected. Heart murmur was not audible. As the CT scan on March 2002 revealed redissection of the aortic root, reoperation was considered. At this time diastolic murmur was audible and echocardiography showed moderate aortic regurgitation. Only 2 months later echocardiography demonstrated that aortic regurgitation was becoming severe.

The patient underwent aortic root replacement on July 2002. The proximal aortic wall seemed necrotic at the site where GRF glue had been used previously. The intimal layer from the left coronary to right coronary (posterior side) was disrupted from the anastomotic site, which caused the formation of a pseudoaneurysm. The artificial graft was covered with peel proximal to the anastomosis and this peel was the outer layer of the pseudoaneurysm. Aortic root replacement using the Carrel button technique was performed with a composite graft prosthesis. The patient's hospital course was unremarkable, without complications, and he was discharged hospital 4 weeks after the operation.

A photograph of the removed anastomotic site is shown in Figure 1.

View larger version (55K): [in this window] [in a new window]   Figure 1. A, Resected proximal anastomotic site after the first surgery. B, Longitudinal sectional schema of the anastomotic site at the line marked with *. Left, Immediately after first surgery. Right, At reoperation. The specimen of Figure 2 was taken at the line marked with **.

View larger version (115K): [in this window] [in a new window]   Figure 2. A, Photomicrograph of a longitudinal section of proximal anastomosis by hematoxylin-and-eosin staining along the line marked ** in Figure 1. There is an almost complete disappearance of intima and media at the proximal side where GRF glue was applied. The bar represents 1 mm. B, Higher magnification of A. Staining of necrotic tissue of the aortic wall with van Gieson staining. The bar represents 100 µm. C, Higher magnification of A. Staining of aortic wall with Masson trichrome staining. There is an aggregation of macrophages ingesting necrotic tissue. The bar represents 50 µm.

Discussion
Bingley and colleagues² studied the histologic features of the redissected intima by H-E staining. A nonspecific dense acellular fibrous tissue with islands of hyaline material and widespread hemosiderin deposition were seen there. The intimal flap's microscopic appearance together with its degenerate appearance and associated periadventitial fibrosis may have resulted from tissue damage due to the glue.

Kazui and coworkers³ reported that histopathologic examination of endothelium of the redissected aortic wall at the site of GRF glue application showed almost complete disappearance of the nuclei of the medial smooth muscle cells and hemosiderin deposition on the false luminal side of the media. Van Gieson staining revealed disruption of the medial elastic lamellae at the false luminal side. Neither cystic degeneration nor inflammatory change was found there.

In this report we present photomicrographs showing almost complete disruption and necrosis of the intima and media by H-E staining and necrosis of the aortic wall by van Gieson staining. These findings suggest more severe damage of the aortic wall compared with previous reports. We also show aggregation of macrophages ingesting the necrotic tissue by Masson trichrome staining. These findings suggest that inflammatory changes had occurred in this lesion. As the redissection caused inflammation during the healing period, an inflammatory sequence was thought to be associated with the redissection.

It was reported that complications associated with GRF glue are likely to be due to the toxic effect of its formalin component and that care should be taken that the amount of formalin used in the composition of the glue be as low as possible.⁵

Failure of GRF glue may be due partly to the relatively high concentrations of formaldehyde (37%). On the other hand, BioGlue (Cryolife International, Inc, Kennesaw, Ga), the newest of the biologic glue, contains a lower concentration of glutaraldehyde (10%). BioGlue may improve the incidence of redissection after repair of type A dissection.

References

1. Bachet J, Goudot B, Dreyfus G, Banfi C, Ayle NA, Aota M, et al. The proper use of glue: a 20-year experience with the GRF glue in acute aortic dissection. J Card Surg. 1997;12:243–253[Medline]
   
2. L Bingley JA, Gardner MA, Stafford EG, Mau TK, Pohlner PG, Tam RK, et al. Late complications of tissue glues in aortic surgery. Ann Thorac Surg. 2000;69:1764–1768[Abstract/Free Full Text]
   
3. Kazui T, Washiyama N, Bashar AH, Terada H, Suzuki K, Yamashita K, et al. Role of biologic glue repair of proximal aortic dissection in the development of early and midterm redissection of the aortic root. Ann Thorac Surg. 2001;72:509–514[Abstract/Free Full Text]
   
4. Fukunaga S, Karck M, Harringer W, Cremer J, Rhein C, Haverich A. The use of gelatin-resorcin-formalin glue in acute aortic dissection type A. Eur J Cardiothorac Surg. 1999;15:564–569[Abstract/Free Full Text]
   
5. Raanani E, Latter DA, Errett LE, Bonneau DB, Leclerc Y, Salasidis GC. Use of "BioGlue" in aortic surgical repair. Ann Thorac Surg. 2001;72:638–640[Abstract/Free Full Text]
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Fumikazu Nomura Katsuhiko Ihara Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Yoshitatsu, M. Articles by Nakashima, Y. Search for Related Content PubMed PubMed Citation Articles by Yoshitatsu, M. Articles by Nakashima, Y. Related Collections Great vessels