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A systematic English language literature search was con- ducted using MEDLINE and PubMed between January 1974 and August 2008. Keywords used for the search in- cluded bleeding, hemostatic agent, sealant, and cardiac surgery. Additional reports were identified by references cited in the publications found using the search terms and also in published review articles. Emphasis was placed on randomized controlled studies where possible.
97 30% mortal ec bleed Know 2%
Bleeding is a life-threatening complication in thoracic aortic surgery. Multiple interrelated factors Peng Hao et al. / Journal of Medical Colleges of PLA 24 (2009) 99–104 are associated with hemostasis, which can be summarized into four categories: 1. the integrity of aortic wall and condition of the aortic tissue; 2. disturbance of blood clotting and coagulation caused by cardiopulmonary bypass; 3. material of the composite graft; 4. surgical technique . As no significant difference was found in general clinical information, diseases involved, preoperative hemotologic values, duration of cardiopulmonary bypass and aortic cross-clamp time, and type of composite graft used, difference in hemorrhage should be attributed to different surgical techniques performed between the groups. Crawford and associates  reported that reoperation for bleeding was a predictor of early mortality in aortic dissections. Uncontrollable oozing and bleeding after aortic anastomo- sis can occur in aortic surgery. Recently, the prosthetic graft has been improved, and a number of documents have reported various methods for achieving good hemostasis [1–7]. In these documents there are two methods for reduc- tion of bleeding. One method is suture line reinforcement to prevent bleeding from anastomosis. This type of proce- dures includes the use of Bioglue (CryoLife), an adventitial inversion technique, or a graft insertion technique [4–6]. These are performed during the primary anastomosis, and these are oftentimes complex and may not always be perfect. The other method is performed after anastomosis as an additional procedure, such as the Cabrol shunt technique [3, 7]. Our technique is the latter and should be performed after anastomosis when necessary. Additional stitches using pledgets is also a simple technique, but new bleeding will often come from new suture holes when using this method. On the contrary, our technique requires no suture on the suture line and is very simple. Earlier re- ported wrapping methods are also effective but can not seal the bleeding coming from small gaps of anastomotic sites. In the present warpping method, fat tissue inserted be- tween the anastomotic site and the Teflon felt strip can completely seal the gap, because it is plastic and conform- able. We have used this technique in 12 cases from October 2007 to January 2009. We placed many additional stitches with this technique and used a lot of transfusions of platelets and fresh frozen plasma in the first three cases, in which we found that this technique showed perfect hemo- stasis. After these cases, we used this method whenever we had a case of persistent bleeding, which resulted in the reduction of operation time and blood transfusion. There was no thrombus between the fat tissue and the graft in the postoperative computed tomographic scan (Fig 1). In con- clusion, this novel hemostatic technique is very simple and leads to excellent operative results.
All aortic anastomoses were performed using a standard- ized technique. Prolene (3-0) was used in the vast major- ity; a few patients had anastomosis performed with 4-0 Prolene. The back wall of the anastomosis was carried out open, with a continuous suture passing through the graft, the strip of Teflon felt, and the aorta The graft was then positioned carefully inside the aorta and the Teflon felt strip outside, and the suture line was tight- ened with a nerve hook (Fig 1B). The anterior portion of the anastomosis was then performed either open or closed, with particular attention to positioning the graft within the aorta, and placing the Teflon felt outside (Figs 1C and 1D). Thus the suture material compresses the aortic wall between the Teflon felt and the graft material, and the sutures per se do not pull on the aortic wall. Biological glue, which consisted of concentrated fibrin- ogen and topical thrombin, was used in a few cases in the early 1990s, but glue containing denaturing agents (such as glutaraldehyde or formaldehyde) was never utilized. Tightly woven grafts soaked with albumin and subse- quently autoclaved were used in the early 1990s; there- after, commercially prepared open weave grafts impreg- nated with albumin (Hemashield) were used in all cases
Excessive bleeding after aortic surgery is generally related to a combination of several alterations in the hemostatic system pertaining to the dilution and activa- tion of the coagulation system, which is mainly attributed to the use of extracorporeal circulation.
The repair of spontaneous dissecting aortic aneurysms or iatrogenic aortic dissections can be very complex because of the extreme friability of the aortic tissue, the extent of damage to structures, and in many cases, secondary organ involvement [1, 2]. Many techniques have been used to reinforce the friable aortic tissue. Teflon felt has been amply used, but many times the resultant aortic cuff is tough and of small size. Bleeding from this graft– “sandwiched” aorta can be troublesome. Resorcinol glue, although extremely useful to reinforce the aortic tissues [7, 8], is not available in the United States. Topical 25% glutaraldehyde, as described by Vasseur and Hamond  for dissecting aneurysms and later by us for friable aortas , is very effective in toughening aortic tissue. How- ever, the procedure of applying the glutaraldehyde is tedious, and it can damage the surrounding tissue. The adventitial inversion technique described by Flo- ten and colleagues  is an effective method of modifying the friable aorta to create a tough but soft aortic cuff. The toughness ensures that the sutures hold without tearing. The softness allows the use of small needles and sutures to facilitate a hemostatic anastomosis. Their remarkably low (7.1%) mortality  alerted us to the versatility of this technique. Dissecting aneurysms can create practically unsolvable surgical situations. Our experience expands the use of the adventitial inversion technique to other complex surgical situations. Thus, most patients can be handled with the techniques outlined here. None of the 11 aortic cuff–graft anastomoses bled intraoperatively or postop- eratively. We recommend this simple technique to repair dis- secting aneurysms, because it has changed our percep- tion and approach to this highly complex problem. Our experience is small; thus, it is difficult to draw meaningful conclusions about the universal applicability of the tech- nique and long-term results. However, in 1995, Floten and colleagues  had treated 29 patients with excellent results in the short- and long-term follow-up.
However, there are some experimental reports suggesting that, due to the extrinsic coagulation pathway via exposed adventitial collagen and tissue factor, inverted adventitia may elicit thrombus formation with subsequent emboliza- tion,4) although the thrombogenicity of inverted adventitia has not been tested clinically to our knowledge. Wishing to address this technique’s advantages and its potential complications, we integrated this method with our method of telescopic graft insertion.5) This resulted in complete coverage of the inverted adventitia, eliminating the potential risk of thrombus formation. Furthermore, reinforcement of the intima by two adventitial layers, an external felt strip, and tube graft (Fig. 1C) lead to com- plete hemostasis, eliminating the need for hemostatic stitches and resulting in stable anastomosis.
