Comparison of a Plasma-based Composite Biologic Sealant With Fibrin Glue (Tisseel??) for Vascular Anastomoses

The Potential Utility of Fibrin Sealant Dressing in Repair of Vascular Injury in Swine

BACKGROUND

A previous study in which fibrin sealant dressing (FSD) secured hemostasis in major arterial hemorrhage for 96 hours suggested the applicability of this dressing in damage control operations after severe trauma. The objective of this study was to determine the effective duration of FSD hemostatic function in vivo and to examine its potential utility for definitive repair of a major arterial injury in swine.

METHODS

High pressure bleeding in an infrarenal aortotomy was controlled by placing FSD on the wound with 4-minute compression (n = 15). If hemostasis was achieved, the abdominal cavity was closed. Surviving animals were killed at 2, 4, 6, and 8 weeks and aortotomy sites collected for histology.

RESULTS

FSD stopped arterial hemorrhage after 4-minute compression in 14 of 15 (93%) pigs. Dressings failed in two pigs at 36 and 53 minutes after treatment. Twelve (80%) animals recovered and resumed normal activities. Of the remaining 12, two developed rebleeding at the aortotomy site on days 8 and 11 and were killed; another was killed because of idiopathic low hematocrit on day 10. Nine pigs survived until scheduled to be killed, maintaining hemostasis with stable hematological values. In the surviving animals, serial computed tomography scans showed formation of a pseudoaneurysm at the aortotomy site, which resolved after 2 to 3 weeks. The initial vascular defect and pseudoaneurysm were filled with fibroblast-myoblast collagen rich tissues covered by endothelium.

CONCLUSION

FSD can seal an arterial injury, stop high pressure bleeding, and prevent rebleeding for at least 7 days. The dressing may be most beneficial in damage control operations. If combined with an elective interventional radiologic procedure (e.g. embolization or stenting), it may also offer an alternative to suture repair of vascular injuries in cases where profuse bleeding obstructs visualization.

Prospective randomized study evaluating an absorbable cyanoacrylate for use in vascular reconstructions

BACKGROUND

An easy-to-use vascular sealant with good safety and efficacy is needed to prevent anastomotic bleeding in vascular surgery. This study evaluated the safety and efficacy of cyanoacrylate surgical sealant in establishing hemostasis of expanded polytetrafluoroethylene to arterial vascular anastomoses in arteriovenous (AV) grafts and femoral bypass grafts.

METHODS

This multicenter, randomized, controlled, open-label study was conducted in a hospital setting at 12 sites: 10 in the United States and 2 in Europe. A total of 151 patients undergoing femoral bypass procedures or AV shunt procedures for hemodialysis access using expanded polytetrafluoroethylene grafts were randomized 2:1 to receive cyanoacrylate surgical sealant or the control (oxidized cellulose) between April 26, 2004, and January 18, 2005. Randomization was stratified by clinical site and type of procedure. After the anastomosis, cyanoacrylate surgical sealant or the control was applied to all anastomosis sites for patients undergoing femoral bypass procedures and to only the arterial anastomosis sites for patients undergoing AV shunt procedures. The primary end point was the elapsed time from clamp release to hemostasis. Secondary end points were the proportion of patients achieving hemostasis at t = 0 (immediate), 1, 5, or 10 minutes after clamp release, use of additional adjunctive measures to achieve hemostasis, and occurrence of adverse events.

RESULTS

Baseline demographics and clinical characteristics showed that the two treatment groups were similar at baseline. The mean time from clamp release to hemostasis was 119.3 seconds with cyanoacrylate surgical sealant vs 403.8 seconds with the control (P < .001). Immediate hemostasis was achieved in 54.5% of patients receiving cyanoacrylate surgical sealant and in 10% of those receiving the control. The proportion of patients requiring additional adjunctive measures was lower with cyanoacrylate surgical sealant, and the occurrence of adverse events was similar in both groups.

CONCLUSIONS

This study demonstrates that cyanoacrylate surgical sealant is effective at reducing the time to hemostasis and achieving immediate hemostasis in AV shunt and femoral bypass procedures and that it is safe for internal use. Cyanoacrylate surgical sealant is an easy-to-use vascular sealant with good safety and efficacy that significantly decreases anastomotic bleeding in vascular surgery.