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Ma GW, Kucey A, Tyagi SC, Papia G, Kucey DS, Varcoe RL, Forbes T, Neville R, Dueck AD, Kayssi A. The role of sealants for achieving anastomotic hemostasis in vascular surgery. Cochrane Database Syst Rev 2024; 5:CD013421. [PMID: 38695613 PMCID: PMC11064762 DOI: 10.1002/14651858.cd013421.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
BACKGROUND During vascular interventions, connections that link arteries, veins, or synthetic grafts, which are known as an 'anastomosis', may be necessary. Vascular anastomoses can bleed from the needle holes that result from the creation of the anastomoses. Various surgical options are available for achieving hemostasis, or the stopping of bleeding, including the application of sealants directly onto the bleeding vessels or tissues. Sealants are designed for use in vascular surgery as adjuncts when conventional interventions are ineffective and are applied directly by the surgeon to seal bleeding anastomoses. Despite the availability of several different types of sealants, the evidence for the clinical efficacy of these hemostatic adjuncts has not been definitively established in vascular surgery patients. OBJECTIVES To evaluate the benefits and harms of sealants as adjuncts for achieving anastomotic site hemostasis in patients undergoing vascular surgery. SEARCH METHODS The Cochrane Vascular Information Specialist conducted systematic searches of the following databases: the Cochrane Vascular Specialised Register via the Cochrane Register of Studies; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE via Ovid; Embase via Ovid ; and CINAHL via EBSCO. We also searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform for clinical trials. Reference lists of included trials and relevant reviews were also searched. The latest search date was 6 March 2023. SELECTION CRITERIA We included randomized controlled trials that compared fibrin or synthetic sealant use with alternative interventions (e.g. manual compression, reversal of anticoagulation) for achieving anastomotic-site hemostasis in vascular surgery procedures. We included participants who underwent the creation of an anastomosis during vascular surgery. We excluded non-vascular surgery patients. DATA COLLECTION AND ANALYSIS We have used standard Cochrane methods. Our primary outcomes were time to hemostasis, failure of hemostatic intervention, and intraoperative blood loss. Our secondary outcomes were operating time, death from bleeding complications up to 30 days, postoperative bleeding up to 30 days, unplanned return to the operating room for bleeding complications management up to 30 days, quality of life, and adverse events. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We found 24 randomized controlled trials that included a total of 2376 participants who met the inclusion criteria. All trials compared sealant use with standard care controls, including oxidized cellulose, gelatin sponge, and manual compression. All trials were at high risk of performance bias, detection bias, and other sources of bias. We downgraded the certainty of evidence for risk of bias concerns, inconsistency, imprecision and possible publication bias. Combining data on time to hemostasis showed that sealant use may reduce the mean time to hemostasis compared to control (mean difference (MD) -230.09 seconds, 95% confidence interval (CI) -329.24 to -130.94; P < 0.00001; 7 studies, 498 participants; low-certainty evidence). Combining data on failure of hemostatic intervention showed that sealant use may reduce the rate of failure compared to control, but the evidence is very uncertain (risk ratio (RR) 0.46, 95% CI 0.35 to 0.61; P < 0.00001; 17 studies, 2120 participants; very low-certainty evidence). We did not detect any clear differences between the sealant and control groups for intraoperative blood loss (MD -32.69 mL, 95% CI -96.21 to 30.83; P = 0.31; 3 studies, 266 participants; low-certainty evidence); operating time (MD -18.72 minutes, 95% CI -40.18 to 2.73; P = 0.09; 4 studies, 436 participants; low-certainty evidence); postoperative bleeding (RR 0.78, 95% CI 0.59 to 1.04; P = 0.09; 9 studies, 1216 participants; low-certainty evidence), or unplanned return to the operating room (RR 0.27, 95% CI 0.04 to 1.69; P = 0.16; 8 studies, 721 participants; low-certainty evidence). No studies reported death from bleeding or quality of life outcomes. AUTHORS' CONCLUSIONS Based on meta-analysis of 24 trials with 2376 participants, our review demonstrated that sealant use for achieving anastomotic hemostasis in vascular surgery patients may result in reduced time to hemostasis, and may reduce rates of hemostatic intervention failure, although the evidence is very uncertain, when compared to standard controls. Our analysis showed there may be no differences in intraoperative blood loss, operating time, postoperative bleeding up to 30 days, and unplanned return to the operating room for bleeding complications up to 30 days. Deaths and quality of life could not be analyzed. Limitations include the risk of bias in all studies. Our review has demonstrated that using sealants may reduce the time required to achieve hemostasis and the rate of hemostatic failure. However, a significant risk of bias was identified in the included studies, and future trials are needed to provide unbiased data and address other considerations such as cost-effectiveness and adverse events with sealant use.
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Affiliation(s)
- Gar-Way Ma
- Division of Vascular Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Andrew Kucey
- Division of Vascular Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Sam C Tyagi
- Department of Surgery, University of Kentucky, Lexington, Kentucky, USA
| | - Giuseppe Papia
- Division of Vascular Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Daryl S Kucey
- Division of Vascular Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Ramon L Varcoe
- Department of Vascular Surgery, Prince of Wales Hospital, Randwick, Australia
| | - Thomas Forbes
- Division of Vascular Surgery, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Richard Neville
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Andrew D Dueck
- Division of Vascular Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Ahmed Kayssi
- Division of Vascular Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
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Seguchi N, Sakamoto Y, Kikuchi A, Kishi K. Hemostatic Efficacy of Oxidized Regenerated Cellulose Powder in Le Fort 1 Osteotomy. J Craniofac Surg 2024; 35:189-191. [PMID: 37830815 DOI: 10.1097/scs.0000000000009772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/20/2023] [Indexed: 10/14/2023] Open
Abstract
A challenging aspect of Le Fort I osteotomy is bleeding control. Osteotomy techniques, devices, drugs, and anesthetic management have been reported to reduce bleeding; however, there are no reports on the use of hemostatic agents. We aimed to evaluate the hemostatic efficacy of a new topical absorbent hemostatic agent, Surgicel Powder, consisting of oxidized regenerated cellulose (ORC). We reviewed the records of 40 patients who underwent Le Fort I surgery for jaw deformities, with or without cleft lip and palate. Twenty of the 40 patients did not have cleft lips or cleft palates (CLCP); the remaining 20 had CLCP. In each group, an absorbent hemostatic agent was used in 10 patients but not in the other 10. Total blood loss and operative time for each group were evaluated. In the jaw deformity without CLCP group, the amount of bleeding with or without ORC was 112.0±33.8 and 158.6±75.3 mL, respectively, with a significant difference between groups ( P <0.05). Operative time with or without ORC was 206.4±31.3 and 238.3±42.5 minutes, respectively, with a significant difference observed between groups ( P <0.05). In the jaw deformity with CLCP group, the amount of bleeding with or without ORC was 199.7±64.6 and 476.8±104.8 mL, respectively, with a significant difference between groups ( P <0.05). Operative time with or without ORC was 213.7±27.6 and 220.8±41.5 minutes, respectively, with no significant difference between groups ( P =0.329). In conclusion, oxidized regenerated cellulose powder may be a beneficial hemostatic agent for reducing blood loss during Le Fort I osteotomy.
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Affiliation(s)
- Noriko Seguchi
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
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Karpenko AA, Cheban AV, Rabtsun AA, Sokurenko GY, Andreychuk KA, Kim IN, Volf VA, Kuznetsov MR, Prostov II, Sapronova NG, Mzhavanadze ND, Kamaev AA, Suchkov IA. Fibrin Sealant TISSEEL Lyo as a haemostatic agent in vascular surgery: Results of randomized, controlled, patient-blinded, multicentre clinical study in the Russian population. Sci Prog 2023; 106:368504231182834. [PMID: 37427979 PMCID: PMC10358634 DOI: 10.1177/00368504231182834] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
BACKGROUND This phase III, controlled, patient-blinded, multicentre study in two parallel, equal-sized treatment groups compared the efficacy and safety of TISSEEL Lyo, fibrin sealant versus Manual Compression (MC) with surgical gauze pads for use as a haemostatic agent in patients who underwent vascular surgery in Russia. METHODS Adult patients, both genders, who received peripheral vascular expanded polytetrafluoroethylene conduits and had suture line bleeding after surgical haemostasis were enrolled. Patients were randomized to be treated with TISSEEL Lyo or MC. The bleeding needed additional treatment and had to be assessed as grade 1 or 2 bleeding according to the Validated Intraoperative Bleeding scale. The primary efficacy endpoint was the proportion of patients achieving haemostasis at 4 min after treatment application (T4) at the study suture line, which was maintained until the closure of the surgical wound. The secondary efficacy endpoints included the proportion of patients achieving haemostasis at 6 min (T6) and 10 min (T10) after treatment application at the study suture line, which was maintained until closure of the surgical wound, as well as the proportion of patients with intraoperative and postoperative rebleeding. Safety outcomes included incidence of adverse events (AEs), surgical site infections and graft occlusions. RESULTS A total of 110 patients were screened; 104 patients were randomized: (TISSEEL Lyo: 51 [49%] patients; MC: 53 [51%] patients). T4 haemostasis was achieved in 43 (84.3%) patients in the TISSEEL Lyo group and in 11 (20.8%) patients in the MC group (p < 0.001). Significantly more patients in TISSEEL Lyo group achieved the haemostasis at T6 (relative risk (RR) of achieving haemostasis 1.74 [95% confidence interval (CI) 1.37; 2.35]) and T10 (RR 1.18 [95% CI 1.05; 1.38]) versus MC. No one had intraoperative rebleeding. Postoperative rebleeding was reported only in one patient in the MC group. No treatment-emergent serious AEs (TESAEs) related to TISSEEL Lyo/MC, TESAEs leading to withdrawal and TESAEs leading to death were reported in patients during the study. CONCLUSIONS Data demonstrated TISSEEL Lyo had clinically and statistically significant superiority to MC as a haemostatic agent in vascular surgery at all measured time points including 4, 6 and 10 min and had proven to be safe.
