A pledget is a small pad of material, often made from polytetrafluoroethylene (PTFE, commonly known by the brand name Teflon), cotton, or cellulose, used during surgical procedures to reinforce sutures, control bleeding, protect delicate tissues, or deliver medication. They range from tiny rectangles barely half a centimeter across to larger textile pads, and they show up in almost every surgical specialty. Despite their simplicity, pledgets play a surprisingly varied role in modern medicine, and their presence or absence can influence surgical outcomes in ways that are still being studied.
A Simple Pad With a Specific Job
At its most basic, a pledget is a small cushion placed between a suture and the tissue it passes through. Think of it like a washer under a bolt: the suture pulls tight, but instead of the thread cutting into soft tissue, the pledget spreads the force over a wider area. This prevents the suture from tearing through, which is especially important in tissues that are fragile, inflamed, or under constant mechanical stress like a beating heart.
The most common surgical pledgets are made from expanded PTFE, a synthetic fluoropolymer that the body tolerates well and that does not absorb fluids. A typical PTFE pledget used in cardiac surgery measures roughly 6.5 mm by 4 mm by 1.5 mm, small enough to sit on a fingertip. Cotton and cellulose pledgets are also widely used, particularly in neurosurgery and ENT procedures, where their absorbent properties are actually the point. The choice of material depends entirely on what the pledget needs to do: reinforce a suture, soak up blood, protect a brain surface, or carry a drug.
Reinforcing Sutures During Heart Valve Surgery
The best-known use of pledgets is in cardiac surgery, particularly during aortic valve replacement. When a surgeon sews a new valve into position, the sutures pass through the annulus, the ring of tissue where the valve sits. This tissue can be calcified, thinned by disease, or weakened by the removal of the old valve. A bare suture pulled tight against damaged annular tissue risks cutting through, which can cause a paravalvular leak, meaning blood seeps around the edges of the new valve instead of flowing through it.
Pledgets address this by acting as small buttresses on the tissue side of each suture. The standard technique places a PTFE pledget on the ventricular side of the annulus so that when the suture is tied, the pledget presses against the tissue and distributes the load. This approach has been a mainstay of valve surgery for decades. A novel bidirectional design, where sutures exit through the side of the pledget rather than the base, increases the distance between the suture holes from about 2 to 3 mm to around 5 mm, which may further reduce the risk of the thread cutting through fragile annular tissue.1PubMed Central. A novel bidirectional side exiting pledgetted suture for valve replacement surgery
Whether pledgets actually improve long-term outcomes compared to sutures alone, though, is less clear-cut than you might expect. A propensity-matched analysis drawing on data from a prospective multicenter trial found that clinical outcomes were comparable between patients who received pledgeted and nonpledgeted sutures up to five years after aortic valve replacement.2Journal of Thoracic and Cardiovascular Surgery. Pledgeted versus nonpledgeted sutures in aortic valve replacement: Insights from a prospective multicenter trial In other words, both groups did about equally well in terms of survival and freedom from major complications. The same analysis hinted that pledgets might slightly reduce the effective opening area of the valve over time, though that finding needs confirmation from other studies.
How Pledgets Affect Blood Flow Through the Valve
That hint about reduced valve opening deserves a closer look, because it connects to a real hemodynamic concern. Pledgets sit inside the aortic root after surgery, and even though they are small, they are not invisible to blood flow. A laboratory and computational study tested biological aortic valve substitutes with and without pledget-armed sutures and found that the pledgets significantly increased the pressure drop across the valve while decreasing the effective orifice area.3PubMed Central. Pledget-Armed Sutures Affect the Haemodynamic Performance of Biologic Aortic Valve Substitutes: A Preliminary Experimental and Computational Study The average increase in mean pressure gradient was about 2 mmHg compared to the same valve tested without pledgets.
