Microsoft word - oxidized cellulose as a cause of acute ischemic event after coronary revascularization1.docx
Oxidized cellulose as the cause of an acute ischemic event after coronary
Jose Rubio Alvarez , Juan Sierra Quiroga , Jose Martinez Cereijo , Laura Reija Lopez
Cardiovascular Department . Universitary Hospital of Santiago de Compostela . Spain .
Publicado : Interactive Cardio Vascular Thoracic Surgery 2010 ; 11 : 488.
Absorbable topical hemostatic agents are commonly used in cardiac surgery . In this
study we report an unusual case of an acute ischemic event after coronary
revascularization produced by interaction between oxidized cellulose and epsilon
aminocaproic acid . An in vitro study was also performed to test the interaction
between oxidized cellulose and epsilon aminocaproic acid .
Key Words : Ischemic event , Oxidized cellulose , Coronary revascularization .
Postoperative bleeding is one of the most frequent complications in cardiac surgery .
Bleeding necessitating reoperation occurs in 4 % to 7 % of patients after CPB and
50% to 70% of them will not have a surgical bleeding source . Fibrinolysis has been
reported to be the cause of 25% to 45% of postoperative bleeding [ 2 ] and the use of
both systemic antifibrinolytic agents and absorbable topical hemostatic agents is
commonplace during cardiac surgical procedures [3,4] . The adverse effects after
systemic use of antifibrinolytic agents is one of the reasons these agents are applied
topically [5 ] . Until recently there were no reports in the literature describing
ischemic events produced by the interaction of oxidized cellulose with topical epsilon
We report the case of a 79-year-old man with unstable angina who was referred to
our departement for surgical revascularization . The coronariography showed
significant left main coronary artery and right coronary artery lesions . The patient had
insulin-dependent diabetes and chronic obstructive lung disease . A routine coronary
revascularization with left internal Mammary artery to Anterior Descending and
saphenous veins to Right Coronary artery and 1st Marginal ( OM ) was performed
under cardiopulmonary bypass . Oxidized cellulose was placed around the OM
anastomotic suture because of a continous oozing and before proceeding with the
sternal closure the pericardial cavity was washed with 100 ml of saline solution
containing 8 g of EACA . During the sternal closure , a severe hypotension with ST
elevation in the posterior leads and a ventricular fibrillation occurred . Defibrillation was
performed and because the ST modifications remained , the oxidized cellulose which
had formed a solid and rigid shape , was removed . The ST elevation inmediately
disappeared . The subsequent intraoperative and postoperative course was uneventful
An in vitro study was performed using three different doses of EACA ( 4 , 8 , 12 Gr ) .
When the oxidized cellulose contacted the saline solution containing EACA , it rolled
up immediately and it turned into a rigid shape ( Fig 1 ) . A segment of the saphenous
vein with a hemostatic clip at the distal end was gently distended and a piece of
oxidized cellulose was placed around the vein . Then we placed the vein in a saline
solution containing EACA and when the oxidized cellulose turned into the rigid shape ,
Figure 1 .- The rigid shape that the oxidized cellulose takes after contac with EACA .
We show a control , unexposed piece for comparison .
Figure 2 .- Saphenous vein constriction caused by oxidized cellulose ( in vitro study ) .
Postoperative bleeding requiring re-exploration occurs in 4% to 7% of patients after
cardiopulmonar bypass and an identifiable surgical bleeding source cannot be found in
more than 50% of these occurrances [ 1 ]. Brown and colleagues [ 3 ] conducted a
meta-analysis to compare the effectiveness of aprotinin , EACA and tranexamic acid
with placebo . They concluded that all antifibrinolytic agents were effective in reducing
blood loss and transfusion . However intravenous antifibrinolytic agents administration
have been associated with an increased risk of thromboembolic events and early graft
closure after coronary revascularization  and new data have emerged regarding an
increase in adverse outcomes associated with the systemic use of antifibrinolytic
agents and most of these effects are avoided by topical application [5,7] . The fact
that after topical use of Tranexamic acid and Aprotinin , they could not be detected in
any of the blood samples  strongly suggest that their effects were due to topical
action . On the other hand topical hemostatic agents are efficacious in reducing blood
loss during surgery [ 4 ] and they can be temporarily administered to avoid sternal
bleeding complications [ 9 ] . Canver [ 10 ] reported a draping technique to prevent
coronary bypass graft kinking and sutureline oozing using oxidized regenerated
Oxidation is the only process that renders cellulose bioabsorbable in man , however a
major problem with oxidation is the difficulty of producing materials that are
homogeneous in chemical and physical properties .