Although various techniques have been advocated in the surgical treatment for acute aortic dissection, hemostasis at anastomotic sites is still a difficult part of the surgery [1-2]. We began using the ‘turn-up’ technique which involved eversion of the graft at both proximal and distal ends for acute type A dissection since February 2003. Consecutive 30 patients underwent emergent operation with this technique safely. 2. Technique Open distal anastomosis was performed at 25—28 8C with ante-grade selective cerebral perfusion. ‘Turn-up’ anastomosis was performed by the following methods. After trimming the end of the aorta, 6—8 U-stay sutures were placed between the graft and the aorta with reinforcement by a felt strip on the external border of the aortic wall (Fig. 1). The U-stay sutures were tied down with everting the end of the graft (Fig. 1). Excellent cross-sectional exposure of the aortic wall layer and the graft was obtained and continuous 4-0 polypropylene sutures could be easily added to complete the anastomosis (Fig. 2). Proximal anastomosis was performed in the same method. This turn-up method was used in con- secutive 30 patients of acute aortic dissection. There was no hospital mortality and one case of re-exploration for bleeding. that the significance of the U- stay sutures was not hemostasis, but eversion of the end of the graft for good cross-sectional exposure of the aortic layer and graft, we decrease the number of the U-stay sutures. Six to eight U-stay sutures might be enough for everting the ends of the graft. In addition to easiness of the following continuous suturing, the cross-sectional exposure enables it easy to find bleeding points and put additional stitches for hemostasis. Unlike elephant trunk technique or other techniques, the turn-up technique can be applicable to both proximal and distal ends
The aortotomy is extended distally but never beyond the arterial ligament to protect the recurrent and phrenic nerves, and transversely, and the posterior aspect (Asian Cardiovasc Thorac Ann 2008;;16:416–8) of the aorta is incised longitudinally until it reaches the distal anastomotic area of the descending aorta. The left mediastinal pleura is widely opened so that the distal anastomotic area can be approached and palpated directly from the lateral side through the left thoracic cavity. This maneuver makes distal anastomosis quite easy and secure (Figure 1). For quick and accurate transection of the descending aorta in the deep surgical ﬁeld, DeBakey valve scissors (Pilling Weck, Markham, Canada) are very useful as the blades are acutely curved. The mediastinal pleura covering the lateral wall of the anastomotic area is left to be used as reinforcement material for anastomosis. Small arterial branches around the anastomotic area are ligated and severed at this point. A double-layer graft, approximately 3 cm long, is introduced into the transected aorta with its cuff side accurately adjusted to the suture line. A Teﬂon felt strip is positioned outside to reinforce the anastomosis. Several intermittent sutures are placed on its circumference to prevent dislodgment of the graft and felt strip. The felt strip, mediastinal pleura, aorta, and both layers of the graft are tightly sewn together using an over-and-over continuous suture of 4/0 polypropylene (Figure 2A). The inner layer of the graft is pulled out, while the outer layer works as an “elephant trunk” (Figure 2B). After the former is anastomosed to the 4-branched graft, graft perfusion is started. During systemic rewarming, reconstruction of the arch vessels and proximal anastomosis of the graft to the ascending aorta are completed.
Surgical repair of acute aortic dissection can be very complex because of the extreme friability of the aortic tissue, and hospital mortality is still high (10–20%),2 largely owing to anastomosis complications such as bleeding and dehiscence. Methods currently employed to minimize suture line complications make use of Teflon felt strips for reinforcement combined with biologic glue (gelatin-resorcin-formalin). The procedure of applying this glue is tedious, and it can damage the surrounding tissue. The use of biologic glues to re-approximate layers of the dissected aortic root is reported to be associated with increased risk of aortic wall necrosis.4 Various techniques of aortic anastomosis have been reported to reduce anastomosis complications in the repair of aortic dissection,3,5 such as the so-called sandwich technique.6 Our method has three main advantages: the stiffness of the cuff, the broadness of surface area between the graft and native aortic wall, and the safety of cerebral perfusion during the distal anastomosis. The proximal and distal stumps are reinforced by the adventitial inversion and the outer felt strip. The surface area between thegraft and the native aortic wall is significantly increased 1. by the graft turn-up procedure, and complete hemostasiscan be achieved by the graft turn-up and the additional continuous sutures. In our patients, we applied this technique only in replacement of the ascending aorta. However we hypothesize that partial arch replacement or total arch replacement can be performed with this technique ifthe intimal tear continues to the aortic arch. Although 4. complicated, these procedures can be performed safely under selective cerebral perfusion with moderate hypothermia. As a result, intraoperative and postoperative bleeding was reduced. The adventitial inversion and graft turn-up method, or modified sandwich technique, will likely be useful for the surgical treatment of acute aortic dissection. Tech The distal cuff is prepared with the adventitial inversion as on the proximal side. A collagen coated graft (Hemashield, Meadox Medical, Oakland, NJ, USA) is anastomosed with four everting mattress sutures of 2-0 polybutylate-coated braided polyester (Ethibond, Ethicon Inc., Somerville, NJ, USA) (Figure 2), and 3-0 polypropylene (Prolene, Ethicon Inc., Somerville, NJ, USA) running sutures are placed at the outermost side (Figures 3, 4). After completion of the distal anastomosis, reperfusion of the body is started. During systemic rewarming, another Hemashield graft is anastomosed with four everting mattress and running sutures for the proximal anastomosis as on the distal side. The two grafts are trimmed and anastomosed with 4-0 prolene running sutures. For cases complicated by an open false channel with thrombosis or by dissection of carotid branches, the distal adventitial and graft turn-up procedure is performed first under selective cerebral perfusion. Proximal management and graft-graft anastomosis are carried out during systemic rewarming.
Resection of the aortic arch and ascending aorta was undertaken and a Dacron tube graft was used as a replace- ment conduit. Felt or BioGlue was placed between the intima and adventitia to obliterate the false lumen and recreate a neo-media (Fig. 1). Hemiarch repair was used in 96 patients, and an extensive or total aortic arch replacement (elephant trunk procedure) was used in 8 patients. The primary tear site was resected in all patients. On completion of the aortic arch reconstruction, blood was allowed to occupy the native aorta and graft, allowing air and debris to be evacuated from the cerebrovascular system. The entire arterial circulation was deaired at this time via the RCP circuit. The arch graft was cannulated and then proximally cross-clamped, with RCP termination and resumption of arterial perfusion and rewarming directly through the aortic arch graft for antegrade perfusion. The aortic root was replaced or repaired depending on the pathology present. When repair was deemed possible, the aortic valve leaflets were resuspended using three pledgeted supracommissural sutures. The sinus of Valsalva segments were then reinforced with Teflon felt as a neo-media (Fig. Figure 1. Application of felt “neo-media” placed between adventitia and intima. 2), and more recently BioGlue was used as an adjunct. In 81 patients, the aortic root was repaired, and in 23 patients the aortic root was replaced with either a biologic or a mechan- ical valved conduit (see Table 2). Indications for the re- placement of the aortic root included bicuspid aortic valve (n 9), Marfan syndrome (n 10), Ehlers-Danlos syn- drome (n 1), primary abnormalities of the aortic valve leaflets, obvious sinus of Valsalva aneurysm, and extension of both the tear and dissection to the aortic annulus (see Table 2). TEE was used in all patients to assess the ade- quacy of the aortic root repair All patients received 1 g methylprednisolone (Solu-Medrol) intravenous bolus, 1 g MgS04 intravenous, 2.5 mg/kg lidocaine intrave- nous, and 12.5 g mannitol intravenous. These neuroprotec- tive agents were given immediately before initiation of CPB In conclusion, our data show improved survival and low postoperative stroke rates with the use of an integrated perioperative approach to acute type A dissection. Together, these measures create a new paradigm that consists of: 1. Rapid admission to the operating room for diagnosis and therapy 2. Intraoperative TEE3. Neurocerebral monitoring4. Routine open aortic arch reconstruction with RCP5. Routine antegrade arch graft perfusion after comple- tion of arch repair6. Aortic root repair and aortic valve resuspension in most patients when preexisting leaflet or root pathology is absent 7. Creation of a neo-media using either felt or BioGlue to New Paradigms for Acute Type A Dissection 341 strengthen the aortic and sinus walls and obliterate the false lumen.