For context, a couple of extra millimeters of mercury may not sound like much, but in a patient with a small aortic root or borderline valve size, that added resistance can matter. It is one reason some surgeons have moved toward pledgetless techniques or rapid-deployment valves that avoid traditional sutures altogether. The trade-off is real: pledgets protect against suture pull-through but introduce small objects into the flow path that can create turbulence and slightly obstruct the valve opening. Surgical teams weigh these factors on a case-by-case basis.
Controlling Bleeding at Vascular Access Sites
Outside the heart itself, pledgets are used to manage bleeding where large-bore catheters or devices have been introduced into arteries. Modern transcatheter procedures, such as valve replacements done through the femoral artery, require large puncture sites that can be difficult to seal. A technique known as pledget-assisted hemostasis addresses residual bleeding that persists after standard closure devices have been deployed.
In this approach, a small PTFE pledget is placed over the closure sutures at the artery’s surface. The pledget is then pushed down with a knot-pusher and tied in place with a sliding knot, pressing it firmly against the vessel wall to compress any remaining leak.4PubMed Central. Pledget-assisted hemostasis to fix residual access-site bleedings after double pre-closure technique The pledget acts like a small patch, reinforcing a closure that sutures alone could not fully achieve. This is a bailout strategy rather than a first-line technique, used when the standard closure falls short.
Pledgets also appear in more complex vascular work. In a case involving a patient with vascular Ehlers-Danlos syndrome, a condition that makes arteries dangerously fragile, surgeons used a pledgeted “preclose U” stitch before accessing the artery for stent placement.5PubMed Central. Management of spontaneous dissection and rupture of common iliac artery in vascular Ehlers-Danlos syndrome (VEDS) In tissue this fragile, the pledget was part of a careful strategy to distribute forces across the vessel wall and provide an emergency option if ligation became necessary. The principle is the same as in valve surgery: prevent the suture from tearing through compromised tissue.
Protecting Brain Tissue During Neurosurgery
In neurosurgery, pledgets take a different form and serve a different purpose. Known in operating rooms as “patties” or “cottonoids,” these are small textile pads, typically made from cotton or a cotton-rayon blend, with a radiopaque thread attached so they can be seen on X-ray if one goes missing. Neurosurgical patties are placed directly against exposed brain tissue during most cranial operations. They protect delicate neural structures from instrument contact, help manage cerebrospinal fluid and blood in the surgical field, assist with hemostasis, and allow the surgeon to gently retract tissue without touching it directly.6PubMed. Neurosurgical patties: adhesion and damage mitigation
The challenge with neurosurgical patties is that they can stick to the brain surface, and peeling off an adherent patty risks pulling away a thin layer of cortex. Keeping them moist with saline reduces adhesion, but the problem is not entirely eliminated. Research into patty materials has focused on reducing this sticking tendency while maintaining the absorbency and handling characteristics that surgeons rely on. It is a deceptively difficult materials-engineering problem, since the patty needs to absorb fluid to do its job but must release cleanly from tissue when removed.
Drug Delivery in Eye Surgery
One of the more practical and patient-friendly uses of pledgets is in ophthalmology, where cellulose sponge pledgets serve as drug-delivery devices. Before cataract surgery, the pupil needs to be dilated wide enough for the surgeon to work. The traditional method involves repeated instillation of eye drops over a period of time, which ties up nursing staff and can delay the surgical schedule if the pupil does not dilate adequately.
An alternative approach soaks a small cellulose pledget in the dilating medication and places it in the lower eyelid pocket, where it slowly releases the drug over several minutes. A randomized controlled trial found that this pledget method produced pupil dilation equal to the conventional repeated-drop technique and was not associated with any adverse effects.7PubMed. Pupil dilation using a pledget sponge: a randomized controlled trial The practical advantages go further: a quality improvement project at an ambulatory surgery center found that switching to pledget-delivered mydriatics reduced the number of surgical delays caused by inadequate pupil dilation and decreased procedure turnover time.8PubMed. Improved pupil dilation with medication-soaked pledget sponges The pledget does the work while the patient waits, freeing up staff for other tasks.