Oxidized cellulose is a fabric material that is obtained by the oxidation of cotton gauze
or other cellulose fabric using nitrous oxide to achieve oxidation . The oxidation
reaction makes the material soluble at physiological conditions . Oxidized regenerated
cellulose similar to oxidized cellulose , but natural cellulose is first dissolved and then
extruded as a continuous fiber . The fabric made from the fiber is very uniform in
chemical composition and its oxidation therefore is more closely regulated . This
uniform oxidation results in less variation in stability and absorbability of the material .
In our in vitro study , when the oxidized regenerated cellulose contacted EACA , it
turned a yellowish brown color and became gelatinous . However when the oxidized
cellulose contacted EACA , it rolled up immediately and turned into a rigid shape .
Within a few days , most of the fibrous structure is gone .
The information presented in this report is the first case of adverse interactions
between oxidized cellulose and topical epsilon aminocaproic acid and we do not
1.- Kajani MK , Waxman HS . Hematologic problems after open heart surgery . In :
Kotler MN , Alfieri A editors . Cardiac and noncardiac complications of open heart
surgery: Prevention , diagnosis and treatment .New York: Futura Publishing Company,
2.- Kevy SV , Glickman RM , Bernhard WF , Diamond LK , Grass RE . The
pathogenesis and control of the hemorrhagic defect in open heart surgery . Surg
3.- Brown JR , Birkmeyer NJ , O´Connor GT . Meta-analysis comparing the
effectiveness and adverse outcomes of antifibrinolytic agents in cardiac surgery .
Circulation 2007 ; 115 (22) : 2801 - 2813 .
4.- Krishnan S , Conner TM , Leslie R , Stemkowski S , Shander A . Choice of
hemostatic agent and hospital length of stay in cardiovascular surgery . Semin
Cardiothorac Vasc Anesth . 2009 ; 13 (4) : 225 - 230 .
5.- Baric D , Biocina B , Unic D , Sutlic Z , Rudez I , Basic Vrca V , Brkic K , Ivkovic M
Topical use of antifibrinolytic agents reduces postoperative bleeding : a double-blind ,
prospective , randomized study . Eur J Cardiothorac Surg 2007 ; 31 : 366-371 .
6.- Ovrum E, Holen EA , Abdelnoor M , Oystese R , Ringdal ML . Tranexamic acid (
Cyklokapron ) is not necessary to reduce blood loss after coronary artery bypass
operations . J Thorac Cardiovasc Surg 1993 ; 105 : 78 - 83 .
7.- Mangano DT , Tudor IC , Dietzel C . The risk associated with aprotinin in cardiac
surgery . N Engl J Med 2006 ; 354 : 353 - 365 .
8.- De Bonis M , Cavaliere F , Alessandrini F , Lapenna E , Santarelli F , Moscato U ,
Schiavello R , Possati GF . Topical use of Tranexamic acid in coronary artery bypass
operations : A double-blind , prospective , randomized , placebo-controlled study . J
Thorac Cardiovasc Surg 2000 ; 119 : 575 - 580 .
9.- Mair H , Kaczmarek I , Oberhoffer M , Groetzner J , Daebritz S , Reichart B .
Surgicel Nu-Knit hemostat for bleeding control of fragile sternum . J Thorac Cardiovasc
10.- Canver CC . A draping technique for prevention of coronary bypass graft kinking
and suture - line oozing . J Card Surg 1996 ; 11(6) : 408 - 410 .
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