The use of cyanoacrylate adhesive (Krazy Glue) in cardiac surgery

Left Ventricular Dissecting Hematoma Caused by Tissue Stabilizer

Coronary artery bypass grafting is a commonly performed procedure for coronary revascularization. We describe the successful management of left ventricular dissecting hematoma, caused by the tissue stabilizer, while performing off-pump coronary artery bypass graft procedure.

To Evaluate the Efficacy and Effectiveness of N-butyl-2-cyanoacrylate glue (TRU SEAL) in Closure of Oral and Maxillofacial Laceration and Surgical Incisions

Introduction

Effective wound closure is critical for minimizing wound complications and preventing wound dehiscence. The various wound closure techniques include staples, traditional nylon and skin sutures, subcuticular sutures, and skin adhesives. Currently topical skin adhesives are frequently being used. It offers countless advantages: short application time, easy execution as well as possessing hemostatic character. N-butyl-2-cyanoacrylate is bacteriostatic and biodegradable and exhibits suitable tensile strength.

Materials and Methods

Under nasoendotracheal intubation, the reduction in fracture and plating was done. In 80% of the patients, subcutaneous sutures were placed. Skin closure was done with N-butyl-2-cyanoacrylate glue.

Results

In this study, REEDA scale was used to assess healing. Redness, edema, and ecchymosis were seen in all 10 patients, which subsided by the second week postoperatively. None of the patients had discharge from surgical site on the first postoperative day but was noted in two patients the first week postoperatively. There was evidence of wound gaping in one patient on the first postoperative day and two patients at end of the first week postoperatively. Stony Brook Scar Evaluation was used to evaluate postoperative cosmesis. No significant cosmetic impairment was found in all patients at the end of the study.

Conclusion

The study reflects qualitative assessment of cyanoacrylates which is simple to use and proper application which resulted in uniform and everted closure of wound. It is cost-efficient as compared to other wound closure materials.

Biocompatible alkyl cyanoacrylates and their derivatives as bio-adhesives

Cyanoacrylate adhesives and their homologues have elicited interest over the past few decades owing to their applications in the biomedical sector, extending from tissue adhesives to scaffolds to implants to dental material and adhesives, because of their inherent biocompatibility and ability to polymerize solely with moisture, thanks to which they adhere to any substrate containing moisture such as the skin.

Late Follow-Up of Cyanoacrylate Usage in Cardiothoracic Surgery

In cardiovascular and thoracic surgery, troublesome bleeding and sternal dehiscence can be life-threatening if not managed appropriately. We used commercially available cyanoacrylate adhesive 21 times in 20 sporadic patients for the management of 6 different problems: sternal gluing in 7 cases; anastomotic line reinforcement and bleeding control with a glued Teflon or pericardial patch in 6; right ventricular or superior vena caval patch repair in 5; and 1 case each of left ventricular apical glued Teflon felt, arterial wall reinforcement, and control of air leakage after lung surgery. The mean age of the patients was 55.7 ± 12.5 years, ranging from 34 to 71 years. Successful results were obtained in 18 patients and 17 were alive on follow-up at 7.7 ± 5.5 months (range, 2 to 16 months). We used two different commercial brands of adhesive but obtained good results with only one of these preparations. Although commercially available cyanoacrylate is a new adjunct to cardiac surgery with documented safety and lifesaving results at negligible cost, the appropriate polymer for best results needs to be defined.

Management of haemostasis in surgery: sealant and glue applications

Blood loss has always been a sensitive issue in surgery. Traditional techniques, such as suturing and electrocautery, have drastically reduced operatory bleeding. Unfortunately, wound edges and point application devices are frequently characterized by bleeding and infections. Over the past 20 years, haemostatic agents and tissue sealants have been developed and now are currently used, along with classic suture in various surgical specialties. Their fluid nature allows management of blood loss along any point of the wound and tissue repair. This review presents an overview of the most diffused haemostatic sealants, focusing on their main use in surgery and their adverse effects.

