Anastomotic hemorrhage due to needle holes is a complication encountered by even experienced surgeons performing emergency operations for acute type A aortic dissection (AADA). Some patients may require further intervention for distal anastomotic new entry tear (DANE) even after surviving the acute phase of tear-oriented surgery (Fig. 1) [1-3]. While total arch replacement (TAR) is often considered for better long-term outcomes, less extensive surgical procedures may be preferred in cases of poor preoperative conditions. In this report, we present a modified distal reinforcement technique employing a balloon and glue to prevent DANE.

Figure 1. Schematic and actual images of a distal anastomotic new entry tear in a dissection operation. (A) Challenges faced by surgeons at the distal anastomotic site in the context of acute type A aortic dissection. A distal anastomotic new entry tear (indicated by the star) can serve as an entry point into the false lumen (denoted by the arrow) to maintain its patency. This can lead to subsequent aneurysmal changes. (B) Coronal view following ascending aorta replacement. The image reveals a patent false lumen (indicated by arrowheads), in contrast to the preoperative thrombosed false lumen. (C) Sagittal view of distal anastomotic new entry tear (indicated by the star). (D) Coronal view of distal anastomotic new entry tear (denoted by the arrow). (E) Sagittal view of the same case.

This study was conducted in accordance with the principles of the Declaration of Helsinki. The study protocol was reviewed and approved by the institutional review board of Fukuoka University Hospital (approval number: U22-07-005).

At the start of the emergency operation for AADA, median full sternotomy was performed. Cardiopulmonary bypass was generally established through cannulation of the true lumen of the ascending aorta, bicaval venous drainage, and left ventricular venting. If the ascending aorta was not accessible, alternative cannulation sites were used, such as the femoral and/or axillary artery or the apex. Following the initiation of deep hypothermic circulatory arrest at temperatures below 25°C, the aortic wall was opened. Cardioplegia and retrograde cerebral perfusion were simultaneously initiated. The Supplementary Video 1 presents an overview of the surgical technique. A thorough inspection was conducted from the aortic arch to the root to identify the entry tear, which was subsequently resected. After transitioning from retrograde cerebral perfusion to selective cerebral perfusion (SCP), the dissected aorta was trimmed either just before or after the brachiocephalic artery (Fig. 2). If no large tear was present nearby, an aortic balloon was carefully inserted into the true lumen and inflated just distal to the left subclavian artery. To prevent glue from dripping, gauze was placed in the true lumen before minimal BioGlue (Cryolife Inc., Kennesaw, GA, USA) was injected into the false lumen [4]. The aortic balloon was moved 1 to 2 seconds after the injection and then re-inflated to ensure adhesion of the false lumen at the transverse arch. After a 2-minute wait for the distal end reinforcement to set, the graft was anastomosed using a 4-0 polypropylene suture with the turn-up technique [5]. Following distal anastomosis, systemic perfusion was resumed through a side branch of the graft, and the patient was gradually rewarmed.

Figure 2. Distal end anastomosis. (A) A balloon-tip catheter was inserted into the neck vessels for selective cerebral perfusion (SCP) following circulatory arrest, while maintaining a dry field. Further details on SCP are not discussed herein. (B) The aortic balloon was carefully inserted into the true lumen and inflated just distal to the left subclavian artery. Subsequently, small pieces of gauze were placed in front of the true lumen to prevent glue from dripping. (C) BioGlue (Cryolife Inc., Kennesaw, GA, USA) was injected into the false lumen. (D) The aortic balloon was shifted 1–2 seconds following injection. (E) Subsequently, the aortic balloon was positioned to ensure adhesion of the false lumen at the transverse arch. Reinforcement at the distal site was completed after a 2-minute waiting period. (F) The graft was anastomosed using a 4-0 polypropylene suture in a standard fashion, having been stabilized by BioGlue (indicated by the star).

From January to December 2023, a total of 10 patients with AADA underwent treatment using this technique: 9 received either ascending aorta replacement or hemiarch replacement (HAR), including one concurrent aortic root replacement, and 1 had partial arch replacement. The mean age of the patients was 80.0±8.8 years (range, 59–93 years), and 1 patient (10%) was male. The mean follow-up period was 7.3±3.2 months (range, 1–11 months). Computed tomography performed on the 7th postoperative day showed no DANE while revealing thrombosis in the transverse aortic arch (Fig. 3). Complications included 1 case of reoperation due to sternal bleeding on the first postoperative day and 1 case requiring pericardial drainage for late tamponade on the 24th postoperative day. No patients experienced stroke or systemic embolization. Furthermore, during the follow-up period, no aorta-related events or deaths were reported.