From 1994 to 2005, 100 patients with acute type A aortic dissection underwent supracommissural graft replacement using a fabric as “neomedia” and fibrin glue. Mean patient age was 65.7 ± 11.3 years
Two long strips of Teflon (0.8-1 cm width) are tailored to corre- spond to the circumference of the proximal and distal aor- tic stump. A 25 mm automatic stapler applies 9.8 mm large ligation clips (ETHICON®, LIGACLIP®, MCA, USA) at five to eight sites along the periphery of each stump (Figure 1). Care is taken to space the clips in such a fash- ion so as to avoid loops and gaps of the strips. The left ventricle (LV) is vented with a suction cannula inserted through the AV. A small piece of gauge with a central whole at the level of the AV prevents accidental fall of the clips in the LV. In the event of acute aortic dissection a sin- AFipgpulirceat1ion of stapler for Teflon strips fixationApplication of stapler for Teflon strips fixation. A. Sur- gical field image, B. Graphic design representing the tech- nique. gle strip of Teflon between the two layers of the dissected aortic wall is used, applying the same principle. In as much as the teflons strip surface a thin layer of glue is injected and left to fuse (Gelatin resorcinol formalin glue GRF®, Cardial, Technopole, France or BioGlue BIOGLUE® Surgical Adhesive glue, CryoLife, USA) (figure 2, 3). The edges of the remodelled aortic portions are sub- sequently sewn to the Dacron graft -at the appropriate level- with a continuous 4-0 Prolene suture. The clips are easily removed with a gentle pull during the anastomosis (figure 4). It is a matter of judgement as to how much glue needs to be injected. In some cases the extended use of biologic glue is regarded as precarious. Although no complication has been reported as yet, reservations relating to the use of glue still remain. The above technique allows exact cooptation and facili- tates suturing, regardless the use of glue. Stay clips may always be used to optimize symmetric positioning and proper Teflon structural adaptation; they can be easily removed in the course of the Dacron- Aortic anastomosis. The technique described above diminishes considerably the stump preparation-time, contributes to reduced fria- bility and is expected to contribute to better short term survival. The use of bulldogs instead of ligation clips has been described in surgical textbooks and could certainly be an alternative option. However their size makes the surgical manipulations much harder. In addition, their use demands that the assistant holds them in certain position until the glue sets.
The distal anastomoses of the aortic arch were performed by the following methods: two or three U stay sutures were placed between the graft (outside-in) and the distal end of the aorta (inside-out) evenly. The graft was rolled back approximately 5 mm. This inverted graft was placed into the opened distal end of the aorta. The suture line was observed circumferentially and easily anastomosed with 4-0 polypropylene sutures (Fig 1). The four-branched, gelatin-coated woven Dacron (C.R. Bard, Haverhill, PA) graft was used for arch replacement. The proximal aortic anastomosis was also performed by the cuffed technique. The brachiocephalic artery, left carotid artery, and left subclavian artery were end-to-end-anastomosed with each branched prosthetic graft, respectively. This simple method was used in 41 cases of true aortic arch aneurysm and 8 cases of chronic dissecting aneu- rysm. The hospital mortality was 2%. The cause of only 1 patient death was multiorgan failure. The ideal anastomotic technique results in absence of bleeding, stenosis, and other injury. The distal arch anastomosis tends to be complicated because of the depth of the surgical field, and thus, open distal anasto- mosis has been widely accepted as a standard technique. The inversion of the graft within itself was first reported by Griepp and colleagues , in which a graft was anastomosed to the proximal descending aorta during aortic arch replacement. Svensson  modified this tech- nique and emphasized that the suture line is automati- cally tightened after the graft is unfolded, resulting in freedom from bleeding.
The ascending aorta and arch were approached through a redo median sternotomy. Arterial return was established into the bilateral subclavian arteries via the divided pre-existing axillo-axillary bypass graft, along with the bilateral common carotid arteries and the right femoral artery. Venous cannulae were placed into the superior vena cava directly and the inferior vena cava via the right femoral vein. A vent tube was introduced from the right upper pulmonary vein into the left ventricle. The patient was cooled down to 22°C. After cross-clamping the ascending aorta, antegrade and retrograde cardioplegia was administered. Lower body circulatory arrest was established. The aortic arch was incised longitudinally employing an open distal technique. Aortic ruptures caused by the flares at the proximal side of the thoracic aortic endograft were identified as depicted in Fig. 2a and b. The proximal flares of the stent graft had appar- ently perforated the aortic wall at two sites. Purulent discharge was not observed in the pseudoaneurysms, nor was slime around the stent graft. After the flares of the previously inserted stent graft were cut, a 26-mm Triplex® (Terumo Corporation, Tokyo, Japan), 2 cm in length, was inserted into the proximal end of the stent graft as a short elephant trunk. After trimming the distal aortic wall, a distal anastomosis  was performed with a modified cuffed anastomosis technique. Eleven U-stay sutures of 4–0 polypropylene with a felt pledget were placed evenly through the distal end of the aorta (outside-in), the stent graft, the graft as an elephant trunk, and a four-branched prosthetic graft (inside-out). Also, in order to prevent the edge of the trans- ected stent graft from injuring the surrounding tissue, the everted graft end was folded over the external side of the aortic stump. Continuous running 3–0 polypropylene suture was cir- cumferentially placed with felt strip reinforcement. A schema of the anastomosis is illustrated in Fig. 2c and d. After completion of the distal anastomosis, reconstruction of the arch vessels and of the proximal aortic anastomosis were performed.
The aortic wall was trimmed to leave only 0.5 cm above the sinotubular junction and any hematoma was cleared. The vascular graft was chosen according to the diameter of the tunica intima plus 2 to 3 mm. Twelve multiple interrupted pledgeted 3-0 horizon- tal mattress sutures were passed from the proximal aortic lumen into the outside circumferentially (Fig 1). Those sutures were then passed from the inside to the outside of the vascular graft and exited approximately 5 mm from the edge. The vascular graft was then lowered to include the proximal aorta telescopically. After the sutures were tied, the edge of the vascular graft was sutured to the aortic adventitia layer with continuous 5-0 prolene cir- cumferentially for reinforcement. Then the clamp was moved to the right innominate artery. The distal aorta was trimmed to the relatively healthy region after re- moval of the thrombus, and the prosthesis graft was cut to the approximate length. Twelve multiple interrupted nonpledgetted 3-0 horizontal mattress sutures were passed from the inside to the outside of the vascular graft, and then passed from the distal aortic lumen to the outside; the exit was 5 mm from the distal aortic stump The sutures were tied and reinforced with a Teflon strip (Bard PTFE felt; Bard, Tempe, AZ) circumferentially. The distal end of the vascular graft was thereby telescoped into the distal aortic lumen. Then the patient was re- warmed and the cardiopulmonary bypass was weaned. The cardiopulmonary bypass time was 185 minutes, the cross-clamp time was 101 minutes, and the selective anterior cerebral perfusion time was 44 minutes. The 24-hour pericardial drainage was 300 cc postoperatively. The patient experienced an uneventful postoperative recovery. After 6 months, the follow-up computed tomo- graphic scan revealed complete obliteration of the dis- sected lumen with a perfect telescopic aortic shape (
To create the distal anastomosis, about 12 stay sutures are inserted through a Teflon felt strip placed around the end of the distal aortic stump and through the stump, as in aortic valve replacement. These sutures are then inserted through the cuff of the graft (Figure 2A). After tying the graft down and pushing its trunk into the aortic stump, the anastomosis is secured with a 3/0 continuous suture (Figure 2B). Systemic perfusion is resumed, and the femoral cannula is switched to graft perfusion. The proximal portion of the graft is anastomosed to the proximal aortic stump, and the brachiocephalic branches are reconstructed. We began to use stay sutures prior to insertion of the continuous suture after we experienced bleeding from the anastomosis made with a 3/0 continuous suture alone. Securing the graft to the stump with stay sutures facilitates insertion of the continuous suture. Unlike the original elephant trunk technique, which involves the insertion of a tube graft into the descending aorta, there is no fear of bleeding from the anastomosis in our technique with the creation of a cuff. Previously, using a different technique of graft preparation, we used only knitted Dacron grafts because of their elasticity.4 However, with the present technique, a cuff can be created easily in any type of prosthesis, including woven Dacron graft, which we are now using. The simplified elephant trunk graft reduces hemorrhagic complications and promotes thrombotic closure of the false lumen in the descending aorta. However, this technique is contraindicated when the distal aorta is small and does not allow the graft to open fully.