Is skin closure with cyanoacrylate glue effective for the prevention of sternal wound infections?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed whether cyanoacrylate glue was effective at preventing wound infection following sternotomy incision. Altogether more than 108 papers were found using the reported search, of which seven represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that applying cyanoacrylate glue to a sternal wound has superior outcomes in terms of infection rates, both if applied preoperatively (decreasing from 10.8% to 2.7% or 7.8% to 1.1%, according to two studies) and postoperatively (4.9%-2.1%). This trend is true of both deep surgical site infections (0.6%-0%) and superficial site infections (4.3%-2.1%). Furthermore, in patients who had developed mediastinitis following cardiac surgery rates of recurrent sternal detachment and osteomyelitis were significantly reduced in cases where sealant was applied compared to controls (35.3% vs. 0%). In all studies examining hospital stay, duration was reduced in cases where cyanoacrylate glue was used, both in patients treated for recurrent mediastinitis (24.06 vs. 14.16 days) and those with uncomplicated recovery following cardiac surgery (13 vs. 9 days). In addition, two studies examining the use of cyanoacrylate glue to secure the sternum in complicated cases of recurrent detachment report success rates of 86% and 100%.

Haemostatic efficacy of an ethyl-2-cyanoacrylate-based aerosol in combination with tourniquet application in a large wound model with an arterial injury

BACKGROUND

Tourniquet application is the standard method for the control of severe trauma haemorrhage. However, it may result in severe ischaemic injuries when used for a long time. In this study, we developed a modified ethyl-2-cyanoacrylate-based aerosol (ECA) aerosol spray and determined its efficacy for short-time control of bleeding of large wounds in pigs when used in combination with tourniquet application.

METHODS

A large wound model with a femoral arterial injury was made in the middle of either thigh of the pig. Thirty white female hybrid pigs were divided evenly and randomly into three groups, including tourniquet application only group (group A), tourniquet-ECA group (group B, a combination of ECA with tourniquet application) and tourniquet-ECA with wound cleaning group (group C, a combination of ECA with tourniquet application plus wound cleaning).

RESULTS

The success rates of haemostasis were 0%, 30%and 90% in groups A, B and C, respectively (P<0.05). The incidence of haematoma and the membrane forming time were 100% and 20%, and 5.9+/-1.0min and 8.3+/-1.1min, respectively, in groups B and C (both P<0.05). The haemostatic time and the thickness of membrane were 11.9+/-1.8min and 10.2+/-1.4min, and 0.68+/-0.29mm and 0.79+/-0.25mm, respectively, in the two groups (P>0.05, both).

CONCLUSION

The ECA spray achieves haemostasis within a very short time when it is used in combination with tourniquet application in a large wound model with an arterial injury. It may effectively prevent the wound from bleeding without the need for any long-term pressure bandage to wrap the wound, and it is easy to be disposed in debridement. Therefore, it may serve as an optimal choice for the first aid of large wounds with an arterial injury.

Adhesive strength and curing rate of marine mussel protein extracts on porcine small intestinal submucosa

An adhesive protein extracted from marine mussels (Mytilus edulis) was used to bond strips of connective tissue for the purpose of evaluating the use of curing agents to improve adhesive curing. Specifically, mussel adhesive protein solution (MAPS, 0.5mM dihydroxyphenylalanine) was applied, with or without the curing agents, to the ends of two overlapping strips of porcine small intestinal submucosa (SIS). The bond strength of this lap joint was determined after curing for 1h at room temperature (25 degrees C). The strength of joints formed using only MAPS or with only the ethyl, butyl or octyl cyanoacrylate adhesives were determined. Although joints bonded using ethyl cyanoacrylate were strongest, those using MAPS were stronger than those using butyl and octyl cyanoacrylates. The addition of 25mM solutions of the transition metal ions V5+, Fe3+ and Cr6+, which are all oxidants, increased the bond strength of the MAPS joints. The V5+ gave the strongest bonds and the Fe3+ the second strongest. In subsequent tests with V5+ and Fe3+ solutions, the bond strength increased with V5+ concentration, but it did not increase with Fe3+ concentration. Addition of 250mM V5+ gave a very strong bond.

SURGICAL APPLICATIONS OF CYANOACRYLATE ADHESIVES: A REVIEW OF TOXICITY

Cyanoacrylate (CA) and its homologues have a variety of medical and commercial applications as biological adhesives and sealants. Homologues of CA are being widely promoted in surgery as a tissue adhesive to replace traditional suturing techniques. Potential benefits of using CA adhesives include better cosmetic results, more rapid wound closure, and perhaps most significantly, the potential for significant reductions in percutaneous injuries from suture needles, which would in turn also reduce the risk of transmission of infectious diseases. Nevertheless, certain concerns have been raised regarding the potential toxicity of CA within patients, as well as among health professionals who are occupationally exposed when using CA compounds. Reported toxicity of CA in the workplace may result in dermatological, allergic and respiratory conditions. To help reduce the occupational burden, therefore, medical staff using CA adhesives should avoid direct contact with the compound and use appropriate personal protective measures at all times. Maintaining higher levels of humidity, optimizing room ventilation and using special air conditioning filters in surgical suites and operating theatres may also be useful in minimizing the exposure to volatile CA adhesives.