Figure 3. Representative case of hemiarch replacement in which the distal anastomosis was reinforced using the balloon-and-glue technique. (A) Preoperative computed tomography (CT) reveals an entry tear (indicated by the arrow) at the junction of the ascending aorta and the aortic arch, seen in the axial view. (B) Preoperative CT shows an entry tear (indicated by the arrow) and a false lumen (marked with an asterisk) involving the lesser curvature of the aortic arch, seen in the coronal view. (C) CT performed on postoperative day 7 reveals the distal anastomosis (indicated by dotted arrows) in the axial view. (D) CT performed on postoperative day 7 reveals the distal anastomosis (indicated by dotted arrows) and proximal arch with a sealed false lumen (denoted by arrowheads) in the coronal view. This technique successfully eliminated the false lumen depicted in image (B).

Despite advances in surgical techniques and the use of hemodynamic agents, TAR remains more invasive and has a higher mortality rate compared to ascending aortic replacement or HAR. For AADA, procedures that are less extensive may be more appropriate for older adults or those with poor preoperative conditions, including brain complications, especially when prioritizing life-saving measures. Furthermore, even when the primary entry tear is excluded, subsequent surgery to address aneurysmal change due to DANE may be required [2]; to prevent this, various techniques have been developed [6,7]. However, these methods can be challenging to apply in cases of a narrow aorta, as they involve the insertion of a layer into the false lumen. Furthermore, it remains unclear whether TAR can be avoided when retrograde flow is present in the false lumen. To overcome these challenges, we introduced a technique that combines the application of glue with the use of a balloon to reinforce the distal aorta, aiming to prevent complications such as DANE.

With our technique, we observed that sealing the false lumen with glue applied via a balloon can avoid the need for TAR, even in the presence of a small re-entry in the transverse arch (Supplementary Fig. 1). However, using BioGlue in patients with an intimal tear in the arch carries the risk of distal embolization due to leakage. Consequently, this technique is not recommended when the transverse arch has even a small tear, considering the risk of embolization. In our case, the success of the procedure may have been fortuitous, influenced by patient-specific factors or distinct circumstances, and thus may not be generalizable. Nevertheless, in select patients without an intimal tear in the aortic arch, this technique could convert a patent dissection into an intentionally thrombosed dissection. By carefully applying this method, it is possible to reduce the surgical extent and thus decrease operative time and bleeding. Moreover, this technique is straightforward and easy to apply, combining available hemostatic agents with tools such as occlusion balloons. While BioGlue has been used by many surgeons, we believe our study represents the first attempt to maximize its effectiveness by sealing the false lumen with a balloon. For this technique, aortic balloons designed for stent grafts are ideal, but large urinary catheters, such as 26F, may also be employed.

Another advantage of this technique is its applicability to the distal aspect in TAR, which may assist in consolidating the false lumen of the descending aorta and aid in reducing dissecting aneurysms. While the frozen elephant trunk procedure is an alternative for decreasing the extent of dissecting aneurysms, it carries the risk of inducing new entry tears at the distal stent graft edge [3,8].

When employing our technique, several considerations are critical. First, maintaining a dry field at the distal site is essential. To secure a dry field and support the effectiveness of the glue, SCP of the 3 neck vessels or circulatory arrest is required. Second, the balloon should be moved and re-inflated immediately after BioGlue injection. Effective sealing of the false lumen is achieved by re-inflating the balloon, which allows the BioGlue to naturally distribute toward the rear of the false lumen under the influence of gravity during balloon manipulation. Notably, BioGlue can spread along the aortic wall at a rate of 5 to 6 mm/sec, primarily due to gravitational effects. Patience is key during the setting phase of BioGlue, with a minimum waiting time of at least 2 minutes. Reducing this time may adversely impact the success of the procedure.

Some points of caution must be considered when applying this technique. First, to prevent intimal tearing, it is crucial to avoid inflating the aortic balloon beyond the diameter of the true lumen. Second, this technique should be avoided if a re-entry position is suspected around the level of the left subclavian artery, to prevent enlarging the tear.

To conclude, modified distal reinforcement using the balloon-and-glue technique can be an effective measure to prevent DANE. Additionally, it represents a palliative approach involving a less extensive surgical procedure, which is particularly useful in cases with concerns regarding the extent of future surgery.

Author contributions

Conceptualization: MF. Methodology: MF, HW. Investigation: GK, YS. Data collection: MF, GK, YS. Writing–original draft preparation: MF. Writing–review and editing: MF, HW. Supervision: HW. Final approval of the manuscript: all authors.

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Supplementary materials

Supplementary materials can be found via https://doi.org/10.5090/jcs.24.098. Supplementary Video 1. Overview of the procedure for acute type A aortic dissection. Supplementary Fig. 1. A representative case illustrating the use of the balloon-and-glue technique to avoid total arch replacement.