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ICVTS on-line discussion A It's better to let well alone

Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014 Paris, France

Devastating late complication for repair of type A acute aortic dissection with usage of gelatin-resorcinol-formalin glue

eComment: In their article entitled ‘Devastating late complication for repair of type A acute aortic dissection with usage of Gelatin-Resorcinol-Formalin glue’ Izutani and co-workers [1] report on a single case of false aneurysms on the proximal and distal anastomoses in a patient who had undergone emergency surgery for acute type A dissection 34 months earlier with the aid of GRF glue. The authors consider that this adjunct was responsible for the occurrence of the late false aneurysms. Is it so?

In the present report, the authors seem to have used the glue appropriately. In particular, being aware of the potential toxicity of the polymerizing agent, they have reduced its quantity according to the manufacturer's recommendations.

However, it is somewhat intriguing that, whereas the GRF glue has been used liberally for several decades worldwide (except in the US), most of the few reported cases of late complication (mainly aortic necrosis and false aneurysms) have been observed in Japan. One may wonder whether this is not related to the fact that the surgeons, in their legitimate desire to obtain a safe, reliable and stable result, do not trust the GRF glue alone as being a safe adjunct and use concomitantly other adjuncts to reinforce the aortic anastomoses. This includes Teflon felt bands, autologous or heterologous pericardium, put outside and/or inside the true and false channels in various modes of ‘sandwiches’, In addition, those adjuncts are often glued again after completion of the anastomosis to enhance local haemostasis. Could it be that, ‘better being the enemy of good’, those complicated and somewhat overcautious methods induce some necrosis at the site of the anastomosis and subsequent occurrence of false aneurysms?

This hypothesis is strengthened by the very high and unusual rate of false aneurysms reported by the authors. Despite the reduction in the quantity of Formalin and Glutaraldehyde, 3 out of 8 patients (40%) experienced a postoperative false aneurysm. In the largest series of acute dissections operated on with the aid of GRF glue appearing in the literature, such a high rate of late false aneurysms has never been reported. Indeed, in many groups, and particularly in Europe, the glue is the only adjunct used to stick together the dissected layers and to reinforce the anastomoses. For instance, in our experience extending over exactly three decades and including 242 patients, only glue was used in most patients and Teflon felt was very seldom required. Reoperation on the proximal aorta was necessary in 17 patients out of the 196 survivors (9%) and in only 4 patients (2%) for occurrence of a false aneurysm. Even if we consider that some patients have been lost to follow-up and might have been re-operated on elsewhere, the rate of false aneurysm possibly related to the use of GRF glue is quite different from the one reported in the present article.

Izutani and co-workers allude to this problem in their discussion but state that they have decided to discard the use of GRF glue albeit keeping their technique of aortic sandwiching. They could have chosen to keep the glue and discard the ‘sandwich’ procedure. The improvement in the results could be similar. Future will tell.

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1. Izutani H, Shibukawa T, Kawamoto J, Ishibashi K, Nishikawa D. Devastating late complication for repair of type A acute aortic dissection with usage of gelatin-resorcinol-formalin glue. Interact CardioVasc Thorac Surg 2007; 6:240–242.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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): Jean Bachet Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Bachet, J. Search for Related Content PubMed PubMed Citation Articles by Bachet, J. Related Collections Related Article