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Affiliation(s)
- Andrey A Karpenko
- National Research Center Named after Academician E.N. Meshalkin, Novosibirsk, Russia
| | - Alexey V Cheban
- National Research Center Named after Academician E.N. Meshalkin, Novosibirsk, Russia
| | - Artem A Rabtsun
- National Research Center Named after Academician E.N. Meshalkin, Novosibirsk, Russia
| | - German Y Sokurenko
- A.M. Nikiforov All-Russian Center of Emergency and Radiation Medicine, St-Petersburg, Russia
| | - Konstantin A Andreychuk
- A.M. Nikiforov All-Russian Center of Emergency and Radiation Medicine, St-Petersburg, Russia
| | - Igor N Kim
- State Novosibirsk Regional Clinical Hospital, Novosibirsk, Russia
| | - Valentin A Volf
- State Novosibirsk Regional Clinical Hospital, Novosibirsk, Russia
| | - Maksim R Kuznetsov
- Institute of Cluster Oncology Named after L. L. Levshin of the Sechenov University, Moscow, Russia
- City Clinical Hospital Named after S. S. Yudin, Moscow, Russia
| | | | | | - Nina D Mzhavanadze
- Ryazan State Medical University Named after Academician I.P. Pavlov, Ryazan, Russia
| | - Alexey A Kamaev
- Ryazan State Medical University Named after Academician I.P. Pavlov, Ryazan, Russia
| | - Igor A Suchkov
- Ryazan State Medical University Named after Academician I.P. Pavlov, Ryazan, Russia
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Beverly A, Ong G, Kimber C, Sandercock J, Dorée C, Welton NJ, Wicks P, Estcourt LJ. Drugs to reduce bleeding and transfusion in major open vascular or endovascular surgery: a systematic review and network meta-analysis. Cochrane Database Syst Rev 2023; 2:CD013649. [PMID: 36800489 PMCID: PMC9936832 DOI: 10.1002/14651858.cd013649.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
BACKGROUND Vascular surgery may be followed by internal bleeding due to inadequate surgical haemostasis, abnormal clotting, or surgical complications. Bleeding ranges from minor, with no transfusion requirement, to massive, requiring multiple blood product transfusions. There are a number of drugs, given systemically or applied locally, which may reduce the need for blood transfusion. OBJECTIVES To assess the effectiveness and safety of anti-fibrinolytic and haemostatic drugs and agents in reducing bleeding and the need for blood transfusion in people undergoing major vascular surgery or vascular procedures with a risk of moderate or severe (> 500 mL) blood loss. SEARCH METHODS We searched: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL, and Transfusion Evidence Library. We also searched the WHO ICTRP and ClinicalTrials.gov trial registries for ongoing and unpublished trials. Searches used a combination of MeSH and free text terms from database inception to 31 March 2022, without restriction on language or publication status. SELECTION CRITERIA We included randomised controlled trials (RCTs) in adults of drug treatments to reduce bleeding due to major vascular surgery or vascular procedures with a risk of moderate or severe blood loss, which used placebo, usual care or another drug regimen as control. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were units of red cells transfused and all-cause mortality. Our secondary outcomes included risk of receiving an allogeneic blood product, risk of reoperation or repeat procedure due to bleeding, risk of a thromboembolic event, risk of a serious adverse event and length of hospital stay. We used GRADE to assess certainty of evidence. MAIN RESULTS We included 22 RCTs with 3393 participants analysed, of which one RCT with 69 participants was reported only in abstract form, with no usable data. Seven RCTs evaluated systemic drug treatments (three aprotinin, two desmopressin, two tranexamic acid) and 15 RCTs evaluated topical drug treatments (drug-containing bioabsorbable dressings or glues), including fibrin, thrombin, collagen, gelatin, synthetic sealants and one investigational new agent. Most trials were conducted in high-income countries and the majority of the trials only included participants undergoing elective surgery. We also identified two ongoing RCTs. We were unable to perform the planned network meta-analysis due to the sparse reporting of outcomes relevant to this review. Systemic drug treatments We identified seven trials of three systemic drugs: aprotinin, desmopressin and tranexamic acid, all with placebo controls. The trials of aprotinin and desmopressin were small with very low-certainty evidence for all of our outcomes. Tranexamic acid versus placebo was the systemic drug comparison with the largest number of participants (2 trials; 1460 participants), both at low risk of bias. The largest of these included a total of 9535 individuals undergoing a number of different higher risk surgeries and reported limited information on the vascular subgroup (1399 participants). Neither trial reported the number of units of red cells transfused per participant up to 30 days. Three outcomes were associated with very low-certainty evidence due to the very wide confidence intervals (CIs) resulting from small study sizes and low number of events. These were: all-cause mortality up to 30 days; number of participants requiring an allogeneic blood transfusion up to 30 days; and risk of requiring a repeat procedure or operation due to bleeding. Tranexamic acid may have no effect on the risk of thromboembolic events up to 30 days (risk ratio (RR) 1.10, 95% CI 0.88 to 1.36; 1 trial, 1360 participants; low-certainty evidence due to imprecision). There is one large ongoing trial (8320 participants) comparing tranexamic acid versus placebo in people undergoing non-cardiac surgery who are at high risk of requiring a red cell transfusion. This aims to complete recruitment in April 2023. This trial has primary outcomes of proportion of participants transfused with red blood cells and incidence of venous thromboembolism (DVT or PE). Topical drug treatments Most trials of topical drug treatments were at high risk of bias due to their open-label design (compared with usual care, or liquids were compared with sponges). All of the trials were small, most were very small, and few reported clinically relevant outcomes in the postoperative period. Fibrin sealant versus usual care was the topical drug comparison with the largest number of participants (5 trials, 784 participants). The five trials that compared fibrin sealant with usual care were all at high risk of bias, due to the open-label trial design with no measures put in place to minimise reporting bias. All of the trials were funded by pharmaceutical companies. None of the five trials reported the number of red cells transfused per participant up to 30 days or the number of participants requiring an allogeneic blood transfusion up to 30 days. The other three outcomes were associated with very low-certainty evidence with wide confidence intervals due to small sample sizes and the low number of events, these were: all-cause mortality up to 30 days; risk of requiring a repeat procedure due to bleeding; and risk of thromboembolic disease up to 30 days. We identified one large trial (500 participants) comparing fibrin sealant versus usual care in participants undergoing abdominal aortic aneurysm repair, which has not yet started recruitment. This trial lists death due to arterial disease and reintervention rates as primary outcomes. AUTHORS' CONCLUSIONS Because of a lack of data, we are uncertain whether any systemic or topical treatments used to reduce bleeding due to major vascular surgery have an effect on: all-cause mortality up to 30 days; risk of requiring a repeat procedure or operation due to bleeding; number of red cells transfused per participant up to 30 days or the number of participants requiring an allogeneic blood transfusion up to 30 days. There may be no effect of tranexamic acid on the risk of thromboembolic events up to 30 days, this is important as there has been concern that this risk may be increased. Trials with sample size targets of thousands of participants and clinically relevant outcomes are needed, and we look forward to seeing the results of the ongoing trials in the future.
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Affiliation(s)
- Anair Beverly
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Giok Ong
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Catherine Kimber
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Josie Sandercock
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Carolyn Dorée
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Nicky J Welton
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Peter Wicks
- Cardiac Anaesthesia and Intensive Care, University Hospital Southampton, Southampton, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
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Dhandapani V, Ringuette V, Desrochers M, Sirois M, Vermette P. Composition, host responses and clinical applications of bioadhesives. J Biomed Mater Res B Appl Biomater 2022; 110:2779-2797. [PMID: 35748414 DOI: 10.1002/jbm.b.35113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 05/08/2022] [Accepted: 06/08/2022] [Indexed: 12/15/2022]
Abstract
Bioadhesives are medical devices used to join or seal tissues that have been injured or incised. They have been classified into tissue adhesives, sealants, and hemostatic agents. Bioadhesives such as FloSeal®, CoSeal®, BioGlue®, Evicel®, Tisseel®, Progel™ PALS, and TissuGlu® have been commercialized and used in clinical setting. They can be formulated with natural or synthetic components or a combination of both including albumin, glutaraldehyde, chitosan, cyanoacrylate, fibrin and thrombin, gelatin, polyethylene glycol (PEG), along with urethanes. Each formulation has intrinsic properties and has been developed and validated for a specific application. This review article briefs the mechanisms by which bioadhesives forms adhesion to tissues and highlights the correlation between bioadhesives composition and their potential host responses. Furthermore, clinical applications of bioadhesives and their application-driven requirements are outlined.
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Affiliation(s)
- Vignesh Dhandapani
- Department of Chemical and Biotechnological Engineering, Laboratoire de bio-ingénierie et de biophysique de l'Université de Sherbrooke, Université de Sherbrooke, Sherbrooke, Québec, Canada.,Faculté de médecine et des sciences de la santé, Centre de Recherche du CHUS, Sherbrooke, Québec, Canada
| | - Vickie Ringuette
- Department of Surgery, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Monika Desrochers
- Department of Chemical and Biotechnological Engineering, Laboratoire de bio-ingénierie et de biophysique de l'Université de Sherbrooke, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Marco Sirois
- Faculté de médecine et des sciences de la santé, Centre de Recherche du CHUS, Sherbrooke, Québec, Canada.,Department of Surgery, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Patrick Vermette
- Department of Chemical and Biotechnological Engineering, Laboratoire de bio-ingénierie et de biophysique de l'Université de Sherbrooke, Université de Sherbrooke, Sherbrooke, Québec, Canada.,Faculté de médecine et des sciences de la santé, Centre de Recherche du CHUS, Sherbrooke, Québec, Canada
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Schulten L, Spillner J, Kanzler S, Teubner A, Jockenhoevel S, Apel C. A polyurethane-based surgical adhesive for sealing blood vessel anastomoses-A feasibility study in pigs. J Biomed Mater Res B Appl Biomater 2022; 110:1922-1931. [PMID: 35293688 DOI: 10.1002/jbm.b.35049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/24/2022] [Accepted: 03/03/2022] [Indexed: 12/14/2022]
Abstract
Peri- and postoperative anastomotic leakage from blood vessel anastomosis is a common and potentially life-threatening complication. As an adjunctive therapy providing an additional layer of safety, a new biodegradable, polyurethane-based adhesive was developed. It consists of two components: an isocyanate-functionalized prepolymer and an amino-based curing agent. The adhesive was investigated in a porcine animal model to seal sutured blood vessel anastomoses of arteries, veins, aortas and prosthetic aortic graft replacements. The material-determined properties of the adhesive like viscosity, processing and polymerization time as well as bonding strength were well suited for this application. The adhesive stopped perioperative suture-line bleedings and stayed on all anastomoses until sacrifice. Hematological and serological inflammation marker assessments were unobtrusive. The histological evaluation showed a mild to moderate local tissue reaction to the adhesive constituting a physiological, non-adverse tissue-biomaterial interaction. The adhesive did not interfere with vascular wound healing. The adhesive demonstrated to be suitable to improve the outcome of cardiovascular surgeries by securing the classical sutured anastomoses in a fast, easy and safe manner. However, further studies are required to quantitatively evaluate efficacy in terms of anastomotic leakage prevention as well as long-term tissue compatibility and degradation.
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Affiliation(s)
- Lisanne Schulten
- Department of Biohybrid & Medical Textiles, Institute of Applied Medical Engineering, Helmholtz-Institute for Biomedical Engineering, RWTH Aachen University, Aachen, Germany
| | - Jan Spillner
- Clinic for Thoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | | | - Andreas Teubner
- Central Animal Facility, Faculty of Health, Medicine & Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Stefan Jockenhoevel
- Department of Biohybrid & Medical Textiles, Institute of Applied Medical Engineering, Helmholtz-Institute for Biomedical Engineering, RWTH Aachen University, Aachen, Germany
| | - Christian Apel
- Department of Biohybrid & Medical Textiles, Institute of Applied Medical Engineering, Helmholtz-Institute for Biomedical Engineering, RWTH Aachen University, Aachen, Germany
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7
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Roina Y, Auber F, Hocquet D, Herlem G. ePTFE-based biomedical devices: An overview of surgical efficiency. J Biomed Mater Res B Appl Biomater 2021; 110:302-320. [PMID: 34520627 DOI: 10.1002/jbm.b.34928] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 07/26/2021] [Accepted: 08/01/2021] [Indexed: 12/19/2022]
Abstract
Polytetrafluoroethylene (PTFE) is a ubiquitous material used for implants and medical devices in general because of its high biocompatibility and inertness: blood vessel, heart, table jawbone, nose, eyes, or abdominal wall can benefit from its properties in case of disease or injury. Its expanded version, ePTFE is an improved version of PTFE with better mechanical properties, which extends its medical applications. A material as frequently used as ePTFE with these exceptional properties deserves a review of its main uses, developments, and possibility of improvements. In this systematic review, we examined clinical trials related to ePTFE-based medical devices from the literature. Then, we excluded all trials using ePTFE as a control to test other devices. ePTFE-coated stents, hemodialysis and bypass grafts, guided bone and tissue regeneration membranes, hernia and heart repair and other devices are reviewed. The rates of success using these devices and their efficiency compared to other materials used for the same purposes are reported. ePTFE appears to be more or just as efficient compared to them. Some success rates remain low, suggesting the need of improvement ePTFE for medical applications.
