Barbed sutures in cardiac surgery
Authors:   , Haenen Filip 
Published: November 2024

Barbed sutures, which have mono-directional barbs on their exterior surfaces and a needle on one or both ends, were already described in the patent issued to Dr. John H. Alcamo in 1964. In 1999, Dr. Harry J. Buncke received a patent for his advancements in the technology and in 2004, the US Food and Drug Administration approved the first widely commercialized barbed suture. Since then, several companies have released their own proprietary versions of this type of suture, including Ethicon Endo-surgery and Covidien Healthcare. Barbed sutures have shown the potential to reduce operation duration in various types of surgery, compared to traditional suture methods. However, the use of barbed sutures also has some drawbacks, such as the potential difficulty in removal, the reduction in tensile strength and the absence of long-term data. In addition, specifically for use in the field cardiac surgery, there are no safety data available on this type of suture. Already having described a potential mechanism for complications using barbed sutures in 2015, in aesthetic surgery, this thesis aims to assess the potential benefits and safety profile of using barbed sutures in cardiac surgery. In aesthetic surgery, the potential complication we described is the risk of the barbs catching textile fibers during use, which can lead to foreign body granulomas and a less aesthetically pleasing result. To prevent this, surgeons can use techniques such as covering the surrounding sterile drapes with a pure polyurethane adhesive foil, maintaining distance between the surgical drapes and the surgical site, and taking care when using surgical gauze near barbed sutures. Even in 2015 we concluded, despite this potential complication, barbed sutures are still considered advantageous for certain procedures. In cardiac surgery, the surrounding sterile drapes are often already covered in a polyurethane layer, reducing the risk of foreign body granulomas. (Chapter 1). A prospective trial aimed to compare the use of knotless barbed sutures versus conventional sutures in closing sternal fascia in cardiac surgery was conducted to validate the proposed advantageous properties of barbed sutures. 77 patients were randomized into two comparable groups and the primary outcome measures were the incidence of knot-related wound complications and the time needed to close the presternal fascia. The results showed no significant difference in the time to closure, wound healing, or infection between the two groups. The use of knotless barbed sutures in deeper lying tissue resulted in similar wound healing compared to conventional sutures. This study might suggest that using knotless barbed sutures is feasible for sternal fascia closure in cardiac surgery with no complications. A potential learning curve may exist for those not familiar with this type of suture. A prospective trial comparing conventional to barbed sutures in the closure of presternal fascia was conducted to validify the proposed advantageous properties of barbed sutures. This study did not attain statistical significance in time-to-closure, and a learning curve is suspected when using barbed sutures, after analysis of the data. The increased experience in using this type of sutures made us aware of the potential of barbed sutures, more than just the closure of presternal tissue. The aim of the described in-vitro study (Chapter 3) was to assess the feasibility of using barbed sutures in high-pressure prosthesis anastomosis compared to traditional sutures. Here, paired prosthesis anastomosis specimens were connected to a custom setup using extracorporeal circulation and subjected to high mean pressure (300-350mmHg) for a minimum of 48 hours. The anastomoses were made using either barbed suture or conventional suture, and the strength and endurance of the anastomoses were evaluated. The results showed that barbed suture was able to withstand high pressure and had similar performance to traditional suture in maintaining anastomosis strength and endurance. These findings suggest that barbed suture may be a feasible option for use in high-pressure prosthesis anastomosis in clinical practice, but further research is needed to confirm these results. Our second clinical study investigated the use of barbed suture for closing the venous cannulation site during cardiac surgery through sternotomy. The primary goal was to determine the safety and efficacy of using knotless barbed suture (Stratafix 2/0 non-resorbable, spiral polypropylene) for this purpose, with the primary endpoint being the need for reoperation for bleeding or tamponade and the secondary endpoint being major adverse cardiovascular events (MACE). The study included patients over 18 years old who were undergoing elective coronary artery bypass grafting (CABG) through sternotomy and did not have concomitant valvular surgery. The procedure involved using conventional purse-string sutures (3-0, polypropylene) at the venous cannulation site, followed by closure of the venous cannulation site at the right atrium using the barbed suture after weaning from extracorporeal circulation, and removal of the polypropylene purse-string suture. The results of the study showed that the barbed suture was safe and effective for closing the venous cannulation site, with no reoperations for bleeding or tamponade and no MACE events. (Chapter 4) A new technique was developed during our extended use of barbed sutures. The automatic locking purse string suture (ALPSS) technique is a method of using barbed suture to close the cannulation site after the removal of a cannula in cardiac surgery. It involves passing the suture through a felt pledget, placing a purse-string suture using barbed suture, once again passing the suture through the same felt pledget, and then tying the suture to the venous cannula. After weaning from extracorporeal circulation and removing the (venous) cannula, the purse string suture is tightened, sealing the cannulation site, then, the excess length is cut off. This technique could be effective in reducing blood loss and loss of vision in minimal invasive surgery and may also have potential applications in other surgical disciplines such as closure of surgical access sites or drainage tubes. (Chapter 5) In collaboration with colleagues from Thomas Jefferson University a retrospective review of 90 patients who underwent robotic cardiac surgery (RCS) and received barbed nonabsorbable sutures for various reasons, including the fixation of the mitral annuloplasty band during robotic mitral valve repair was performed. The primary outcome measure was dehiscence of the soft tissue annuloplasty band for which barbed sutures were used, while other notable measures included 30-day mortality, 30-day readmission, intensive care unit (ICU) length of stay, and post-operative complications. The study found that the use of barbed sutures was associated with a low rate of dehiscence, no 30-day mortality, and no suture-related complications. The study concludes that the use of barbed sutures in RCS is a viable alternative to mechanical suturing for mitral valve repair in robotic cardiac surgery. Chapter seven is about the preliminary short-term results of using barbed sutures in high pressure tissue, using techniques that make a fitting ending. To conclude, barbed sutures are feasible and safe in cardiac surgery, potentially reducing operative time. Additional long-term research is advisory to support these early findings.