The graft size should be approximately 4 mm smaller than the distal anastomotic site diameter in the descending aorta be- cause the graft wall at the eaves is about 2 mm in thickness. First, we determined the optimal length of graft distal to the fourth branch. Four to five centimeters of the length of the graft was invaginated (Fig 1A). One or two 5-0 polypropylene horizontal mattress sutures were put along the line approximately 1 cm from the “new edge” circumferentially (Fig 1B). Then the invaginated portion of the graft was withdrawn and 1-cm wide eaves, which would become the site of anastomosis, were cre- ated (Fig 1C). The eaves were reversed to make anasto- mosis easier (Fig 1D, E). The graft was bound with vessel tape from the eaves to the site proximal to the origin of the first branch to make a working space above eaves and to bundle four branches and the arch graft together (Fig 2A). This maneuver made the anastomosis easier and more secure by facilitating graft handling and by providing a wide surgical view around the anastomosis (Fig 2B). Distal anastomosis was performed as follows: four 4-0 polypropylene U stay sutures were placed between the eaves (upside-underside) and the distal end of the aorta (inside out) evenly. Each suture was passed through polytetrafluoroethylene (PTFE) felt pledgets (1.0 0.5 cm) outside the aortic wall (Fig 3A). After the distal end of the graft was inserted into the descending aorta, the four stitches were ligated to fix the underface of the eaves to the inner wall of aorta. Then the aorta was sutured to the eaves with a continuous 4-0 polypropylene suture incor- porating a 1.5-cm wide strip of PTFE felt, which was positioned outside the aorta for reinforcement (Fig 3B). After completion of the anastomosis, the binding tape was released. Because no surgical bleeding was found in the anastomoses, additional stitches were not needed for hemostasis.
The ascending aorta is dissected posteriorly opposite the cannulation site and separated from the pulmonary artery at this level. The dissection is continued up to the innom- inate artery. An 8- or 10-mm Dacron graft is passed under the aorta and wrapped over the site (Fig 1A). A right- angled clamp is used to provide sufficient tension over the site (Fig 18). Horizontal mattress sutures are placed under the clamp using nonabsorbable braided suture to secure the Dacron wrap. Alternatively, a 30-mm stapler can be used to secure the graft in place. The amount of tension is critical, and proper tension results in mild constriction of the aortic lumen. The free ends of the graft are then trimmed close to the securing sutures (Fig 1C). Hemo- static materials can be placed under the graft overlying the site in question before completion of the wrap, although the pressure supplied by the bodice usually is sufficient to arrest any bleeding In contradistinc- tion, the bodice, by constricting the aorta at a very specific level, provides security by decreasing tension at the site. We, therefore, limit our total number of sutures at the aortic cannulation site to three: two original concentric sutures and one repair suture-the latter in double pledget mattress configuration in a cephalocaudal orien- tation to avoid &quot;hourglass&quot; deformity of the aorta. If there is continued bleeding, or if the integrity of the aortic closure is in question, we employ the bodice technique to reinforce the aorta.
Persistent oozing and bleeding after aortic anastomosis can occur during aortic surgery. This may become uncontrollable because of severe coagulopathy, resulting from induced hypothermia, long cardiopulmonary bypass time, or fragile aortic walls by acute aortic dissection. There are a lot of methods used to prevent this bleeding, such as anastomosis techniques to reinforce a suture line, Bioglue (CryoLife Inc, Kennesaw, GA) for anastomosis, or wrapping methods, such as the Cabrol shunt, which have been reported [1–3]. However, these techniques are not always perfect and are too complex to perform for every anasto- mosis during a tough operation. In this report, we describe a novel wrapping technique with insertion of fat tissue between the anastomotic site and the Teflon felt (DuPont, Wilmington, DE), which is a simple, effective, and reliable technique, and should be useful to obtain perfect hemosta- sis on the suture line. Enough fat tissue is harvested, sometimes around the peripleura under the divided sternum. The thickness and width of harvested fat should be adjusted to bleeding conditions. The thickness of 1 mm is enough to be an even suture line like graft-to-graft anastomosis. However, 3-mm to 4-mm thickness is necessary to completely seal a bumpy surface after placing some stitches and pledgets. The width of 1-cm to 2-cm is enough to cover bleeding points. hen, harvested fat tissue is placed on a Teflon felt strip (DuPont) or a used prosthetic graft, which is 1.5-cm to 2.0-cm wide, and fixed to these using some interrupted stitches by a 5-0 Prolene suture (Ethicon, Somerville, NJ). Finally the anastomotic portion including bleeding points is wrapped by this composite felt. We can control the applied pressure by using our fingers, which will immediately reduce the bleeding. Then, both ends of the felt strip are tightened using interrupted sutures after confirming a perfect hemostasis (Fig 1).
One of the biggest challenges during surgery for AAD, besides adequate neurological protection, is preventing suture line bleeding. Fragile aortic walls weakened by the pathological process and further antagonized by impaired coagulation resulting from induced hypothermia and long ECC times, leads to such bleeding. Several techniques are employed in efforts to resolve uncontrollable bleeding, notably the Cabrol-shunt w3x. With the development of novel perfusion and brain protection techniques, bleeding became the biggest problem, despite the development of tissue glues and zero-porosity grafts. This novel method for suction-assisted bioglue application on the aortic suture lines impregnates the prostheses and the aortic wall, rein- forcing it and closing the needle holes. Technically elegant, this procedure requires only the house suction and cell saver suction, adding approximately 30 s to the surgery’s duration. There were no bleeding complications during surgery, and re-exploration was not necessary in any instance. Additionally, no bleeding-related deaths occurr- ed. Although literature reports exist describing bioglue mbolization through needle holes w4x, no such complica- tion was observed, and we try to use the minimal amount of the necessary bioglue to achieve optimal hemostasis. In conclusion, this new hemostatic technique during sur- gery on acute aortic dissection using suction-assisted bio- glue application for aortic suture line reinforcement is simple and safe and demonstrates excellent operative results. After completing the anastomosis, we apply bioglue Surgi- cal Adhesive (Cryo-Life, Inc, Kennesaw, GA) on the outside of the anastomosis while applying suction from the inside of the prosthesis using catheters from the house suction, thus forcing the bioglue to impregnate the suture line, reinforcing it and closing the needle holes (Figs. 1 and 2, Video 1). Care should be taken to ensure that the tissue surface is dry and bloodless. In the case of a normal size aortic root and no pathological change on the valve or commissural detachment, proximal anastomosis is performed at the sinotubular junction using previously cut prostheses strips after reconstruction of the dissected layers. The proximal suture line is reinforced with the application of bioglue on the outside of the suture line while applying suction from the inside using a needle placed proximally to the aortic cross clamp and connected to the house suction (Figs. 3 and 4, Video 1). Following the de-airing process, the operation is finished in a conven- tional way.