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Affiliation(s)
- Yaëlle Roina
- Nanomedicine Lab EA4662, Bat. E, Université de Franche-Comté, UFR Sciences & Techniques, Besançon Cedex, France
| | - Frédéric Auber
- Nanomedicine Lab EA4662, Bat. E, Université de Franche-Comté, UFR Sciences & Techniques, Besançon Cedex, France
| | - Didier Hocquet
- Hygiène Hospitalière, UMR CNRS 6249, Université de Bourgogne Franche-Comté, Besançon, France
| | - Guillaume Herlem
- Nanomedicine Lab EA4662, Bat. E, Université de Franche-Comté, UFR Sciences & Techniques, Besançon Cedex, France
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8
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Heitzer M, Brockhaus J, Kniha K, Merkord F, Peters F, Hölzle F, Goloborodko E, Modabber A. Mechanical strength and hydrostatic testing of VIVO adhesive in sutureless microsurgical anastomoses: an ex vivo study. Sci Rep 2021; 11:13598. [PMID: 34193930 PMCID: PMC8245481 DOI: 10.1038/s41598-021-92998-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/15/2021] [Indexed: 11/09/2022] Open
Abstract
Conventional anastomoses with interrupted sutures are challenging and inevitably associated with trauma to the vessel walls. The goal of this study was to evaluate a novel alternative adhesive-based suture-free anastomosis technique that uses an intraluminal stent. Overall, 120 porcine coronary vessels were analyzed in an ex vivo model and were examined for their mechanical (n = 20 per cohort) and hydrostatic strength (n = 20 per cohort). Anastomoses were made using the novel VIVO adhesive with an additional intraluminal nitinol stent and was compared to interrupted suture anastomosis and to native vessels. Sutureless anastomoses withstood pressures 299 ± 4.47 [mmHg] comparable to native vessels. They were performed significantly faster 553.8 ± 82.44 [sec] (p ≤ 0.001) and withstood significantly higher pressures (p ≤ 0.001) than sutured anastomoses. We demonstrate that the adhesive-based anastomosis can also resist unphysiologically high longitudinal tensile forces with a mean of 1.33 [N]. Within the limitations of an in vitro study adhesive-based suture-free anastomosis technique has the biomechanical potential to offer a seamless alternative to sutured anastomosis because of its stability, and faster handling. In vivo animal studies are needed to validate outcomes and confirm safety.
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Affiliation(s)
- Marius Heitzer
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Pauwelsstraße 13, 52074, Aachen, Germany.
| | - Julia Brockhaus
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Pauwelsstraße 13, 52074, Aachen, Germany
| | - Kristian Kniha
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Pauwelsstraße 13, 52074, Aachen, Germany
| | - Felix Merkord
- Institute of Textile Technology, RWTH Aachen University, Aachen, Germany
| | - Florian Peters
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Pauwelsstraße 13, 52074, Aachen, Germany
| | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Pauwelsstraße 13, 52074, Aachen, Germany
| | - Evgeny Goloborodko
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Pauwelsstraße 13, 52074, Aachen, Germany
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Pauwelsstraße 13, 52074, Aachen, Germany
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9
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Danker Iii W, DeAnglis A, Ferko N, Garcia D, Hogan A. Comparison of fibrin sealants in peripheral vascular surgery: A systematic review and network meta-analysis. Ann Med Surg (Lond) 2020; 61:161-168. [PMID: 33425351 PMCID: PMC7782199 DOI: 10.1016/j.amsu.2020.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/02/2020] [Indexed: 01/26/2023] Open
Abstract
Background Evidence comparing fibrin sealants (FSs) in surgery are limited. This study evaluated the efficacy and safety of FSs, and manual compression in peripheral vascular surgery. Methods A systematic review of randomized trials was conducted in Medline, Embase, and Cochrane databases within the last 15 years. Data were available to conduct a network meta-analysis (NMA) in peripheral vascular surgery. Fibrin sealant treatment arms were further broken-down and assessed by clotting time (i.e., 2-min [2C] or 1-min [1C]). The primary efficacy outcome was the proportion of patients achieving hemostasis by 4 min (T4). Treatment-related serious and non-serious adverse events (AEs) were qualitatively assessed. Results Five studies (n = 693), were included in the NMA. Results predicted VISTASEAL 2C, followed by EVICEL 1C, had the highest probability of achieving T4. Compared with manual compression, significant improvements in T4 were found with VISTASEAL 2C (relative risk [RR] = 2.67, 95% CrI: 2.13–3.34), EVICEL 1C (RR = 2.58, 95% CrI: 2.04–3.23), VISTASEAL 1C (RR = 2.00, 95% CrI: 1.45–2.65), and TISSEEL 2C (RR = 1.99, 95% CrI: 1.48–2.60). TISSEEL 1C was not significantly different than manual compression (RR = 1.40, 95% CrI: 0.70–2.33). Among FSs, VISTASEAL 2C was associated with a significant improvements in T4 compared with VISTASEAL 1C (RR = 1.33, 95% CrI: 1.02–1.82), TISSEEL 2C (RR = 1.34, 95% CrI: 1.05–1.77), and TISSEEL 1C (RR = 1.90, 95% CrI: 1.18–3.74). Treatment-related serious and non-serious AE rates were typically lower than 2%. Conclusions In peripheral vascular surgeries, VISTASEAL 2C and EVICEL 1C were shown to have the highest probabilities for achieving rapid hemostasis among the treatments compared. Future studies should expand networks across surgery types as data become available. Fibrin sealants can control perioperative bleeding, yet comparative evidence is limited. This network meta-analysis compared fibrin sealants and compression in peripheral vascular surgery. VISTASEAL and EVICEL had the highest probability of achieving hemostasis by 4 min. These results show differences exist between fibrin sealants in peripheral vascular surgery.
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Affiliation(s)
| | | | - Nicole Ferko
- CRG-EVERSANA Canada Inc., 204-3228 South Service Road, Burlington, ON, L7N 3H8, Canada
| | - David Garcia
- CRG-EVERSANA Canada Inc., 204-3228 South Service Road, Burlington, ON, L7N 3H8, Canada
| | - Andrew Hogan
- CRG-EVERSANA Canada Inc., 204-3228 South Service Road, Burlington, ON, L7N 3H8, Canada
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10
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Allotey JK, King AH, Kumins NH, Wong VL, Harth KC, Cho JS, Kashyap VS. Systematic review of hemostatic agents used in vascular surgery. J Vasc Surg 2020; 73:2189-2197. [PMID: 33253866 DOI: 10.1016/j.jvs.2020.10.081] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 10/25/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hemostatic agents are routinely used in vascular surgery to complement proper suture techniques and decrease the risk of perioperative bleeding. A relative lack of comparative research studies have left surgeons with the option of choosing hemostatic agents based on their personal experience. The present review has highlighted the efficacy and safety of hemostatic agents and categorized them according to their primary mechanism of action and cost. METHODS A systematic search strategy encompassing hemostatic agent products was deployed in the PubMed database. Single-center and multicenter, randomized, controlled trials with >10 patients were included in the present study. RESULTS We reviewed 12 studies on the efficacy and safety of hemostatic agents compared with manual compression or other hemostatic agents. Using the time to hemostasis as the primary end point, all studies had found hemostatic agents to be significantly more efficient than manual compression. Likewise, adhesives (high pressure sealants) and dual agents (containing biologically active and absorbable components) were found to be more efficient, but costlier, than agents with either biologically active or absorbable components only. Agents with porcine or bovine constituents were found to trigger anaphylactic reactions in rare cases. Additionally, the absence of fibrin stabilizing factor XIII in a brand of fibrin sealant was speculated to reduce the affinity of the fibrin sealant for the expanded polytetrafluoroethylene graft. The cost of agents varied greatly depending on their active ingredient. CONCLUSIONS Hemostatic agents appear to be highly effective at decreasing the risk of bleeding during surgical procedures. Although some hemostatic agents were demonstrated to achieve hemostasis faster than others, most are able to control bleeding within <10 minutes. Based on the limited data, the least expensive agents might suffice for limited suture lines used in routine procedures.
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Affiliation(s)
- Jonathan K Allotey
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Alexander H King
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Norman H Kumins
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Virginia L Wong
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Karem C Harth
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jae S Cho
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Vikram S Kashyap
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
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11
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Wussler D, Kiefer S, Naumann S, Hackner D, Nadjiri J, Meckel S, Haberstroh J, Kubicki R, Seifert A, Siepe M, Ewert P, Stiller B, Lang N. Evaluation of a biocompatible sealant for on-demand repair of vascular defects-a chronic study in a large animal model. Interact Cardiovasc Thorac Surg 2020; 30:715-723. [PMID: 32159755 DOI: 10.1093/icvts/ivaa012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 01/05/2020] [Accepted: 01/12/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Existing surgical sealants fail to combine design requirements, such as sealing performance, on-demand activation and biocompatibility. The aim of this study was to compare the effectiveness and safety of the SETALIUM™ Vascular Sealant (SVS), a novel, on-demand activatable sealant, with the commercial sealant, BioGlue®, for the repair of vascular defects. METHODS In an in vivo porcine model, the use of SVS was compared with BioGlue, for sealing 2-mm defects of the carotid artery and jugular vein. Animals were followed for 7 days and 5 weeks (each time point and per experimental group, n = 4), respectively. The degree of stenosis and flow velocity was determined, and the local tissue response was evaluated. RESULTS In vivo incision closure succeeded in all cases, and SVS was superior in clinical usability, enabled by its on-demand activation. Unlike BioGlue, SVS use did not induce stenosis and was associated with physiological blood flow in all cases. Moreover, closure with SVS was associated with a low inflammatory reaction and no thrombus formation or intima proliferation, in contrast to BioGlue. CONCLUSIONS SVS demonstrated effective and rapid sealing of 2-mm vascular defects, with favourable biocompatibility compared to BioGlue. Thus, SVS seems to be an effective and safe vascular sealant.
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Affiliation(s)
- Desiree Wussler
- Department of Congenital Heart Defects and Pediatric Cardiology, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg, Germany
| | - Selina Kiefer
- Institute for Surgical Pathology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Susanne Naumann
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich of Technical University, Munich, Germany
| | - Danilo Hackner
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich of Technical University, Munich, Germany
| | - Jonathan Nadjiri
- Department of Diagnostic and Interventional Radiology, Klinikum rechts der Isar of Technical University, Munich, Germany
| | - Stephan Meckel
- Department of Neuroradiology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jörg Haberstroh
- CEMT, Experimental Surgery, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Rouven Kubicki
- Department of Congenital Heart Defects and Pediatric Cardiology, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg, Germany
| | - Andreas Seifert
- CIC nanoGUNE, San Sebastián, Spain.,Ikerbasque, Basque Foundation of Science, Bilbao, Spain
| | - Matthias Siepe
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg, Germany
| | - Peter Ewert
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich of Technical University, Munich, Germany
| | - Brigitte Stiller
- Department of Congenital Heart Defects and Pediatric Cardiology, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg, Germany
| | - Nora Lang
- Department of Congenital Heart Defects and Pediatric Cardiology, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg, Germany.,Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich of Technical University, Munich, Germany
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12
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Gaizo DJD, Spotnitz WD, Hoffman RW, Hermann MC, Sher LS, Spotnitz RH, Genyk YS, Schorn IJ, Gillen DL, White BL, Miller BG, Manson RJ. SPOT GRADE II: Clinical Validation of a New Method for Reproducibly Quantifying Surgical Wound Bleeding: Prospective, Multicenter, Multispecialty, Single-Arm Study. Clin Appl Thromb Hemost 2020; 26:1076029620936340. [PMID: 32703005 PMCID: PMC7383655 DOI: 10.1177/1076029620936340] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The SPOT GRADE (SG), a Surface Bleeding Severity Scale, is a unique visual method for assessing bleeding severity based on quantitative determinations of blood flow. This study assessed the reliability of the SG scale in a clinical setting and collected initial data on the safety and efficacy of HEMOBLAST Bellows (HB), a hemostatic agent, in abdominal and orthopedic operations. Twenty-seven patients were enrolled across 3 centers and received the investigational device. Bleeding severity and hemostasis were independently assessed by 2 surgical investigators at baseline and at 3, 6, and 10 minutes after application of HB and compared for agreement. The mean paired κ statistic for assignment of SG scores was .7754. The mean paired κ statistics for determining eligibility for participation in the trial based on bleeding severity and the mean paired κ statistics determining the presence of hemostasis were .9301 and .9301, respectively. The proportion of patients achieving hemostasis within 3, 6, and 10 minutes of HB application were 50.0%, 79.2%, and 91.7%, respectively. There were no unanticipated adverse device effects and one possible serious adverse device effect, as determined by the Independent Data Monitoring Committee (IDMC). The reliability of the SG scale was validated in a clinical setting. Initial data on the safety and efficacy of HB in abdominal and orthopedic operations were collected, and there were no concerns raised by the investigators or the IDMC.
