Late Sterile Cyst Formation Following Use of Bioglue in Carotid Endarterectomy

Abstract

Introduction - Achieving adequate suture line haemostasis is the backbone of successful vascular surgery and high-pressure sealants such as bovine serum albumin-glutaraldehyde glue (BioGlue, CryoLife Inc., Kennesaw) are available to aid successful anastomosis. BioGlue has been shown to be an important and useful adjunct in achieving suture line haemostasis however literature suggests its use is associated with psuedoaneurysm formation, thromboembolic events due to leakage through suture holes, local tissue damage and late aseptic cyst formation. We present a case of late sterile cyst formation following the use of BioGlue in carotid endarterectomy (CEA). Methods - An 88-year-old female was admitted follow left lacunar stroke with significant right arm weakness and dysarthria. Also noted was one week history of an asymptomatic, enlarging right sided neck mass. Patient had undergone a right carotid endarterectomy 9 months previously for tight 90% stenosis of the right internal carotid artery (ICA). BioGlue (BG3515-5-G, LOT 15MGV110) was used during right CEA to aid haemostasis along the suture line. Examination revealed a 5x3x2cm collection inferior to right sternocleidomastoid muscle. Patient afrebrile and inflammatory markers not raised. Duplex ultrasound of the left ICA confirmed 80% stenosis. CT angiogram of carotids showed concentric soft tissue thickening surrounding the right internal carotid artery but anterolaterally there was an irregular 26mm x 19mm x 22mm fluid attenuation component with faint marginal enhancement. There was no evidence of pseudoaneurysm. Left ICA was managed conservatively however surgical exploration of the right neck swelling was performed. Using an oblique incision to open the neck it was evident there was chronic inflammation and a superficial abscess present with connecting sinus to the patched ICA. A large amount of BioGlue was returned with 1cm area of distal patch appearing to be the central focus of possible infective process. Washout performed and deep drain placed. Results - Empirical antimicrobial therapy of 7 days intravenous teicoplanin followed by 7 days oral docycycline was initiated. All microbiological analysis on theatre specimens (routine culture, extended anaerobic culture, actinomyces and AFB culture, 16S RNA viral assay) was negative. Patient was discharged to a local stroke rehabilitation unit. Conclusion - BioGlue has both adhesive and sealant properties. It acts by formation of strong covalent bonds, within 2-3 minutes, allowing rapid haemostasis and reinforcement of friable tissues A large amount of BioGlue was returned on exploration of the neck which is similar to a case of BioGlue associated aseptic mediastinal cyst after coronary artery bypass described by Szafranek et al [1]. At present, we note no cases of late sterile cyst formation after use of BioGlue in vascular surgery. Agents used to aid haemostasis should be used with caution with minimal volume application used to achieve desired effect.