Full-thickness skin necrosis of the fingertip after application of superglue

We present the case of a 39-year-old woman who applied superglue to her fingertip as a treatment for dry skin. She developed full-thickness necrosis of her thumb pad complicated by a secondary superinfection. This necrosis occurred from the degradation of the cyanoacrylate in the superglue compound to formaldehyde, causing local histotoxicity. This injury necessitated a local flap for coverage, which healed uneventfully and without lasting sequelae.

Prevention of loosening in total hip replacements using guided bone regeneration

The aim of this study was to prevent wear debris from reaching the interface of the acetabular cup and femoral component by using a partially occlusive expanded polytetrafluoroethylene membrane. This membrane initially acted as a physical seal, which became incorporated by bone and soft tissue, forming a secondary biologic seal, preventing loosening. An animal model was developed to test the hypothesis. The model replicated the mechanisms of loosening where the effects of wear debris were studied. Using femoral heads with the appropriate roughness, a goat model produced the radiologic and histologic presentation of loosening as observed in total hip replacements in humans. Loosening was assessed by measurement of the radiolucent lines, and was attributed to wear debris by histologic investigation. The expanded polytetrafluoroethylene membrane prevented acetabular implant loosening to a statistical significance of 0.02 in a blinded assessment when compared with the control groups. Loosening of the first 5 mm of the proximomedial aspect of the femur also was prevented. The authors of the current study prevented wear particle-induced osteolysis in the acetabular component by using an expanded polytetrafluoroethylene membrane to seal the bone-cement interface.

Postoperative Sterno-Mediastinitis

Postoperative sterno-mediastinitis is a life-threatening complication that occurs in about 0.75 to 1.4 per cent of all open heart operations. The result of treatment largely depends on timely diagnosis and appropriate surgical management. Risk factors for infection should be corrected preoperatively whenever possible. Among other preventive measures, meticulous asepsis, atraumatic surgical technique, preserving the blood supply and the mechanical integrity of the sternum, prevention of sternal instability, and correction of the same if it occurs are the most important. The management of sterno-mediastinitis should be tailored to the individual clinical features of the patients. Clearly cases with nonpurulent sternomediastinitis and no soft tissue or bone necrosis (type 1) may be treated with reopening, drainage, sternal stabilization, and primary closure. Virulent infections with tissue necrosis (type II) may be best handled with reopening, several days of open management, and debridement then secondary closure with viable tissue (usually muscle) flaps. Chronic, smoldering infections (type III) are usually managed with debridement and muscle-flap coverage.

Cytotoxicity of polymerized commercial cyanoacrylate adhesive on cultured human oral fibroblasts

Cyanoacrylate (CA) has been used as both a commercial and tissue adhesive. Dentists may have had the experience of patients repairing their own acrylic-based dentures using a cyanoacrylate (CA) adhesive known as 'super glue'. This study evaluated the cytotoxicity of commercial CA adhesives when fully polymerized, as well as the toxicity of substances released from polymerized commercial CA adhesives after incubation of these materials for various periods of time. Toxicity was tested on cultured oral fibroblasts. Dead cells found around the various CA-coated filter papers constituted inhibitory zones which varied from 200-1000 microns and which persisted for two weeks. Control oral fibroblasts grew to approach the wax-coated filter paper. Cell viability testing using MTT and crystal violet staining methods supported the conclusion that polymerized CA-coated filter paper released substances that are toxic to cells, while wax-coated filter paper gave the same result as the control. The crystal violet staining method was also used to investigate the cytotoxicity of various CA materials after incubation for one, three, seven and 14 days and showed that CA continued to release cytotoxic substances at about the same level for at least two weeks. It can be concluded that, if CA adhesive is used for repair of broken dentures, it will release substances which are toxic to human oral fibroblast cells. This release of substances may persist for at least two weeks.