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Affiliation(s)
- Daniel J Del Gaizo
- Department of Orthopedics, University of North Carolina, Chapel Hill, NC, USA
| | - William D Spotnitz
- Department of Surgery, University of Virginia, Charlottesville, VA, USA.,Biom'Up France, SAS, Saint-Priest, France
| | - Rachel W Hoffman
- Biom'Up France, SAS, Saint-Priest, France.,NAMSA, Clinical and Consulting, Minneapolis, MN, USA
| | | | - Linda S Sher
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Yuri S Genyk
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ian J Schorn
- Biom'Up France, SAS, Saint-Priest, France.,NAMSA, Clinical and Consulting, Minneapolis, MN, USA
| | - Daniel L Gillen
- Department of Statistics, University of California, Irvine, CA, USA
| | | | - Bruce G Miller
- Department of Orthopedics, University of North Carolina, Chapel Hill, NC, USA
| | - Roberto J Manson
- Biom'Up France, SAS, Saint-Priest, France.,Department of Surgery, Duke University, Durham, NC, USA
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13
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Gummerer M, Kummann M, Gratl A, Haller D, Frech A, Klocker J, Fraedrich G, Gruber H. Ultrasound-Guided Fibrin Glue Injection for Treatment of Iatrogenic Femoral Pseudoaneurysms. Vasc Endovascular Surg 2020; 54:497-503. [PMID: 32552570 PMCID: PMC7346712 DOI: 10.1177/1538574420934631] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: Arterial pseudoaneurysms (PSAs) are the most common access site complication following transarterial catheter intervention. Ultrasound-guided injection of thrombogenic substances into perfused arterial PSAs followed by compression therapy is a well-established and less invasive treatment option than surgical repair. Different agents are available to induce thrombosis including thrombin and a fibrin-based tissue glue, which is used as first-line treatment at our institution. This paper deals with our experience using ultrasound-guided fibrin glue injection (UGFI). Materials and Methods: Retrospective data analysis: all patients (55) treated for iatrogenic femoral PSA following digital subtraction angiography of the lower extremities between January 1, 2010, and December 31, 2018, were included. Data on epidemiology, PSA location and size, vascular risk factors, fibrin glue injection (fibrin glue volume), primary success rate of UFGI, and complications related to the treatment were analyzed. Results: A total of 55 consecutive femoral iatrogenic PSAs were treated during the defined period and 32 (58.2%) of the patients were female. Imaging was performed using ultrasound in all cases. The most common PSA location (80.0%) was the common femoral artery, mean PSA size (± SD) was 2.7 ± 1.2 cm, and neck length was 1.6 ± 1.0 cm. The dose (mean ± SD) of fibrin glue was 2.6 mL (± 1.0; maximum: 6 mL). Primary UGFI success rate was 87.3% and conversion rate to open surgery was 12.7%. Two (4%) patients required embolectomy for peripheral embolization after UGFI. Conclusion: Early results achieved with UGFI for treatment of iatrogenic femoral PSA are promising. In our cohort, UGFI was a safe and effective first-line alternative to traditional open surgery, which then was unnecessary in the vast majority of PSA cases. Further prospective studies for comparison of ultrasound-guided techniques should be encouraged.
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Affiliation(s)
- Maria Gummerer
- Department of Vascular Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Moritz Kummann
- Department of Radiology, Medical University Innsbruck, Austria
| | - Alexandra Gratl
- Department of Vascular Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Daniela Haller
- Department of Vascular Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Andreas Frech
- Department of Vascular Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Josef Klocker
- Department of Vascular Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Hannes Gruber
- Department of Radiology, Medical University Innsbruck, Austria
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14
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Abstract
Hemostats, sealants, and adhesives are useful adjuncts to modern surgical procedures. To maximize their benefit, a surgeon needs to understand the safety, efficacy, usability, and cost of these agents. To be truly added to a surgeon's own toolbox, the operator must also have knowledge of when and how to best use these materials. This commentary is designed to succinctly facilitate this understanding and knowledge. A nomenclature and classification system based on group, category, and class has been created to help with this process and is provided here. By using this system, materials consisting of similar design and for common indications can be compared. For example, in this system, the three functional groups are hemostats, sealants, and adhesives. The hemostats may be divided into four categories: mechanical, active, flowable, and fibrin sealant. These hemostat categories are further subdivided into generic classes based on the composition of the approved materials. Similarly, categories and classes are provided for sealants and adhesives. In this commentary, the salient points with respect to the characteristics of these agents are presented. A discussion of when these agents can be used in specific indications and how they may be applied to achieve the best results is also provided.
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Affiliation(s)
- William D. Spotnitz
- From the Surgical Therapeutic Advancement Center, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
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15
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Phair J, Futchko J, Trestman EB, Carnevale M, Friedmann P, Shukla H, Garg K, Koleilat I. Protamine sulfate use during tibial bypass does not appear to increase thrombotic events or affect short-term graft patency. Vascular 2020; 28:708-714. [PMID: 32393108 DOI: 10.1177/1708538120924149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES While the use of protamine sulfate as a heparin reversal agent has been extensively reviewed in patients undergoing carotid endarterectomy and coronary artery bypass grafting, there is a lack of literature on protamine's effects on lower extremity bypasses. The purpose of this study was to determine the risk of protamine sulfate dosing after tibial bypass on thrombotic or bleeding events, including early bypass failure. METHODS We performed a retrospective review of our institutional database for patients undergoing primary distal peripheral bypass from January 2009 through December 2015 (contralateral bypass was considered to be a new primary bypass). Primary endpoints include composite thrombotic events (myocardial infarction, stroke, amputation at 30 days and patency less than 30 days) and composite bleeding events (bleeding or transfusion). RESULTS A total of 152 tibial or peroneal bypasses in 136 patients with critical limb ischemia were identified. Of these, 78 (57.4%) patients received protamine sulfate intraoperatively and 58 (42.6%) did not. There were no differences in composite thrombotic or hemorrhagic outcomes. Protamine use had no effect on the rates of perioperative MI (9.0% versus 3.5%, p = 0.20), stroke (1.3% versus 1.7%, p = 0.83), or perioperative mortality (5.1% versus 3.5%, p = 0.64). There was no significant difference in composite post-operative bleeding events (20.7% versus 14.1%, p = 0.31) or composite thrombotic events (17.2% versus 18.0%, p = 0.91). Patients who received protamine undergoing bypass with non-autogenous conduit had significantly higher-recorded median operative blood loss (250 mL versus 150 mL, p = 0.0097) and median procedure lengths (265 min versus 201 min, p = 0.0229). No difference in 30-day amputation-free survival was noted (91.0% versus 91.4%, p = 0.94). Follow-up Kaplan-Meier estimation did not demonstrate a difference in 30-day patency (91.7% versus 88.5%, p = 0.52). CONCLUSIONS Heparin reversal with protamine sulfate after tibial or peroneal bypass grafting is not associated with higher cardiovascular morbidity, bypass thrombosis, amputation, or mortality. Additionally, there was no statistically significant difference in post-operative bleeding or thrombosis complications for patients who did not receive protamine, although the findings are suggestive of a potential difference in a more adequately powered study. Our results suggest that protamine sulfate is safe for intraoperative use without increased risk of thrombotic complications or early tibial bypass graft failure.
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Affiliation(s)
- John Phair
- Division of Vascular Surgery, Mount Sinai Medical Center, New York, NY, USA
| | - John Futchko
- Division of Vascular Surgery, Montefiore Medical Center, New York, NY, USA
| | - Eric B Trestman
- Division of Vascular Surgery, Columbia University Medical Center, New York, NY, USA
| | - Matthew Carnevale
- Division of Vascular Surgery, Montefiore Medical Center, New York, NY, USA
| | - Patricia Friedmann
- Division of Vascular Surgery, Montefiore Medical Center, New York, NY, USA
| | - Harshal Shukla
- Department of Pharmacy, Montefiore Medical Center, New York, NY, USA
| | - Karan Garg
- Division of Vascular Surgery, New York University Langone Health, New York, NY, USA
| | - Issam Koleilat
- Division of Vascular Surgery, Montefiore Medical Center, New York, NY, USA
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16
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Gillman N, Lloyd D, Bindra R, Ruan R, Zheng M. Surgical applications of intracorporal tissue adhesive agents: current evidence and future development. Expert Rev Med Devices 2020; 17:443-460. [PMID: 32176853 DOI: 10.1080/17434440.2020.1743682] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Introduction: Traditional mechanical closure techniques pose many challenges including the risk of infection, tissue reaction, and injury to both patients and clinicians. There is an urgent need to develop tissue adhesive agents to reform closure technique. This review examined a variety of tissue adhesive agents available in the market in an attempt to gain a better understanding of intracorporal tissue adhesive agents as medical devices.Areas covered: Fundamental principles and clinical determinants of the tissue adhesives were summarized. The available tissue adhesives for intracorporal use and their relevant clinical evidence were then presented. Lastly, the perspective of future development for intracorporal tissue adhesive were discussed. Clinical evidence shows current agents are efficacious as adjunctive measures to mechanical closure and these agents have been trialed outside of clinical indications with varied results.Expert opinion: Despite some advancements in the development of tissue adhesives, there is still a demand to develop novel technologies in order to address unmet clinical needs, including low tensile strength in wet conditions, non-controllable polimerization and sub-optimal biocompatibility. Research trends focus on producing novel adhesive agents to remit these challenges. Examples include the development of biomimetic adhesives, externally activated adhesives, and multiple crosslinking strategies. Economic feasibility and biosafety are limiting factors for clinical implementation.
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Affiliation(s)
- Nicholas Gillman
- School of Medicine, Griffith University School of Medicine, Gold Coast, QLD, Australia.,Centre for Orthopaedic Research, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia
| | - David Lloyd
- Griffith Centre for Orthopaedic Research and Engineering, Menzies Health Institute, Gold Coast, QLD, Australia
| | - Randy Bindra
- School of Medicine, Griffith University School of Medicine, Gold Coast, QLD, Australia.,Department of Plastic and Reconstructive Surgery, Gold Coast University Hospital, Southport, QLD, Australia
| | - Rui Ruan
- Centre for Orthopaedic Research, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia.,Griffith Centre for Orthopaedic Research and Engineering, Menzies Health Institute, Gold Coast, QLD, Australia
| | - Minghao Zheng
- Centre for Orthopaedic Research, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia.,Perron Institute for Neurological and Translational Science, Nedlands, Western Australia, 6009, Australia
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17
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Chen K, Sinelnikov MY, Nikolenko VN, Reshetov IV, Cao Y, Li Z, Kochurova EV, Nikolenko SN, Avila-Rodríguez M, Somasundaram SG, Kirkland CE, Aliev G. The Use of Fibrin-based Tissue Adhesives for Breast in Reconstructive and Plastic Surgery. Curr Top Med Chem 2020; 19:2985-2990. [DOI: 10.2174/1568026619666191112101448] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 10/02/2019] [Accepted: 10/10/2019] [Indexed: 12/11/2022]
Abstract
Background:Breast plastic surgery is a rapidly evolving field of medicine. The modern view of surgical trends reflects the desire to minimize complications and introduce advanced technologies. These always will be priorities for surgeons. Reconstructive surgery, a branch of plastic surgery focusing on restoration of lost functional and aesthetic component, seeks to enhance psychological rehabilitation and improves the quality of life, as well as aesthetic recovery.Objective:This review addresses the action of fibrin agents and their effect on the quality of surgical hemostasis.Discussion and Conclusion:The fundamental goals for the surgeon are to perform a minimally traumatic intervention and to prevent any form of complication. Achieving complete hemostasis is an intraoperative necessity. Timely prevention of bleeding and hemorrhagic phenomena can affect not only the outcome of the operation, but also the incidence of postoperative complications. Topics include the integrity of microvascular anastomoses, tissue adhesion, and the incidence of seromas and hematomas associated with fibrin glue usage. The literature on fibrin adhesives with respect to prevention of postoperative complications, and the effectiveness with active drainage also are analyzed.