The diameter of the sinotubular junction is assessed and a tubular, blood-impervious graft slightly smaller than this is selected. A stay suture is passed through one extremity (which becomes the distal extremity) of the graft. Starting from the other (the proximal) extremity, three quarters of the length of the graft is rolled on itself. The graft is folded longitudinally on itself while intro- duced in the left ventricle (to avoid damaging the aortic valve leaflets). The proximal extremity of the graft is positioned at the level of the rim of the aortic root. A strip of Teflon may be used to wrap and reinforce the adven- titia of the aortic wall. The graft is sutured on the aortic root with a running 4/0 polypropylene suture. The expo- sure of the suture line is ideal and at no point obscured by the graft. A precise drive of the needle, which mini- mizes the size of the needle holes, and regular steps, which provide a homogeneous distribution of tension between the graft and aorta, are easy to perform along the entire circumference of the anastomosis (Fig 1). The graft is then pulled out of the left ventricle (ie, returned to its original configuration) by pulling on the stay suture. Distally, the layers of the dissected aorta are glued together and a strip of Teflon is used to reinforce the aortic wall at the line of suture. The graft is sutured directly to the distal ascending aorta or to another graft if a more extended resection of the aortic arch is per- formed. In the latter situation, a beveled anastomosis between two separate grafts, which have different direc- tions (the proximal graft is vertical, the distal one is horizontal), frequently offers a better configuration. Bleeding of the suture line in aortic dissection is trouble- some, especially when this occurs on the proximal anas- tomosis because approximately half of its circumference is inaccessible for placement of additional stitches. The graft invaginated in the aortic root and left ventricle fits exactly the aortic root and results in an everting anasto- mosis along the entire length of anastomosis. In the conventional technique, some parts of the graft are sometimes inverted and others everted. The apposition of the graft to the aorta in these transitional areas is not optimal and may lead to bleeding. Furthermore, because the graft is buried in the heart, the exposure of the aortic root is optimal and allows the precise and regular drive of the needle through the aortic root. The bites should not take more than 3 mm of the graft to result in an everting suture line and not in a folding of the graft within the aortic root. While the anastomosis is being performed, the position of the aortic commissures should be checked (by separating the graft from the aortic root) to avoid their inclusion in the suture line. Competence of the aortic valve depends on normal leaflets and on a normal aortic root . Normally, the diameter of the sinotubular junction is equal to or slightly smaller than the aortic annulus. In aortic dissection, aortic valve insufficiency frequently results from the prolapsus of a commissure. An enlargement of the sino- tubular junction may, however, also occur after dissec- tion and, if not corrected, may lead to a central aortic regurgitation. Competence of the aortic valve is restored by resuspension of the prolapsed commissures and by restoring a normal sinotubular junction diameter. The technique described here imposes selection of a graft with a diameter equal to or slightly smaller than the diameter of the sinotubular junction and hence helps restore or preserve the competence of the aortic valve.
One of the crucial aspects of surgical repair of type A aortic dissection is to achieve hemostasis of the anasto- mosis. Furthermore, the possibility of improving the suture with additional stitches is often technically de- manding. Type A aortic dissection is one of the most dramatic and acute cardiovascular emergencies. Since 1955, when DeBakey and associates  first attempted to resolve this problem surgically, numerous techniques have been proposed given that this pathology involves not only the ascending aorta but often the aortic valve and coronary arteries as well. prosthetic eversion
Buttressing the proximal aortic-graft anastomosis “Tandem suture line” is used to buttress the proximal aortic graft anastomosis, Buttressing the coronary-graft anastomosis Coronary-graft anastomosis is another weakness for hemostasis, especially in patients whose sinuses of valsalva is not dilated and coronary ostia do not elevate sufficiently. “Endo-button buttress” technique has then been used to solve this problem Buttressing the distal aortic-graft anastomosis Distal aortic cut edge was routinely reinforced by an outer and inner strip of Teflon felt with running sutures or interrupted mattress sutures, which was called the “Sandwich technique” Detection of hemorrhage intraoperatively Detection of hemorrhage as early as possible is also very important in the reduction of blood loss in Bentall procedure. Since correction of the anastomotic defect is very difficult after weaning from bypass, examination of leakage of suture lines immediately after completion of anastomosis seems extremely valuable. “Left ventricle filling” technique was introduced to detect any leakage of suture line in both the proximal aortic-graft anastomosis and the coronary-graft anastomosis, which are the main weakness of Bentall procedure
is the so-called suture line inclusion technique. This technique could be used for all distal and proximal anasto- moses, except for the aortic root replacement. After the aorta was completely transected at the predetermined anastomotic line, a very limited dissection was made around the aortic stump. The intimal layer was reap- proximated to the adventitia with the use of fibrin glue inside the false channel. After a stented graft was im- planted into the stump (for patients with aortic arch replacements) or an intraluminal Teflon felt strip (1.0 cm to 1.5 cm in width, C.R. Bard, Inc, Tempe, AZ) was circumferentially placed on the intima of the stump, a series of nonpledgeted 2-0 horizontal mattress sutures were placed (from inside to outside), sequentially en- tered the stented graft or the Teflon felt strip and aortic wall (Figs 1A and 1E). Certain tension on those sutures should be created to keep the intraluminal Teflon felt strip in place. After a Dacron tube graft that is two sizes wider than the aortic stump had been selected, the end of the Dacron tube graft (length of 1 cm to 1.5 cm), called a collar, was everted outward. A continuous 3-0 polypro- pylene suture was used to anastomose the double-folded end of the Dacron tube graft to the aortic stump with incorporation of the proximal end of the stented graft or the intraluminal Teflon felt strip, and this continuous suture line level was never beyond the previous horizon- tal mattress suture level (Figs 1B and 1E). The everted Dacron collar was then returned to its original position (Fig 1C), and the previously placed horizontal mattress sutures were appropriately passed through the corre- sponding site of the Dacron collar and all were securely tied in place (Fig 1D). For facilitating the collar return and sutures through it, three openings had been usually made longitudinally (two thirds of the collar width) from the free edge of the collar toward the double-folded end at three equidistant points (Fig 1C). Our modified anastomotic technique is a useful method of ensuring the suture line tightly wrapped by the Dacron collar and the aortic stump sandwiched by an inner stented graft or Teflon felt and outer Dacron collar so that a more hemostatic and leak-proof anastomosis could be obtained. Therefore, this technique will minimize suture line complications such as anastomotic bleeding and late pseudoaneurysm formation. For this reason, we now routinely use this modified anastomotic technique. With respect to the indications and applicability, the suture line inclusion technique can be used for all distal and proximal anastomoses, except for the aortic root replacement. If the end of the aortic stump is very close to the origin of the coronary or brachiocephalic vessel, longitudinal opening of the collar had been made at the point just opposite the artery, resulting in no compres- sion of the artery. Two technical considerations present our experiences with the use of this modification. Selection of the Dacron graft size is very important for this technique. A Dacron tube that is two sizes larger than the aortic stump is preferred by us, based on the idea that a larger graft collar is easily pulled down to cover the outside of the ortic stump and will not result in anastomotic stenosis. Second, certain tension on the horizontal mattress su- tures should be created to prevent dislodgment of the Teflon felt strip during the continuous suture for anasto- mosis between the double-folded end of the Dacron graft and the aortic stump. This continuous suture line level should never be beyond the previous horizontal mattress suture level in order for the continuous suture line to be totally wrapped by the Dacron collar
Some surgeons have applied a tight wrap to the com- posite graft, using residual aneurysmal aortic wall or autologous pericardium to wrap the proximal anastomo- sis, or have created an anastomosis between the perigraft space and right atrial appendage to manage bleeding from the proximal anastomosis . However, this tech- nique could lead to formation of pseudoaneurysm, com- pression of the neoaorta by perigraft hematoma in the supravalvular position, and persisting aortic–right atrial shunt . The modified composite graft presented in this study was designed to avoid these complications Potential problems of coronary anastomosis tension and difficulty in reimplanting coronary ostium could occur when our modified composite graft is used for a nondilated aortic root such as dissecting aortic aneurysm. It is important that the corresponding holes made in the composite graft for reimplantation of the coronary but- tons are above the attachment level of the skirt and higher than in the classic button technique to avoid tension on the anastomosis. The attaching level of the skirt should not be higher than 0.5 cm from the aortic annulus. After detachment of the coronary buttons, if the residual aortic wall proximal to the coronary ostium is not high enough to contact the skirt, it will cause difficulty in the anastomosis. To avoid this drawback, we made the corresponding portions of the skirt long enough to allow no tension on the anastomosis between the residual aortic wall and the skirt. With these technical attentions in our patients without a dilated aortic root, we did not find that the skirt made coronary anastomosis more difficult or required greater mobilization of coronary buttons to avoid tension of the coronary anastomosis.