Fixation of the craniofacial skeleton with butyl-2-cyanoacrylate and its effects on histotoxicity and healing

Butyl-2-cyanoacrylate is an easily applied, biocompatible, bioresorbable polymer glue that provides an alternative to conventional rigid fixation techniques. Our aim was to determine if cyanoacrylate fixation of the bone flap in a rabbit craniotomy model provides the healing and strength afforded by plate and screw fixation. We also investigated the inflammatory responses of adjacent tissues including the scalp, cranium, and brain. A unilateral parietal bone flap was elevated in 33 adult New Zealand rabbits. The bone was fixed in position with cyanoacrylate (n = 13), fixed with a microplate and screws (n = 14), or was replaced without fixation (sham-control, n = 6). Normal scar formation and no residual polymer were found in scalp specimens. Neuropathologic analysis identified the presence of residual polymer on the surface of 2 of the 13 rabbit brains. Histopathologic analysis of the bone flap-to-skull interface revealed no difference in the degree but rather in the quality of inflammation and healing between the plate and screw and polymer fixation groups. Microdensitometric analysis of the bone gap revealed nearly equivalent bone density in the cyanoacrylate and plated groups, tending to less density in the sham group (p = 0.11 and 0.09, respectively). An additional study focusing on neurotoxicity was performed in 20 adult rabbits with 3-week and 11-week recovery periods and similarly found the absence of a marked inflammatory response to the polymer. In conclusion, bone healing and soft-tissue inflammation were comparable between cyanoacrylate and plate and screw fixation groups. Although butyl-2-cyanoacrylate glue fixation may provide a reasonable alternative to hardware fixation, further investigations are necessary to identify its ideal utilization.

Butyl-2-cyanoacrylate fixation of mandibular osteotomies

Butyl-2-cyanoacrylate is an easily applied, bioresorbable, noninfective glue that may provide an alternative to conventional craniofacial fixation techniques. Recent studies have demonstrated that the healing and strength of glue fixation of bone fragments in the craniofacial skeleton is equivalent to that of plate and screw fixation. We sought to determine if this glue could also provide strength and healing in a more stressed environment, that of the mandible. Fourteen New Zealand White rabbits underwent mandibular osteotomies at the angle. The osteotomy was fixed with either a microplate (n = 4) or glue (n = 10). Mandibles were assessed 10 weeks postoperatively and classified according to bone healing, condylar morphology, and dental morphology. Callus and nonunion were more prevalent in the glued group, whereas condylar resorption was similar in both experimental groups. Despite the poor bony healing in the glued group, the teeth did not decay but modified their standard form to meet the demands of the anatomic deformity. Butyl-2-cyanoacrylate does not offer the biomechanical stability afforded by plates and screws in bone subject to large forces.

Use of aluminum strips to fabricate verification jig for an implant-supported fixed partial denture

Verification of the accuracy of the master cast for an implant-supported fixed partial denture will reduce the chair time and laboratory costs of implant prosthodontic treatment. A wire is usually luted in the mouth to machined components that have been secured to the implants, and the luted assembly is then transferred to the cast to evaluate the positional accuracy of the implant analogs. Unless this wire is dead soft, inaccuracies as a result of elastic memory of the wire can occur. Also, if the wire is not completely rigid, it can be distorted during handling. This article describes a more reliable verification jig for an implant-supported fixed partial denture that can be fabricated with 1.5 mm thick aluminum strips that are luted to the implant components. The use of two aluminum strips creates a metal framework that is rigid and not easily distorted. Also the aluminum pieces do not have elastic memory because they were cut and not bent to shape.

Management of the uncontrollable pulmonary air leak with cyanoacrylate glue

Massive pulmonary air leak from a ruptured bleb in a patient with emphysema may be uncontrollable by the usual methods. A technique is illustrated where fibrin glue, cyanoacrylate glue, and a bovine pericardial patch are used in combination to seal the leak.

Reoperative aortic root surgery late after use of histo-acryl

Cardiovascular reoperations after the use of histo-acryl are extremely rare. A patient is described, who underwent an aortic root replacement according to Bentall's technique, for a postdissectional aneurysm. At that time, to achieve hemostasis, histo-acryl adhesive was applied and a Cabrol's fistula was created. Fourteen years later, a recurrent 'false', aneurysm had developed and the fistula had a hemodynamically significant left-right shunt. At reoperation, the composite graft was replaced by a cryopreserved aortic root allograft with long coronary arteries. To our knowledge, this is the first report of a cardiovascular reoperation after previous use of histo-acryl. This patient also merits attention as to the fact that it illustrates a failure of a modified Cabrol's procedure.