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Affiliation(s)
- Kuo Chen
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya str., Moscow 119991, Russian Federation
| | - Mikhail Y. Sinelnikov
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya str., Moscow 119991, Russian Federation
| | - Vladimir N. Nikolenko
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya str., Moscow 119991, Russian Federation
| | - Igor V. Reshetov
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya str., Moscow 119991, Russian Federation
| | - Yu Cao
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya str., Moscow 119991, Russian Federation
| | - Zhi Li
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya str., Moscow 119991, Russian Federation
| | - Ekaterina V. Kochurova
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya str., Moscow 119991, Russian Federation
| | - Svetlana N. Nikolenko
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya str., Moscow 119991, Russian Federation
| | - Marco Avila-Rodríguez
- Department of Clinical Sciences, Faculty of Health Sciences, University of Tolima, Ibagué –730001, Colombia
| | - Siva G. Somasundaram
- Department of Biological Sciences, Salem University, 223 West Main Street Salem, WV 26426, United States
| | - Cecil E. Kirkland
- Department of Biological Sciences, Salem University, 223 West Main Street Salem, WV 26426, United States
| | - Gjumrakch Aliev
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya str., Moscow 119991, Russian Federation
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18
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Nenezić D, Ayguasanosa J, Menyhei G, Tamás H, Mátyás L, Muluk S, Courtney K, Ibáñez J, Chen J. A prospective, single-blind, randomized, phase III study to evaluate the safety and efficacy of Fibrin Sealant Grifols as an adjunct to hemostasis compared with manual compression in vascular surgery. J Vasc Surg 2019; 70:1642-1651. [PMID: 30926276 DOI: 10.1016/j.jvs.2018.12.051] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 12/03/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE New formulations and applications of hemostatic adjuncts such as fibrin sealant (FS) to support local hemostasis and sutures continue to be developed. In a pivotal, confirmatory, controlled, prospective, single-blinded, randomized, multicenter phase III clinical trial, the efficacy and safety of FS Grifols during vascular surgeries were evaluated. METHODS Patients undergoing a nonemergency, open, peripheral vascular surgical procedure with moderate arterial bleeding were recruited. In an initial preliminary part of the study, all patients were treated with FS Grifols. In a subsequent primary part, patients were randomized (2:1) to FS Grifols or manual compression (MC). The primary efficacy end point was the proportion of the primary part patients achieving hemostasis by 4 minutes after the start of treatment. Cumulative proportion and time to hemostasis were secondary efficacy end points. Safety end points (in pooled preliminary and primary parts) included adverse events (AEs), vital signs, physical assessments, clinical laboratory tests, viral markers, and immunogenicity. RESULTS The primary efficacy end point was met by 76.1% of patients (83/109) for the FS Grifols group versus 22.8% of patients (13/57) for the MC group (P < .001). The cumulative proportion of patients at 5, 7, and 10 minutes was 80.7%, 84.4%, and 88.1%, respectively, in the FS Grifols treatment group, and 28.1%, 35.1%, and 45.6% in the MC treatment group (P < .001). The median time to hemostasis was shorter in the FS Grifols group (4 minutes vs ≥10 minutes in the MC group; P < .001). The nature of AEs reported were those expected in the study patient profile. The percentage of patients experiencing treatment-emergent AEs were similar in both the FS Grifols (pooled n = 59 + 109) and MC groups (81.0% and 77.2%, respectively), most recurrent being procedural pain (34.5% and 36.8%, respectively) and pyrexia (11.3% and 10.5%, respectively). CONCLUSIONS FS Grifols was superior in efficacy and similar in safety to MC as an adjunct local hemostatic agent in patients undergoing open vascular surgeries.
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Affiliation(s)
- Dragoslav Nenezić
- Institute for Cardiovascular Diseases "Dedinje", Clinic for Vascular Surgery, Belgrade, Serbia.
| | | | - Gábor Menyhei
- Department of Vascular Surgery, Pecs University Clinical Center, Pecs, Hungary
| | - Holjencsik Tamás
- Department of Vascular Surgery, Csolnoky Ferenc County Hospital, Veszprem, Hungary
| | - Lajos Mátyás
- Department of Vascular and Endovascular Surgery, Borsod Teaching County Hospital Miskolc, Borsod, Hungary
| | - Satish Muluk
- Division of Vascular Surgery, Allegheny General Hospital, Pittsburgh, Pa
| | - Kecia Courtney
- Grifols Bioscience Research Group, Grifols, Barcelona, Spain
| | - Julia Ibáñez
- Grifols Bioscience Research Group, Grifols, Barcelona, Spain
| | - Junliang Chen
- Grifols Bioscience Research Group, Grifols, Barcelona, Spain
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Ardehali A, Spotnitz WD, Hoffman RW, Olson SA, Bochicchio GV, Hermann MC, Lakshman S, Dang NC, Centis V, Gillen DL, Schorn IJ, Spotnitz RH. Evaluation of the safety and efficacy of a new hemostatic powder using a quantitative surface bleeding severity scale. J Card Surg 2019; 34:50-62. [PMID: 30629770 DOI: 10.1111/jocs.13982] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AIMS OF THE STUDY The safety and efficacy of a hemostatic powder (HP) versus a control agent, absorbable gelatin sponge and thrombin (G + T), were assessed, using a validated, quantitative bleeding severity scale. METHODS Subjects were randomized to receive HP (256 subjects) or G + T (132 subjects) for treatment of minimal, mild, or moderate bleeding at 20 investigational sites. The primary efficacy endpoint was non-inferiority of HP relative to G + T for success at achieving hemostasis within 6 minutes. Secondary endpoints in rank order included: superiority of HP relative to G + T in mean preparation time; non-inferiority of HP relative to G + T for achieving hemostasis within 3 min; superiority of HP relative to G + T for achieving hemostasis within 6 min; and superiority of HP relative to G + T for success for achieving hemostasis within 3 min. RESULTS A total of 388 subjects were included in the primary efficacy analysis. At 6 min, hemostasis was achieved in 93.0% (238/256) of the HP group compared to 77.3% (102/132) of the G + T group (non-inferiority P < 0.0001, superiority P < 0.0001). All secondary endpoints were met. Complications were comparable between treatment groups. CONCLUSIONS HP had superior rates of hemostasis, shorter preparation time, and a similar safety profile compared to G + T in this prospective, randomized trial using quantitative bleeding severity criteria.
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Affiliation(s)
- Abbas Ardehali
- Department of Surgery, University of California at Los Angeles, Los Angeles, California
| | - William D Spotnitz
- Department of Surgery, University of Virginia, Charlottesville, Virginia.,Department of Medical Affairs, Biom'up, Lyon, France
| | | | - Steven A Olson
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Grant V Bochicchio
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Mark C Hermann
- General Orthopedics and Surgery, Spectrum Medical, Danville, Virginia
| | - Shankar Lakshman
- Department of Surgery, Huntington Hospital, Pasadena, California
| | - Nick C Dang
- Department of Surgery, Queens Hospital, Honolulu, Hawaii
| | - Valerie Centis
- Department of Research and Development, Biom'up, Lyon, France
| | - Dan L Gillen
- Department of Statistics, Department of Epidemiology, University of California at Irvine, Irvine, California
| | - Ian J Schorn
- NAMSA, Clinical and Consulting, Minneapolis, Minnesota
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- Advanced Powder Investigators Group (APIG)
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Chiara O, Cimbanassi S, Bellanova G, Chiarugi M, Mingoli A, Olivero G, Ribaldi S, Tugnoli G, Basilicò S, Bindi F, Briani L, Renzi F, Chirletti P, Di Grezia G, Martino A, Marzaioli R, Noschese G, Portolani N, Ruscelli P, Zago M, Sgardello S, Stagnitti F, Miniello S. A systematic review on the use of topical hemostats in trauma and emergency surgery. BMC Surg 2018; 18:68. [PMID: 30157821 PMCID: PMC6116382 DOI: 10.1186/s12893-018-0398-z] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 08/20/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND A wide variety of hemostats are available as adjunctive measures to improve hemostasis during surgical procedures if residual bleeding persists despite correct application of conventional methods for hemorrhage control. Some are considered active agents, since they contain fibrinogen and thrombin and actively participate at the end of the coagulation cascade to form a fibrin clot, whereas others to be effective require an intact coagulation system. The aim of this study is to provide an evidence-based approach to correctly select the available agents to help physicians to use the most appropriate hemostat according to the clinical setting, surgical problem and patient's coagulation status. METHODS The literature from 2000 to 2016 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses] protocol. Sixty-six articles were reviewed by a panel of experts to assign grade of recommendation (GoR) and level of evidence (LoE) using the GRADE [Grading of Recommendations Assessment, Development and Evaluation] system, and a national meeting was held. RESULTS Fibrin adhesives, in liquid form (fibrin glues) or with stiff collagen fleece (fibrin patch) are effective in the presence of spontaneous or drug-induced coagulation disorders. Mechanical hemostats should be preferred in patients who have an intact coagulation system. Sealants are effective, irrespective of patient's coagulation status, to improve control of residual oozing. Hemostatic dressings represent a valuable option in case of external hemorrhage at junctional sites or when tourniquets are impractical or ineffective. CONCLUSIONS Local hemostatic agents are dissimilar products with different indications. A knowledge of the properties of each single agent should be in the armamentarium of acute care surgeons in order to select the appropriate product in different clinical conditions.