The aortic annulus and the 3- to 5-mm proximal part of the ascending aorta, which remains over from the transected aortic wall, can be used as a strip over the proximal anastomosis to prevent surgical bleeding. Con- tinuous suture technique prevents any bleeding prob- lems caused from the proximal anastomosis. When the aortic annulus is intact, the flanged part of graft is usually prepared 5 mm in length. On the other hand, if an aortic root enlargement must be performed (in cases with small aortic annulus) or there are iatrogenic defects at the annular or subannular areas that require repair, the flange should be prepared more than 10 mm in length. We prefer larger diameters for vascular grafts than prosthetic valves. After the anastomosis of the bottom border of prosthetic valve to the graft, a sinus is created around and above the prosthetic valve. The suture line of the aortic valve within the prosthesis comes at a little higher level than in a classic button technique, but it is never more than 4 to 5 mm. The new sinus allows the reimplantation of the coronary arteries without any prob- lems. The two coronary buttons do not require greater mobilization. They are also not located more distally and not subject to tension.
Interrupted pledgeted sutures are then started on the annulus in an everting mattress fashion, with the pledgets lying on the outside of the annulus. The first needle pass of each subsequent mattress suture is placed behind the second thread of the previous suture, over- lapping by 1 to 2 mm. This is easily assured by observing the needle entry both on the outside and especially on the inside of the aortic annulus (see Fig 1A). Care must be exercised to avoid the needle from piercing the previous suture. If doubt exists, this can be tested by a gentle pull on the previous suture while the needle is in the annulus or following its passage. All interrupted mattress sutures are inserted in this fashion. The sutures are laid out in sequence with two colors alternating in Suture Guides (Deknatel, Teleflex Medical, Research Triangle Park, NC), which clearly identify and separate the first from the second limb of each mattress suture, as well as the mattress sutures themselves from each other. The composite graft is then brought to the operative field, and the annular sutures are passed through the sewing cuff of the prosthetic valve. The same overlap technique is again used on the graft, placing the first needle of the subsequent mattress suture behind the second thread of the previous suture in the prosthetic cuff, overlapping by approximately 1 to 2 mm again. Care must be exercised again to avoid piercing the previous suture while overlapping (see Fig 1B). A slight overlap of the pledgets may be seen on the annulus and the cuff of the prosthesis, which is of no consequence. The width of the mattress bites on the annulus and the cuff for each mattress suture must be slightly wider than normal by approximately 1 or 2 mm to accommodate the overlaps. When all sutures are passed through the cuff, the graft is lowered into the annulus and all sutures are tied and divided. The passing of mattress sutures through the prosthetic cuff and their subsequent tying is aided by the alternating colors, their prior separation on the suture guides, and the placement of hemostats on individual mattress sutures as they are sequentially passed through the cuff prior to tying them. By following this technique, confusion is avoided and the operation can proceed expe- ditiously. The proximal suture line can then be tested for bleeding by filling the left ventricular cavity with blood using the vent catheter and manually squeezing the left ventricle gently into the clamped aortic graft. After a wa- tertight suture line is assured, the left and right coronary buttons are attached to the graft in that order. Coronary button suture lines are tested for bleeding by administering blood cardioplegia antegrade through the aortic graft, fol- lowed by the performance of the distal suture line of the graft onto the divided aorta using running monofilament HOW TO DO IT ROUSOU ET AL 1907 DOUBLE OVERLAP COMPOSITE GRAFT SUTURE LINE suture. The operation is then completed in a conventional manner.
A) The Valsalva sinus skirt of a graft is resected, leaving only approximately 10 mm length as the flange. (B) The composite graft is made with the flange of the Valsalva sinus skirt. (C) A pledgeted 2-0 polyester suture is placed on the aortic annulus and passed through the flange below the sewing cuff of the prosthetic valve. (D) A continuous 3-0 polypropylene suture is used to sew the flange to the residual aortic wall to wrap the proximal anastomosis line.
Coronary ostial reimplantation into the prosthetic graft, such as that performed using a Carrel patch, can be performed easily in plain view and can avoid stress on the anastomosis. If epicardium is left on the aortic wall, the prosthetic graft can be included completely, resulting in quick he- mostasis and resistance to graft infection. We believe that high-pressure hematoma formation is due to the wrap of massive bleeding caused by faulty reconstruction of the coronary ostium. In this series, there were no complications such as pseudoaneurysm, dehiscence, hematoma formation, or graft compression.
The Achilles’ heel in composite valve graft replacement of the aortic root is bleeding from the proximal anastomosis. It is frustrating controlling such bleeding, especially when it is from the posterior aspect of the anastomosis. It consumes a lot of operative time, and needs excessive blood and blood product transfusions. Many modifications have been suggested to prevent this complication. Copeland’s annular and supra-annular aortic wall tandem suture lines technique uses interrupted mattress sutures to anchor the lower part of the valve sewing ring to the aortic annulus. The upper part of the sewing ring is then anchored with a running suture line to the cut edge of the supra-annular aortic wall.2 Sealing of the aortic suture line is achieved by suturing the stump of aorta remaining above the annulus to the sewing ring or the tube graft just above the sewing ring.3 The composite graft is placed at the intra-annular position inside the preserved leaflets, and pasted to the aortic valve leaflets and the sewing cuff with fibrin glue.4 Partial or completely preserved native cusps were used to buttress the suture line in Bentall’s operation using a valved homograft conduit.5 Others have used a pericardial strip to strengthen the repair.6 In this case, we used a new technique to prevent anastomotic bleeding. In the majority of cases, the aortic valve is found to bear thin non-calcified leaflets. In Bentall’s procedure, these leaflets are sacrificed before fixing the composite valved conduit to the left ventricular outflow tract. Instead of excising them, we interposed the aortic valve leaflets in the sutures passed through the aortic valve annulus. We have used this technique in 21 cases so far. The interposed valve acts as a cushion between the annulus and the sewing cuff, which balances the loose suture. Also, it seals the space between the annulus and the sewing cuff tightly, which is the most common site of leakage. In Marfan’s syndrome, where the aortic annulus is considerably dilated and weak, the interposition of aortic valve leaflets gives firm substance to pass the sutures at the left ventricular outflow tract. This technique cannot be used in grossly calcified aortic valves which are seldom seen with aortic aneurysm and dissection; we have never encountered a single case. A few flecks of calcium, if present on the leaflets, can be rubbed off with DeBakey forceps. This technique of valve interposition is essentially easy, reproducible, and consumes little extra time as it is employed at the time of passing the annulus sutures.
Report persistant fistula.. N RV failure.. Repair after 4 month 6mm goretext
Creating a connection between the periaortic space and the right atrium is an effective surgical maneuver to deal with uncontrollable aortic bleeding, as first described by Cabrol and associates  in 1978. In their technique, the right atrial appendage was connected directly to the aneurymal sac. This technique resulted in effective de- compression of the peri-graft, intra-aneurysmal space, and in autotransfusion of blood lost from the bleeding aorta into the central venous system. In 1987, Hoover and colleagues  reported modification of this technique by using a 6-mm Gore-Tex graft (W.L. Gore & Associates, Flagstaff, AZ) interposed between the aneurysm wall and the free wall of the right atrium, as opposed to a direct connection as originally described by Cabrol and associ- ates . More recently, modifications of the Cabrol shunt with autologous pericardium, bovine pericardium, or a Hemashield patch were reported by others [3–5]. In our patient, a shunt was created between the bovine pericar- dial patch, used to cover the reconstructed ascending Ann Thorac Surg 2008;86:669–70 aorta, and the innominate vein (Fig 1). The advantage of this approach is that it can be used in reoperations in which the right atrium has been incompletely dissected, and in situations in which the right atrium is thin and friable, as in our case. Further studies are needed to determine the potential disadvantages of this approach, and to establish whether this shunt will spontaneously close with time, as suggested in other cases after a classic or modified Cabrol shunt.