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Affiliation(s)
- Osvaldo Chiara
- General Surgery-Trauma Team, State University of Milano, Niguarda Hospital Milano, Piazza Benefattori dell’Ospedale, 3, 20162 Milan, Italy
| | | | | | - Massimo Chiarugi
- Emergency Surgery Unit, State University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Andrea Mingoli
- Trauma Surgery Unit-Department of Surgery-Emergency Surgery Department Policlinico Umberto I-Rome, Rome, Italy
| | - Giorgio Olivero
- Department of Surgical Sciences, State University of Torino, Turin, Italy
| | | | | | - Silvia Basilicò
- General Surgery-Trauma Team, State University of Milano, Niguarda Hospital Milano, Piazza Benefattori dell’Ospedale, 3, 20162 Milan, Italy
| | - Francesca Bindi
- General Surgery-Trauma Team, State University of Milano, Niguarda Hospital Milano, Piazza Benefattori dell’Ospedale, 3, 20162 Milan, Italy
| | - Laura Briani
- General Surgery-Trauma Team, State University of Milano, Niguarda Hospital Milano, Piazza Benefattori dell’Ospedale, 3, 20162 Milan, Italy
| | - Federica Renzi
- General Surgery-Trauma Team, State University of Milano, Niguarda Hospital Milano, Piazza Benefattori dell’Ospedale, 3, 20162 Milan, Italy
| | - Piero Chirletti
- General Surgery and Pancreatic Surgery Unit, State University La Sapienza, Rome, Italy
| | | | - Antonio Martino
- Honorable Chief- Emergency Surgery, Cardarelli Hospital, Naples, Italy
| | - Rinaldo Marzaioli
- Department of Emergency and Transplant Surgery, State University of Bari, Bari, Italy
| | | | - Nazario Portolani
- Department of Clinical and Experimental Sciences-State University of Brescia, Bari, Italy
| | - Paolo Ruscelli
- Department of Emergency Surgery, Ospedali Riuniti, Ancona, Italy
| | - Mauro Zago
- Minimally Invasive Surgery Unit- Policlinico S. Pietro, Ponte San Pietro, Bergamo, Italy
| | - Sebastian Sgardello
- General Surgery-Trauma Team, State University of Milano, Niguarda Hospital Milano, Piazza Benefattori dell’Ospedale, 3, 20162 Milan, Italy
| | - Franco Stagnitti
- State University of Rome “La Sapienza”-Polo Pontino, Latina, Italy
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Edwards SJ, Crawford F, van Velthoven MH, Berardi A, Osei-Assibey G, Bacelar M, Salih F, Wakefield V. The use of fibrin sealant during non-emergency surgery: a systematic review of evidence of benefits and harms. Health Technol Assess 2018; 20:1-224. [PMID: 28051764 DOI: 10.3310/hta20940] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Fibrin sealants are used in different types of surgery to prevent the accumulation of post-operative fluid (seroma) or blood (haematoma) or to arrest haemorrhage (bleeding). However, there is uncertainty around the benefits and harms of fibrin sealant use. OBJECTIVES To systematically review the evidence on the benefits and harms of fibrin sealants in non-emergency surgery in adults. DATA SOURCES Electronic databases [MEDLINE, EMBASE and The Cochrane Library (including the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Health Technology Assessment database and the Cochrane Central Register of Controlled Trials)] were searched from inception to May 2015. The websites of regulatory bodies (the Medicines and Healthcare products Regulatory Agency, the European Medicines Agency and the Food and Drug Administration) were also searched to identify evidence of harms. REVIEW METHODS This review included randomised controlled trials (RCTs) and observational studies using any type of fibrin sealant compared with standard care in non-emergency surgery in adults. The primary outcome was risk of developing seroma and haematoma. Only RCTs were used to inform clinical effectiveness and both RCTs and observational studies were used for the assessment of harms related to the use of fibrin sealant. Two reviewers independently screened all titles and abstracts to identify potentially relevant studies. Data extraction was undertaken by one reviewer and validated by a second. The quality of included studies was assessed independently by two reviewers using the Cochrane Collaboration risk-of-bias tool for RCTs and the Centre for Reviews and Dissemination guidance for adverse events for observational studies. A fixed-effects model was used for meta-analysis. RESULTS We included 186 RCTs and eight observational studies across 14 surgical specialties and five reports from the regulatory bodies. Most RCTs were judged to be at an unclear risk of bias. Adverse events were inappropriately reported in observational studies. Meta-analysis across non-emergency surgical specialties did not show a statistically significant difference in the risk of seroma for fibrin sealants versus standard care in 32 RCTs analysed [n = 3472, odds ratio (OR) 0.84, 95% confidence interval (CI) 0.68 to 1.04; p = 0.13; I2 = 12.7%], but a statistically significant benefit was found on haematoma development in 24 RCTs (n = 2403, OR 0.62, 95% CI 0.44 to 0.86; p = 0.01; I2 = 0%). Adverse events related to fibrin sealant use were reported in 10 RCTs and eight observational studies across surgical specialties, and 22 RCTs explicitly stated that there were no adverse events. One RCT reported a single death but no other study reported mortality or any serious adverse events. Five regulatory body reports noted death from air emboli associated with fibrin sprays. LIMITATIONS It was not possible to provide a detailed evaluation of individual RCTs in their specific contexts because of the limited resources that were available for this research. In addition, the number of RCTs that were identified made it impractical to conduct independent data extraction by two reviewers in the time available. CONCLUSIONS The effectiveness of fibrin sealants does not appear to vary according to surgical procedures with regard to reducing the risk of seroma or haematoma. Surgeons should note the potential risk of gas embolism if spray application of fibrin sealants is used and not to exceed the recommended pressure and spraying distance. Future research should be carried out in surgery specialties for which only limited data were found, including neurological, gynaecological, oral and maxillofacial, urology, colorectal and orthopaedics surgery (for any outcome); breast surgery and upper gastrointestinal (development of haematoma); and cardiothoracic heart or lung surgery (reoperation rates). In addition, studies need to use adequate sample sizes, to blind participants and outcome assessors, and to follow reporting guidelines. STUDY REGISTRATION This study is registered as PROSPERO CRD42015020710. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Sutton NY, Schmitz ND. Real-world Bleeding Outcomes and Costs Following Vascular Graft Anastomosis Using PROLENE Sutures with HEMO-SEAL Technology in Patients Undergoing Abdominal Aortic Aneurysm Repair. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2017; 5:140-149. [PMID: 34786419 PMCID: PMC8565849 DOI: 10.36469/9806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Background: Suture hole bleeding is a common complication of vascular graft anastomosis that has potential to prolong vascular procedures, increase costs, and compromise patient outcomes. Objectives: Compare real-world bleeding-related outcomes and costs following vascular anastomosis using PROLENE sutures with HEMO-SEAL technology (HEMO-SEAL sutures) compared with standard PROLENE sutures in patients receiving abdominal aortic aneurysm (AAA) repair in the United States. Methods: AAA repair procedures using hemostats and either HEMO-SEAL sutures or standard PROLENE sutures were identified from 2009 to 2013 using the Premier Healthcare Database. The primary outcome was the number and cost of hemostat units. Secondary outcomes were number and cost of sutures, bleeding complications, and transfusions. Results: A total of 5082 discharges for AAA repairs using hemostats and HEMO-SEAL sutures or standard PROLENE sutures were identified. HEMO-SEAL sutures were used in 79 (1.6%) discharges, standard PROLENE sutures were used in 4946 (97.3%); both sutures (excluded from the analysis) were used in 57 (1.1%). Discharge demographics were similar across suture groups, with the exception of disease severity; the HEMO-SEAL suture group had a higher proportion of minor discharges and a lower proportion of extreme discharges compared with the standard PROLENE suture group. Mean number of hemostat units used per discharge (2.34 vs 3.30; median = 2.0 in both groups; p=0.026) and median hemostat costs per discharge ($111 vs $186; p<0.01) were significantly lower in the HEMO-SEAL suture group compared with the standard PROLENE suture group. Fewer sutures per discharge (p<0.0001), lower mean costs of sutures per discharge, higher median costs of sutures per discharge (p=0.0045), and fewer transfusions (0.0019) were also seen in the HEMO-SEAL suture group compared with the standard PROLENE suture group. No statistically significant difference in bleeding complications was observed between suture groups. Conclusion: The results indicate that real-world use of HEMO-SEAL sutures may be associated with reduced hemostat usage and costs, and reduced bleeding that requires additional hemostats and/or transfusions.
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Fonouni H, Kashfi A, Majlesara A, Stahlheber O, Konstantinidis L, Kraus TW, Mehrabi A, Oweira H. Analysis of the hemostatic potential of modern topical sealants on arterial and venous anastomoses: an experimental porcine study. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2017; 28:134. [PMID: 28755096 DOI: 10.1007/s10856-017-5932-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 06/20/2017] [Indexed: 06/07/2023]
Abstract
One of the widely accepted adjunctive agents in the variety of surgical modalities are sealants. Our study aim was to compare four commonly used modern sealants in a standardized experimental setting to assess their feasibility, and hemostatic efficacy in vascular anastomosis. Forty landrace pigs (weight: 24.7 ± 3.8 kg) were randomized into the control (n = 8) and four sealant groups; TachoSil® (n = 8), Tissucol Duo® (n = 8), Coseal® (n = 8), and FloSeal® (n = 8). After doing a portal vein end-to-end anastomosis as well as stitches of aortic incision, the sealants were applied on anastomotic site. The control group was left intact. In portal vein anastomosis, the sealants led to a complete hemostasis significantly better than control group. The mean of blood loss was also significantly reduced. In successful subgroups, there was a difference in the mean-time to reach complete hemostasis ranging from 15 s in Coseal® to 76 s in FloSeal® group (p < 0.05). In aortotomy experiments, except Tissucol Due®, which had insufficient hemostasis, other sealants led to a complete hemostasis. The mean blood loss was significantly reduced in sealants groups as well. The four sealants are effective in reducing the suture-hole bleeding in portal vein anastomosis. However, the hemostatic potential is heterogeneous among sealants. This means that "one-size-fits-all" approach is not appropriate for application of sealants in diversity of vascular surgery and it should be based on the type and the severity of injury and the structure of tissue. Comparison of hemostasis efficacy of four modern sealants (TachoSil®, Tissucol Duo®, Coseal®, and FloSeal®) in vascular anastomosis in porcine model. The figures below show the total blood loss (g) in the control and sealant groups after aortotomy (left) and portal vein anastomosis (right). The mean of blood loss decreased significantly by the usage of sealants in both experiment groups as compared to control group (*: p < 0.05; sealant groups vs. control group). 1. The right column shows the mean of blood loss (g) in all experiments in each group. 2. The middle column presents the subgroup with unsuccessful hemostasis at the end of observation time (Tmax = 20 sec. for aortotmy and 300 sec. for portal vein anastomosis). 3. The left column shows mean of total blood loss in subgroups with successful hemostasis during observation time (20 sec for aortotomy and 300 sec for portal vein).
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Affiliation(s)
- Hamidreza Fonouni
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Arash Kashfi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Ali Majlesara
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Oliver Stahlheber
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Lukas Konstantinidis
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thomas W Kraus
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
| | - Hani Oweira
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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Chetter I, Stansby G, Sarralde JA, Riambau V, Giménez-Gaibar A, MacKenzie K, Acín F, Navarro-Puerto J. A Prospective, Randomized, Multicenter Clinical Trial on the Safety and Efficacy of a Ready-to-Use Fibrin Sealant as an Adjunct to Hemostasis during Vascular Surgery. Ann Vasc Surg 2017. [PMID: 28647631 DOI: 10.1016/j.avsg.2017.06.043] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Anastomotic or "stitch hole" bleeding is common during vascular surgery with synthetic material such as Dacron or polytetrafluoroethylene. Hemostatic adjuncts such as fibrin sealant (FS) may reduce blood loss and operating time in such circumstances. We evaluated the safety and the hemostatic effectiveness of a ready-to-use human plasma-derived FS in vascular surgery. METHODS Patients with mild/moderate suture line bleeding during elective, open, vascular surgery using synthetic grafts or patches were studied. In an initial Exploratory Study, all patients were treated with FS Grifols, and in a subsequent Primary Study were randomized in a 2:1 ratio to FS Grifols or manual compression (MC). The primary efficacy end point was time to hemostasis (TTH), assessed at defined intervals from the start of treatment application, during a 10-min observational period. Safety end points (in Exploratory + Primary Studies) included adverse events (AEs), vital signs, physical assessments, common clinical laboratory tests (coagulation, complete blood count, serum clinical chemistry parameters, microscopic urinalysis), viral markers, and immunogenicity. RESULTS In the Primary Study, the proportion of patients who achieved hemostasis at the 3-min time point was higher in the FS Grifols group (46.4%, n = 51/110) than in the MC group (26.3%, n = 15/57) (P < 0.05). The benefit was maintained at successive time intervals: 69 FS Grifols patients (62.7%) and 18 MC patients (31.6%) at 4 min; 82 FS Grifols patients (74.5%) and 28 MC patients (49.1%) at 5 min. The differences between the groups persisted for TTH ≤ 7 min and TTH ≤ 10 min. Treatment failure was reported for 13 FS Grifols patients (11.8%) and 16 MC patients (28.1%). TTH was shorter after FS Grifols application than after MC application. Differences were statistically significant in favor of FS Grifols for each TTH category and for the overall comparison (P < 0.001) as well as for each TTH category (cumulative) and for treatment failure (P = 0.016). Overall, AE experience and types of AEs reported were those expected in this patient population and were similar between the 2 treatment groups. The most frequently reported AEs were procedural pain (59.9% and 69.2% of patients in the FS Grifols [n = 72 + 111] and MC [n = 57] groups, respectively) and nausea (23.5% and 19.2% of patients, respectively). CONCLUSIONS FS Grifols was efficacious and safe as an adjunct to anastomotic hemostasis in patients undergoing arterial surgery using prosthetic material with mild to moderate bleeding.
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Affiliation(s)
- Ian Chetter
- Academic Vascular Surgical Unit, Hull and East Yorkshire NHS Trust/University of Hull, Hull, UK.
| | - Gerard Stansby
- Northern Vascular Centre, Level 4, Freeman Hospital, Newcastle upon Tyne, UK
| | - José Aurelio Sarralde
- Service of Cardiovascular Surgery, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Vicente Riambau
- Division of Vascular Surgery, Hospital Clínic, Barcelona, Spain
| | - Antonio Giménez-Gaibar
- Service of Angiology and Vascular Surgery, Hospital de Sabadell, Sabadell, Barcelona, Spain
| | - Kent MacKenzie
- McGill University Health Center, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Francisco Acín
- Service of Angiology and Vascular Surgery, Hospital Universitario de Getafe, Getafe, Madrid, Spain
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Hatakeyama T, Okamoto H, Nakazawa T, Nonaka T, Sasaki S, Hoshino M. Introduction of arteriovenous grafts with graft insertion anastomosis for hemodialysis access. J Vasc Surg 2017; 66:952-957. [PMID: 28619645 DOI: 10.1016/j.jvs.2017.03.441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 03/23/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE An arteriovenous bridging graft is a viable option for patients with compromised arteries or veins because of advanced age or diabetes. Arteriovenous graft with graft insertion anastomosis (AVGI) is the novel technique for graft-vein anastomosis where the prosthesis is inserted into the vein, and the anastomosis is performed on the surface of the prosthesis. This study assessed the short-term and long-term results of AVGI to clarify the efficacy of this technique. METHODS Between 2010 and 2015, AVGI was performed in graft-vein anastomosis of prosthetic forearm loop access. Characteristics and level of complications were assessed. To evaluate the long-term results, functional graft patency and frequency of percutaneous transluminal angioplasty were examined. RESULTS The study comprised 58 patients. There were no deaths related to the surgery. The time of hemostasis after AVGI was recorded at 0 seconds because no bleeding from the suture holes was seen. At 1, 2, and 3 years, primary patency were 45.1% ± 7.5%, 23.1% ± 7.5%, and 23.1% ± 7.5%, respectively, and assisted primary patency rates were 59.4% ± 7.2%, 50.8% ± 7.6%, and 50.8% ± 7.6%, respectively. Secondary patency rates at 4 and 5 years were 100% ± 0% and 94.1% ± 5.7%, respectively. The frequency of percutaneous balloon angioplasty to maintain the patency was 1.61 ± 0.53 times per year. Graft infection occurred in four patients (6.9%). CONCLUSIONS AVGI is an advantageous technique for graft vein anastomosis in an arteriovenous bridging graft in both the short-term and long-term.
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Affiliation(s)
- Takuya Hatakeyama
- Division of Vascular Surgery, Seishokai Memorial Hospital, Tokyo, Japan.
| | - Hiroyuki Okamoto
- Division of Vascular Surgery, Seishokai Memorial Hospital, Tokyo, Japan
| | - Tatsu Nakazawa
- Division of Vascular Surgery, Seishokai Memorial Hospital, Tokyo, Japan
| | - Tatsuya Nonaka
- Division on Nephrology, Seishokai Memorial Hospital, Tokyo, Japan
| | - Sei Sasaki
- Division on Nephrology, Seishokai Memorial Hospital, Tokyo, Japan
| | - Masanobu Hoshino
- Division on Nephrology, Seishokai Memorial Hospital, Tokyo, Japan
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27
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Rogers AC, Turley LP, Cross KS, McMonagle MP. Meta-analysis of the use of surgical sealants for suture-hole bleeding in arterial anastomoses. Br J Surg 2016; 103:1758-1767. [PMID: 27714778 DOI: 10.1002/bjs.10308] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/07/2016] [Accepted: 07/21/2016] [Indexed: 11/12/2022]
Abstract
BACKGROUND Suture-hole bleeding in arterial anastomoses prolongs operating time and increases blood loss, particularly with the use of prosthetic grafts. Surgical sealants (such as fibrin) may be used as haemostatic adjuncts in vascular surgery. This is a systematic review and meta-analysis of published studies that investigated the utility of surgical sealants in arterial-to-prosthetic graft anastomoses. METHODS A systematic review was undertaken of papers published until January 2015 on Embase, MEDLINE, PubMed, PubMed Central and Cochrane databases that analysed the use of surgical sealants as haemostatic adjuncts after arterial anastomoses. RCTs were included, with study endpoints of time to haemostasis or haemostasis at 5 min. Secondary outcomes included treatment failure, mean difference in estimated blood loss and duration of surgery. Sensitivity and subgroup analyses were performed, as well as funnel plot analysis for publication bias. RESULTS A total of 2513 citations were reviewed; 19 RCTs comprising 1560 patients were ultimately included in the analysis. The majority of studies compared fibrin sealant with control haemostatic measures. Pooled analysis suggested that surgical sealants reduced the time to haemostasis (mean difference 243·26 (95 per cent c.i. 183·99 to 302·53) s; P < 0·001), improved haemostasis at 5 min (odds ratio 4·50, 95 per cent c.i. 2·59 to 7·81; P < 0·001), and were associated with less treatment failure, blood loss and shorter duration of surgery. CONCLUSION Surgical sealants appear to reduce suture-hole bleeding significantly in vascular prosthetic graft anastomoses compared with standard haemostatic measures.
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Affiliation(s)
- A C Rogers
- Department of Vascular Surgery, University Hospital Waterford, Waterford, Ireland
| | - L P Turley
- Department of Vascular Surgery, University Hospital Waterford, Waterford, Ireland
| | - K S Cross
- Department of Vascular Surgery, University Hospital Waterford, Waterford, Ireland
| | - M P McMonagle
- Department of Vascular Surgery, University Hospital Waterford, Waterford, Ireland
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Characterization of the Biodistribution and Systemic Absorption of TT-173, a New Hemostatic Agent of Recombinant Human Tissue Factor, Using Radiolabeling with 18F. Eur J Drug Metab Pharmacokinet 2016; 42:583-592. [PMID: 27550654 DOI: 10.1007/s13318-016-0366-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND OBJECTIVES TT-173 is the first topical hemostatic agent based on tissue factor. To prevent thromboembolic events and intravascular coagulation it is necessary to rule out the systemic absorption of new bioactive hemostats. Here, we radiolabeled TT-173 with [18F]SBF to characterize its systemic absorption and biodistribution. METHODS A group of rats were administered intravenously with [18F]TT-173 and were subjected to a positron emission tomography study. A second group of animals received the [18F]TT-173 topically over a skin lesion in the flank. Topical absorption was quantified and the biodistribution patterns observed were compared. RESULTS After topical application, low amounts of [18F]TT-173 were absorbed and distributed without relevant accumulation in any organ. On the other hand, after intravenous injection, [18F]TT-173 accumulated in lungs, liver and spleen, consistent with intravascular clot formation and the posterior capillary trapping and phagocytosis by the reticuloendothelial system. In both cases, a substantial concentration of radioactive product was found in urine consistent with renal excretion of degradation products of [18F]TT-173. CONCLUSIONS After topical application, [18F]TT-173 did not show a significant systemic accumulation in animal organs. Minor radioactive concentration found in lungs, liver and spleen likely corresponds with fragments of the product without procoagulant activity. Radiolabeling with [18F]SFB enables the characterization of systemic absorption and biodistribution of new topical hemostats like TT-173.
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López-López J, Jané-Salas E, Santamaría A, González-Navarro B, Arranz-Obispo C, López R, Miquel I, Arias B, Sánchez P, Rincón E, Rodríguez JR, Rojas S, Murat J. TETIS study: evaluation of new topical hemostatic agent TT-173 in tooth extraction. Clin Oral Investig 2015; 20:1055-63. [PMID: 26374745 DOI: 10.1007/s00784-015-1586-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 08/30/2015] [Indexed: 01/14/2023]
Affiliation(s)
- José López-López
- Department of Odontostomatology, School of Dentistry-Hospital Odontológico Universidad de Barcelona, Barcelona University, C/Feixa Llarga s/n, 08907, Hospitalet de Llobregat, Barcelona, Spain.
| | - Enric Jané-Salas
- Department of Odontostomatology, School of Dentistry-Hospital Odontológico Universidad de Barcelona, Barcelona University, C/Feixa Llarga s/n, 08907, Hospitalet de Llobregat, Barcelona, Spain
| | - Amparo Santamaría
- Hemostasia and Thrombosis Unit, Department of Hematology, Hospital Universitari Vall d'Hebrón, Barcelona, Spain
| | - Beatriz González-Navarro
- Department of Odontostomatology, School of Dentistry-Hospital Odontológico Universidad de Barcelona, Barcelona University, C/Feixa Llarga s/n, 08907, Hospitalet de Llobregat, Barcelona, Spain
| | - Carlos Arranz-Obispo
- Department of Odontostomatology, School of Dentistry-Hospital Odontológico Universidad de Barcelona, Barcelona University, C/Feixa Llarga s/n, 08907, Hospitalet de Llobregat, Barcelona, Spain
| | - Ramón López
- S.L. Parque Mediterráneo de la Tecnología, Thombotargets Europe, Castelldefels, Spain
| | - Ignasi Miquel
- S.L. Parque Mediterráneo de la Tecnología, Thombotargets Europe, Castelldefels, Spain
| | - Belén Arias
- S.L. Parque Mediterráneo de la Tecnología, Thombotargets Europe, Castelldefels, Spain
| | - Pilar Sánchez
- S.L. Parque Mediterráneo de la Tecnología, Thombotargets Europe, Castelldefels, Spain
| | - Esther Rincón
- S.L. Parque Mediterráneo de la Tecnología, Thombotargets Europe, Castelldefels, Spain
| | - Juan R Rodríguez
- S.L. Parque Mediterráneo de la Tecnología, Thombotargets Europe, Castelldefels, Spain
| | - Santiago Rojas
- S.L. Parque Mediterráneo de la Tecnología, Thombotargets Europe, Castelldefels, Spain
| | - Jesus Murat
- S.L. Parque Mediterráneo de la Tecnología, Thombotargets Europe, Castelldefels, Spain
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Yamashita K, Suzuki S, Tabayashi N, Abe T, Hayata Y, Hirose T, Hiraga S, Niwa K, Fukuba R, Takeda M, Ikada Y, Taniguchi S. Experimental use of crosslinked gelatin glue for arterial hemostasis in cardiovascular surgery. Biomed Mater Eng 2015; 25:361-70. [DOI: 10.3233/bme-151534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Keigo Yamashita
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Nara Medical University, Kashihara, Japan
| | - Shuko Suzuki
- Biomedical Engineering, School of Medicine, Nara Medical University, Kashihara, Japan
- Queensland Eye Institute, Brisbane, Australia
| | - Nobuoki Tabayashi
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Nara Medical University, Kashihara, Japan
| | - Takehisa Abe
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Nara Medical University, Kashihara, Japan
| | - Yoshihiro Hayata
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Nara Medical University, Kashihara, Japan
| | - Tomoaki Hirose
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Nara Medical University, Kashihara, Japan
| | - Shun Hiraga
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Nara Medical University, Kashihara, Japan
| | - Kosuke Niwa
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Nara Medical University, Kashihara, Japan
| | - Ryohei Fukuba
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Nara Medical University, Kashihara, Japan
| | - Maiko Takeda
- Diagnostic Pathology, School of Medicine, Nara Medical University, Kashihara, Japan
| | - Yoshito Ikada
- Biomedical Engineering, School of Medicine, Nara Medical University, Kashihara, Japan
- Kyoto University, Kyoto, Japan
| | - Shigeki Taniguchi
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Nara Medical University, Kashihara, Japan
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Gupta N, Chetter I, Hayes P, O-Yurvati AH, Moneta GL, Shenoy S, Pribble JP, Zuckerman LA. Randomized trial of a dry-powder, fibrin sealant in vascular procedures. J Vasc Surg 2015; 62:1288-95. [PMID: 26254451 DOI: 10.1016/j.jvs.2015.05.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 05/15/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Topical hemostats are important adjuncts for stopping surgical bleeding. The safety and efficacy of Fibrocaps, a dry-powder, fibrin sealant containing human plasma-derived thrombin and fibrinogen, was evaluated in patients undergoing vascular surgical procedures. METHODS In this single-blind trial (clinicaltrials.gov: NCT01527357), adult patients were randomized 2:1 to Fibrocaps plus gelatin sponge (Fibrocaps) vs gelatin sponge alone. Results are presented for the patient subset undergoing vascular procedures with suture hole bleeding. The primary efficacy endpoint compared time to hemostasis (TTH) over 5 minutes. Safety follow-up continued to day 29. RESULTS A total of 175 patients were randomized and treated (Fibrocaps, 117; gelatin sponge, 58). Patients were predominately male (69%) and underwent arterial bypass (81%), arteriovenous graft formation (9%), or carotid endarterectomy (9%). Fibrocaps significantly reduced TTH compared with gelatin sponge (hazard ratio [HR], 2.1; 95% confidence interval [CI], 1.5-3.1; median TTH, 2 minutes; 95% CI, 1.5-2.5 vs 4 minutes; 95% CI, 3.0-5.0; P < .002). Significant reductions were also observed in patients receiving concomitant antiplatelet agents alone (HR, 2.8; 95% CI, 1.0-7.4; P = .03; n = 33), anticoagulants alone (HR, 2.0; 95% CI, 1.0-4.0; P = .04; n = 43), or both antiplatelet agents and anticoagulants (Fibrocaps vs gelatin sponge, HR, 2.3; 95% CI, 1.2-4.3; P = .008; n = 65). Incidences of common adverse events (procedural pain, nausea, constipation) were generally comparable between treatment arms. Anti-thrombin antibodies developed in 2% of Fibrocaps-treated patients and no-gelatin-sponge patients. CONCLUSIONS Fibrocaps, a ready-to-use, dry-powder fibrin sealant, was well-tolerated and reduced TTH in patients undergoing vascular procedures, including those receiving antiplatelet agents and/or anticoagulants, demonstrating its safety and usefulness as an adjunct to hemostasis.