In aortic operations, we routinely enter the pericardial space by incising the pericardium along the border of the right pleural space and hang it to the left sternal half with stay stitches in order to prepare a patch of pericardium, measuring roughly 22 inches when needed for a peri- graft to right atrial fistula (Fig 1). It is important to close the transverse sinus to prevent posterior leakage in first-time operations. For this pur- pose posterior wall of the left atrium can be sewn to the anterior aspect of the right pulmonary artery by taking shallow bites. For redo operations, it is not necessary to close the transverse sinus, because of the adhesions. We use 5/0 polypropylene for construction. Inferiorly, suturing starts at the epicardium of the right ventricular wall, continues towards the main pulmonary artery by taking bites from the adventitia. The Teflon felt at the distal suture line constitutes the superior border of the patch (Fig 2). Medially sutures can be placed to the posterior pericardium and then to the lateral aspect of the superior vena cava towards the base of the right atrial appandage (Fig 3). Care should be taken to avoid injury to the sinus node. Before completing the suture line, a large stab wound is created on the medial aspect of the right atrium and this hole is enlarged with the tip of a forceps. The perigraft space is then closed expeditiously (Fig 4). One patient with the right coronary ostium dissection required coronary artery bypass grafting. The proximal anastomosis of the vein graft was constructed to the right brachiocephalic artery after creation of the shunt. The decision to construct a shunt was made when significant bleeding persists about 20 to 30 minutes after the administration of protamine, despite the transfusion of fresh frozen plasma (FFP), fresh whole blood, throm- botic agents, and mechanical packing Hoover and associates  preferred graft interposition instead of a direct shunt, because the grafts may be more likely to thrombose and if not, they can be embolized with coils. Cabrol and associates  reported persistent left to right shunt in 3 of 260 shunt procedures.
The first step in root derivation is the obliteration of the transverse sinus as proposed by Posacioglu et al. w5x. consists of tightening of the sinus by resorbable foam and fibrin or formaldehyde glue. For construction of the barrier, a harvested autologous pericardium is needed (for its pliability). A circular hole smaller than the prosthetic graft is made in the center of the pericardial patch, and an incision is performed on the upper aspect. This preparation allows the creation of the blood-sealed collar surrounding the prosthesis (Fig. 1a). The running suture then closes the collar, and the conjunction of the pericardium with the prosthetic graft is secured with glue. The pericardium is then fixed to the upper aspect of the left pulmonary artery and the pericardium is turned cranially or caudally depend- ing on the type of derivation required. In the case of a root derivation, the pericardial patch suture continues to the pulmonary trunk, epicardium of the right ventricle, right atrium and medial part of the superior vena cava. In the case of an arch derivation, the patch is fixed to the cranial pericardium and surrounding jugular muscles. An extension of another piece of pericardium (autologous or bovine) is used when needed. To secure suture lines in poorly accessible places, glue is also used. Before closing the space, a purse-string suture surrounding the large hole in the low-pressure system (right atrium–root and innomi- nate vein–arch derivation) is created, and sutures pass through the patch and are temporarily tightened using a tourniquet. The next step consists of testing the seal by simultaneous monitoring of pressure in the derivation space and low-pressure system after closing the derivation space. Throughout testing, no bleeding should be present outside the derivation. When the pressure in the former exceeds that in the latter, we simply release the purse-string suture, communication is then opened with a drop in derivation pressure and the procedure can be finished. If the pressure in the former does not exceed that in the latter for a further 15 min, then we simply tighten the suture and finish the operation without creating a link between both systems. The new procedure described above can be summarized in three steps. Creating a derivation by using the technique described above. Testing pressure in the derivation and low-pressure system after temporary closure of the deriv 3. If the former pressure exceeds the latter, then commu- nication between both systems is opened
The ideal topical hemostatic agent would be one that was deployable even against brisk hemorrhage, which was independent of native clotting mechanisms and would not pass through salvage filtration systems, and which was not sourced from a bovine or human origin. From a practical perspective, the cirmcumstances sur- rounding the desire to use a hemostatic agent are crucial to the choice of agent. Hemostatic agents that accelerate clot formation have the disadvantage that they are only effective against surgical bleeding when hemorrhage is minimal, and must therefore be applied before removal of the cross clamp or while at very low flow on cardio- pulmonary bypass. In essence this relegates these agents to either a prophylactic role in which the surgeon must always anticipate excess hemorrhage in advance, or their use necessitates reducing flow rates while on cardiopul- monary bypass or while re-applying the cross clamp, or with both of the latter two situations. The alternative option favored by some surgeons in this scenario may be to use the bovine serum albumin and gluteraldehyde tissue adhesive with its ability to rapidly form a mechan- ical seal that is independent of native clotting factors and which forms even in the presence of some bleeding. The disadvantages of using the albumin and gluteraldehyde combination include the reported risks of embolization, local tissue destruction, and the bovine source of the albumin with the related risks or anaphylaxis. compression hemostatic agents, such as oxidized regenetrated cellulose gauze. This offers the advantages of reducing active bleeding, providing compression, and providing a scaffold for clot formation. Choice of one topical hemostatic agent in comparison with another is variable from one surgeon to another and may depend on individual experiences and availability rather than a strong evidence basis. Efficacy in the control of bleeding within a 10-minute timeframe has been reported for thrombin (95%) , Floseal (96%) , and CoStasis (97%) . A direct comparison has been made between Floseal, Gelfoam, Avitene, Surgicel, and fibrin sealants in an animal model of aortic arterial bleeding in the presence of heparin. In this model fibrin sealant was proven to be the most efficacious hemostatic agent . However, detailed comparisons between hemostatic agents in animal studies are difficult, as clotting mecha- nisms outside of primate studies differ substantially. The disadvantages of using the compression hemostatic agents is that they may not offer a definitive solution to prevent further bleeding, they can not en- hance the process of clot formation in coagulopathic patients, and they can be responsible for postoperative infections. There is a need for caution when choosing hemostatic agents while still on cardiopulmonary bypass or while using cell salvage systems. Microfibrillar collagen agents can pass through filtration systems causing end-organ damage, sponge fabric materials, such as Surgicel, Gel- foam Sponge, and Hemopad can activate the clotting cascade causing the cell salvage system to clot off and liquid agents, such as thrombin and thrombogen may create a fibrin clot by direct action on fibrinogen, again clotting off the cell salvage system. With the development of recombinant thrombin and an increasing number of agents that do not contain any animal or human-sourced components, it may be that there is a shift away from older hemostatic agents. Preliminary results from animal models show great promise for Chitosan-containing agents that are inexpen- sive, bio-absorbable, do not contain any human or bo- vine-derived components, and have no risk of viral agent transmission. Clinical trials are required to delineate the potential benefits of these newer agents and establish their efficacy in comparison with currently used hemo- static adjuncts. CoSeal is a very effective hemostatic agent in surgical appli- cations in which swelling and expansion are not a concern. Its anastomotic sealing performance is equivalent to that of Gelfoam/ thrombin, but the main advantage of CoSeal lies in the speed with which it achieves hemostasis.Although BioGlue has been used as an effective hemostatic agent in cardiac surgery, it must not be circumferentially applied around developing structures in pediatric patients because it can restrict their growth. One should use caution when using this product, because the glutaraldehyde component cross-links proteins and essentially fixes the tissue it is applied to. The ideal hemostatic agent would be easy to use, highly efficacious, nonantigenic, fully absorbable and inexpensive
hoice of one topical hemostatic agent in comparison with another is variable from one surgeon to another and may depend on individual experiences and availability rather than a strong evidence basis. Efficacy in the control of bleeding within a 10-minute timeframe has been reported for thrombin (95%) , Floseal (96%) , and CoStasis (97%) . A direct comparison has been made between Floseal, Gelfoam, Avitene, Surgicel, and fibrin sealants in an animal model of aortic arterial bleeding in the presence of heparin. In this model fibrin sealant was proven to be the most efficacious hemostatic agent . However, detailed comparisons between hemostatic agents in animal studies are difficult, as clotting mecha- nisms outside of primate studies differ substantially. The published studies in this field are heavily domi- nated by trials that have been funded by the manufac- tures of the hemostatic agents that are being tested (Table 1). In the absence of well-controlled clinical trials, a sound evidence basis for the use of one agent in comparison with another will not emerge. The Society of Thoracic Surgeons Blood Conservation Guideline Task Force have recommended that topical sealants used to assist in the repair of complex, high-risk cardiac and aortic procedures are not unreasonable to limit bleeding in certain key situations (eg, left ventricular free-wall rupture and aortic dissection), but they are associated with complications that may limit their usefulness in less high-risk situations. Several of the hemostatic agents discussed in this review contain bovine or human-derived components (Table 2). As with any animal-derived or human plasma- derived component, immunological reactions may occur causing severe hypotension, systemic inflammatory re- sponses, and in rare cases, anaphylaxis. In addition, with bovine or human-derived plasma components, there is a small risk of transmission of viral agents, and this is stated in the manufacturer’s product information. With any bovine sourced components, there is a risk of trans- mission of bovine spongiform encephalopathy, but there is no evidence that such an event has occurred. There has been a reported case of viral transmission with the use of an adhesive agent prepared from human plasma , but this pre-dates the current stringent collection and testing processes, and the current techniques used to reduce viral load. Importantly, surgeons should note that hemostatic agents carry warning labels detailing contraindications to their use. One of the important contraindications is the use of these agents in patients with antibodies against bovine antibodies. As the study by Weaver and col- leagues  details, 27% of patients exposed to agents containing bovine thrombin develop these antibodies and hence should not be exposed to bovine thrombin- containing agents if future surgery is necessary. The Society of Thoracic Surgeons Blood Conservation Guide- line Task Force have recommended that topical hemo- static agents that use bovine thrombin are not helpful for blood conservation during cardiopulmonary bypass and may be potentially harmful . From a practical perspective, the cirmcumstances sur- rounding the desire to use a hemostatic agent are crucial to the choice of agent. Hemostatic agents that accelerate clot formation have the disadvantage that they are only effective against surgical bleeding when hemorrhage is minimal, and must therefore be applied before removal of the cross clamp or while at very low flow on cardio- pulmonary bypass. In essence this relegates these agents to either a prophylactic role in which the surgeon must always anticipate excess hemorrhage in advance, or their use necessitates reducing flow rates while on cardiopul- monary bypass or while re-applying the cross clamp, or with both of the latter two situations. The alternative option favored by some surgeons in this scenario may be to use the bovine serum albumin and gluteraldehyde tissue adhesive with its ability to rapidly form a mechan- ical seal that is independent of native clotting factors and which forms even in the presence of some bleeding. The disadvantages of using the albumin and gluteraldehyde combination include the reported risks of embolization, local tissue destruction, and the bovine source of the albumin with the related risks or anaphylaxis. A further strategy is to deploy one of the compression hemostatic agents, such as oxidized regenetrated cellulose gauze. This offers the advantages of reducing active bleeding, providing compression, and providing a scaffold for clot formation. The disadvantages of using the compression hemostatic agents is that they may not offer a definitive solution to prevent further bleeding, they can not en- hance the process of clot formation in coagulopathic patients, and they can be responsible for postoperative infections. There is a need for caution when choosing hemostatic agents while still on cardiopulmonary bypass or while using cell salvage systems. Microfibrillar collagen agents can pass through filtration systems causing end-organ damage, sponge fabric materials, such as Surgicel, Gel- foam Sponge, and Hemopad can activate the clotting cascade causing the cell salvage system to clot off and liquid agents, such as thrombin and thrombogen may create a fibrin clot by direct action on fibrinogen, again clotting off the cell salvage system. The ideal topical hemostatic agent would be one that was deployable even against brisk hemorrhage, which was independent of native clotting mechanisms and would not pass through salvage filtration systems, and which was not sourced from a bovine or human origin. With the development of recombinant thrombin and an increasing number of agents that do not contain any animal or human-sourced components, it may be that there is a shift away from older hemostatic agents. Preliminary results from animal models show great promise for Chitosan-containing agents that are inexpen- sive, bio-absorbable, do not contain any human or bo- vine-derived components, and have no risk of viral agent transmission. Clinical trials are required to delineate the potential benefits of these newer agents and establish their efficacy in comparison with currently used hemo- static adjuncts.
I wish you 1 thing, to give you the chance to see yourself as I see you, only then you would realize how special you really are.. all my best for you.. happy birthday youngman.. As you grow up, make sure you have more dreams than memories, more opportunities than chances, more hard work than luck and more friends than acquaintances. May you have the very best in life…. Happy Birthday youngman.. Love you
• Dx : Acute Aortic Dissection (DeBakey II)
– Total Arch Replacement
– Ascending aorta replacement
(w hemashield 4 branched graft [26-10-8-8-10]
& frozen elephant trunk 26x110mm)
– Reopen due to massive bleeding
– Dehiscence on proximal anastomosis
• Postoperative hemorrhage, redo sternotomy for bleeding,
and transfusion of blood products are all associated with
poorer outcomes in cardiovasular surgery
• A number of case reports of disseminated intravascular
coagulopathy (DIC) associated with aortic dissection,
TAAA,and abdominal aortic aneurysms (AAAs)
• Bleeding is a life-threatening complication in thoracic aortic
• management of hemostasis during surgery
has many key components that start, first and
foremost, with good surgical technique
• advances in graft materials, hemostasis, and
surgical techniques have facilitated surgery on
Ann Thorac Surg. 2007 May;83(5):1615-20.
Midterm results of aortic repair using a fabric neomedia and fibrin glue for type A
acute aortic dissection.
Nakajima T, Kawazoe K, Kataoka T, Kin H, Kazui T, Okabayashi H, Niinuma H.
Department of Cardiovascular Surgery, Iwate Medical University Memorial Heart
Center, Iwate Medical University, Morioka, Japan. email@example.com
(A) The fibrinogen solution and the thrombin
solution were applied to the fabric strip, which
was placed between the dissected layers. (B)
Geometrically fashioned fabric was soaked in
fibrinogen solution and was inserted into the
false lumen of the aortic root to obliterate
Journal of Cardiothoracic Surgery 2009, 4:66 doi:10.1186/1749-8090-4-66
Interactive CardioVascular and Thoracic Surgery 14 (2012) 677–679
Interposition of aortic valve leaflets for reinforcement of Bentall proximal
Prashant N Mohite2, Tanveer Ahmad1, Sudesh V Prabhu1, Shyam K Thingnam1
1 Department of Cardiothoracic and Vascular Surgery, Post Graduate Institute of
Medical Research and Education, Sector-12, Chandigarh 160012, India
2 Harefield Hospital, Harefield, UK
Asian Cardiovasc Thorac Ann 2012; 20:455-456
• Graft size.. Smallest appropriate diameter
– Size, 3-0
– Tie knot
– Small bite in the graft, big bite on the aorta
– Pledgeted mattress sutures
• The challenge of hemostasis in operative ther- apy
remains first defining which patients are ei- ther likely
to bleed or clot too much
• much infor- mation is still needed on how to optimize
a patient’s hemostatic system to improve out- comes.
• Topical agents are immensely attractive but should not
obscure the need to assess these agents carefully for
effi- cacy and safety.
• The goal with hemostasis in operative therapy is to
maintain physiologic bal- ance and avoid the
complications of bleeding or thrombosis.
• As.. An hemolitic n sign of inflam
• Blood flow through the false lumen is a
powerful activator of the hemostatic system
even before the operation. This remarkable
activation may influence postoperative
outcome of AAD patients
• Ann Thorac Surg 2011;91:1364–70