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Affiliation(s)
- NavYash Gupta
- Division of Vascular Surgery, NorthShore University HealthSystem, Skokie, Ill
| | - Ian Chetter
- Department of Vascular Surgery, University of Hull, East Yorkshire, United Kingdom
| | - Paul Hayes
- Department of Vascular Surgery, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Albert H O-Yurvati
- Department of Surgery, University of North Texas Health Science Center, Fort Worth, Tex
| | - Gregory L Moneta
- Division of Vascular Surgery, Oregon Health & Science University Hospital & Clinic, Portland, Ore
| | - Surendra Shenoy
- Division of General Surgery, Section of Transplantation Surgery, Washington University School of Medicine, St. Louis, Mo
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Blutkompatibler und adhäsionsstarker Gewebekleber. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2015. [DOI: 10.1007/s00398-015-0015-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Lumsden AB, Morrissey NJ, Staffa R, Lindner J, Janousek L, Treska V, Stadler P, Moursi M, Storck M, Johansen K, Schermerhorn M, Powell R, Panneton J, Zhou W, Naoum J, Lipsitz E, Buckley C, Timaran C, Jordan W, Darling RC, Silhart Z, Buckley C, Armstrong P, Belkin M, Morrissey N, Porreca F, Cayne N. Randomized controlled trial comparing the safety and efficacy between the FUSION BIOLINE heparin-coated vascular graft and the standard expanded polytetrafluoroethylene graft for femoropopliteal bypass. J Vasc Surg 2015; 61:703-12.e1. [DOI: 10.1016/j.jvs.2014.10.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 10/06/2014] [Indexed: 11/25/2022]
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Use of a novel hybrid vascular graft for sutureless revascularization of the renal arteries during open thoracoabdominal aortic aneurysm repair. J Vasc Surg 2014; 60:622-30. [DOI: 10.1016/j.jvs.2014.03.256] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 03/16/2014] [Indexed: 11/22/2022]
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Lewis KM, Schiviz A, Hedrich HC, Regenbogen J, Goppelt A. Hemostatic efficacy of a novel, PEG-coated collagen pad in clinically relevant animal models. Int J Surg 2014; 12:940-4. [DOI: 10.1016/j.ijsu.2014.07.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 07/09/2014] [Accepted: 07/22/2014] [Indexed: 01/23/2023]
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Bektas H, Nadalin S, Szabo I, Ploder B, Sharkhawy M, Schmidt J. Hemostatic efficacy of latest-generation fibrin sealant after hepatic resection: a randomized controlled clinical study. Langenbecks Arch Surg 2014; 399:837-47. [PMID: 25037462 DOI: 10.1007/s00423-014-1227-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 07/09/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE This randomized, controlled, single-blinded multicenter study evaluated the efficacy of latest-generation fibrin sealant containing synthetic aprotinin as fibrinolysis inhibitor as supportive treatment for hemostasis after elective partial hepatectomy. METHODS Adult subjects undergoing resection of at least one liver segment were assigned to treatment with fibrin sealant or manual compression with a surgical gauze swab if persistent oozing necessitated additional hemostatic measures after primary control of arterial and venous bleeding. The primary outcome measure was the proportion of subjects with intraoperative hemostasis at 4 min after start of randomized treatment application. Secondary efficacy outcome measures included intraoperative hemostasis at 6, 8, and 10 min, intra- and postoperative rebleedings, transfusion requirements, and drainage volume. RESULTS Seventy subjects were randomized. Hemostasis at 4 min was achieved in 29/35 (82.9 %) fibrin sealant subjects compared with 13/35 (37.1 %) control subjects (p < 0.001). Significantly more fibrin sealant subjects achieved hemostasis at 6 (p < 0.001), 8 (p = 0.028), and 10 min (p = 0.017). The number of rebleedings was low in both study arms. Transfusion requirements and 48-h drainage volumes were similar between the study arms. No adverse events related to study treatment were reported. CONCLUSIONS Fibrin sealant was shown to be safe and superior to manual compression in the control of parenchymal bleeding after hepatic resection. The use of synthetic aprotinin as fibrinolysis inhibitor further improves the safety margin of fibrin sealant by eliminating the risk of transmission of bovine spongiform encephalopathy and other bovine pathogens.
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Affiliation(s)
- Hüseyin Bektas
- Clinic for General, Visceral and Transplant Surgery, Medical University of Hannover, 30625, Hannover, Germany
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Dwyer JF, McCoy JA, Yang Z, Husser M, Redl H, Murphy MA, Wolfsegger M, DiOrio JP, Goppelt A, Donovan S. Thrombin based gelatin matrix and fibrin sealant mediated clot formation in the presence of clopidogrel. Thromb J 2014; 12:10. [PMID: 24891841 PMCID: PMC4041347 DOI: 10.1186/1477-9560-12-10] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 04/21/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Platelet inhibitors are commonly used to reduce the risk of atherothrombotic events. The aim of this study was to determine the impact of platelet inhibitors, specifically clopidogrel and aspirin, on clot kinetics, strength, and/or structure during the use of thrombin based gelatin matrices and fibrin sealants. METHODS Blood was collected and heparinized from donors on clopidogrel (and aspirin) and age matched control donors. Blood component analysis, whole blood platelet aggregometry, and activated clotting time (ACT) were used to monitor compliance to therapy and identify any differences between donor groups. Clot kinetics and strength were analyzed using thrombelastography (TEG). Field Emission Scanning Electron Microscopy (FESEM) was used to analyze clot structure. RESULTS Blood component profiles were similar for both donor groups. Aggregometry indicated that aggregation response to adenosine diphosphate (ADP) for clopidogrel donors was 12% of that for the controls (p = 0.0021), an expected result of clopidogrel induced platelet inhibition. However, blood from both donor groups had an elevated thrombin induced aggregation response. Heparinization of donor blood resulted in similarly elevated ACTs for both donor groups. TEG results indicated similar clot kinetics and strength between clopidogrel and control donor groups for blood alone and when clotting was induced using thrombin based gelatin matrices and fibrin sealants. FESEM images supported TEG findings in that similar morphologies were observed in ex vivo formed clots from both donor groups when thrombin based gelatin matrices and fibrin sealants were used. CONCLUSION These results suggest that platelet inhibitors do not negatively impact clot kinetics, strength, and structure when clotting is initiated with thrombin based gelatin matrices and fibrin sealants.
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Affiliation(s)
| | - Jill A McCoy
- Baxter Healthcare Corporation, Deerfield, IL, USA
| | - Ziping Yang
- Baxter Healthcare Corporation, Deerfield, IL, USA
| | | | - Heinz Redl
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Center, Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | | | | | | | - Andreas Goppelt
- Baxter Innovations GmbH, Wagramerstrasse 17-19, 1220 Wien, Austria
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Shander A, Kaplan LJ, Harris MT, Gross I, Nagarsheth NP, Nemeth J, Ozawa S, Riley JB, Ashton M, Ferraris VA. Topical hemostatic therapy in surgery: bridging the knowledge and practice gap. J Am Coll Surg 2014; 219:570-9.e4. [PMID: 25151345 DOI: 10.1016/j.jamcollsurg.2014.03.061] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 02/02/2014] [Accepted: 03/03/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Aryeh Shander
- Department of Anesthesiology, Critical Care Medicine, and Hyperbaric Medicine, Englewood Hospital & Medical Center, Englewood, NJ; Department of Surgery, Englewood Hospital & Medical Center, Englewood, NJ; Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Lewis J Kaplan
- Department of Surgery, Section of Trauma, Surgical Critical Care and Surgical Emergencies, Yale School of Medicine, New Haven, CT; Tactical Medicine, Tactical Police Surgeon, Police Departments, South Central SWAT North Haven, North Branford, East Haven, CT
| | - Michael T Harris
- Department of Surgery, Englewood Hospital & Medical Center, Englewood, NJ; Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Irwin Gross
- Department of Transfusion Services, Eastern Maine Medical Center, Bangor, ME
| | - Nimesh P Nagarsheth
- Department of Obstetrics and Gynecology, Englewood Hospital & Medical Center, Englewood, NJ; Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jeffrey Nemeth
- Department of Pharmacy, Englewood Hospital & Medical Center, Englewood, NJ
| | - Sherri Ozawa
- Institute for Bloodless Medicine and Patient Blood Management, Englewood Hospital & Medical Center, Englewood, NJ
| | - Jeffrey B Riley
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester MN
| | | | - Victor A Ferraris
- Division of Cardiothoracic Surgery, University of Kentucky, Lexington, KY
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Abstract
INTRODUCTION Fibrin sealants (FS) have been approved for use in the United States since 1998. Since approval, they have been used in a wide variety of clinical settings and new products continue to be introduced. AREAS COVERED This review covers the literature supporting the USA FDA-approved indications for FS products produced by Baxter Corp. Literature review of PubMed, the Cochrane Library, FDA approval documents and product websites yielded information contained in this article. Mechanism of action, efficacy and safety of these products are covered. EXPERT OPINION FS are generally safe, popular and are used for a wide variety of off-label indications. Their use appears to be expanding rapidly. For many uses, including approved ones, large well-controlled trials are still needed. Additionally, cost-effectiveness data for these products would be a great benefit in guiding their future use.
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Affiliation(s)
- Samuel P Mandell
- Harborview Medical Center , 325 9th Avenue, Box 359796, Seattle, WA 98104-2499 , USA +1 206 744 3140 ; +1 206 744 2896 ;
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Fibrin Sealant: The Only Approved Hemostat, Sealant, and Adhesive-a Laboratory and Clinical Perspective. ISRN SURGERY 2014; 2014:203943. [PMID: 24729902 PMCID: PMC3960746 DOI: 10.1155/2014/203943] [Citation(s) in RCA: 200] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 11/18/2013] [Indexed: 02/07/2023]
Abstract
Background. Fibrin sealant became the first modern era material approved as a hemostat in the United States in 1998. It is the only agent presently approved as a hemostat, sealant, and adhesive by the Food and Drug Administration (FDA). The product is now supplied as patches in addition to the original liquid formulations. Both laboratory and clinical uses of fibrin sealant continue to grow. The new literature on this material also continues to proliferate rapidly (approximately 200 papers/year). Methods. An overview of current fibrin sealant products and their approved uses and a comprehensive PubMed based review of the recent literature (February 2012, through March 2013) on the laboratory and clinical use of fibrin sealant are provided. Product information is organized into sections based on a classification system for commercially available materials. Publications are presented in sections based on both laboratory research and clinical topics are listed in order of decreasing frequency. Results. Fibrin sealant remains useful hemostat, sealant, and adhesive. New formulations and applications continue to be developed. Conclusions. This agent remains clinically important with the recent introduction of new commercially available products. Fibrin sealant has multiple new uses that should result in further improvements in patient care.
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Abstract
INTRODUCTION Over the past 15 years, a wide range of agents have been developed for use in surgical procedures to achieve hemostasis. These agents can be divided into three broad categories: hemostats, sealants and adhesives. They vary widely related to their mechanism of action, composition, ease of application, adherence to wet or dry tissue, immunogenicity and cost. AREAS COVERED This article focuses on the agents used in vascular surgery to achieve hemostasis; agents involved in clinical trials are also covered. EXPERT OPINION When surgeons achieve rapid hemostasis, potential benefits include better visualization of the surgical area, shorter operative times, decreased requirement for transfusions, better management of an anticoagulated patient, decreased wound healing time and overall improvement in patient recovery time. The need for safe and efficacious hemostatic agents that can provide a range of benefits is clearly a significant surgical issue.
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Affiliation(s)
- Krishna S Vyas
- University of Kentucky, Division of Cardiothoracic Surgery, Department of Surgery, Kentucky Clinic A301 , 740 South Limestone, Lexington, KY 40536-0284 , USA +1 859 278 1227 ; +1 859 257 4682 ;
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