Nasal Pledgets and Patient Comfort
If you have ever had a nasal endoscopy or sinus surgery, there is a good chance a pledget was involved, and it may not have been the most pleasant part. Cotton pledgets soaked in decongestant and anesthetic solutions are routinely placed in the nasal passages before procedures to shrink the nasal lining and numb the area. This reduces bleeding and makes it easier to pass the endoscope or surgical instruments.
The downside is comfort. A trial comparing cotton pledget packing to topical spray for nasal preparation before endoscopy found that patients in the pledget group reported significantly more discomfort during the packing itself, during the waiting period, and even during the procedure that followed.9Nepal Medical College Journal. Nasal preparation prior to nasal endoscopy: a comparison of cotton pledget packing versus topical spray The sensation of having packed material in your nose is inherently unpleasant, and the pledget’s physical presence can trigger a pressure sensation or gagging reflex in some people.
Post-surgical nasal packing removal is another pain point. After procedures like septoplasty or endoscopic sinus surgery, the nose may be packed with pledgets or similar materials that need to come out a day or two later. Research has explored whether injecting local anesthetics around the packing site before removal can help. One study found that infiltrating levobupivacaine or prilocaine before pack removal significantly reduced pain scores and improved patient tolerance compared to no anesthetic.10PubMed. The effect of prilocaine or levobupivacaine infiltration on pain during nasal packing removal If your surgeon offers a local anesthetic before pulling nasal packing, it is worth accepting.
When Pledgets Stay Behind
Because pledgets are small and often blend into the surgical field, one of the most serious risks is unintentional retention. A pledget left inside the body after surgery can remain inert for years before causing symptoms, or it can provoke a foreign body reaction that mimics far more alarming conditions.
A striking case report describes a man who underwent a craniotomy for a subdural hematoma and then presented a decade later with worsening neurological symptoms. Imaging revealed a ring-enhancing lesion on CT and MRI, a pattern that in neurosurgery typically raises concern for a brain tumor or abscess. The actual cause turned out to be a delayed foreign body reaction to a retained cotton wool pledget from the original surgery.11PubMed Central. Differential diagnosis for a ring-enhancing lesion on CT/MRI brain: retained cotton ball pledget Ten years of immune response to the cotton had produced a mass of inflammatory tissue that looked, on imaging, like something far worse.
Retained PTFE pledgets can cause problems of a different kind. A case involving a patient who had undergone aortic valve replacement documented a massive fatal heart attack caused by compression of the right coronary artery from a Teflon pledget granuloma, an inflammatory mass that had formed around the pledget material six months after surgery.12Journal of Forensic Sciences. Coronary Artery Compression by Teflon Pledget Granuloma Following Aortic Valve Replacement The pledget had done its job reinforcing the suture line, but the body’s reaction to it created a growing mass in a catastrophically bad location. Cases like these are rare, but they illustrate why the choice of pledget material, the number used, and their precise placement all matter.
Operating-room safety protocols for counting surgical materials exist partly because of pledgets. Neurosurgical patties include radiopaque markers specifically so they show up on X-ray during a post-operative count. PTFE pledgets used in cardiac surgery are typically counted before and after the procedure. Still, the tiniest pledgets can be difficult to track, especially in long and complex operations where dozens may be used. The consequences of missing one can surface months or years later, as the cases above demonstrate.
Pledgets in Veterinary Surgery
Pledgets are not limited to human medicine. In veterinary surgery, PTFE pledgets serve the same suture-reinforcement function in animals. One application involves treating intrahepatic portosystemic shunts in dogs, a condition where blood bypasses the liver through an abnormal vessel. The standard treatment uses a cellophane band to gradually close the shunt, but fully dissecting the vessel to place the band is not always possible.
A study of 23 dogs found that a mattress suture reinforced with pledgets could partially occlude the shunt as an alternative when cellophane banding was not feasible, with acceptable long-term survival.13PubMed. A mattress suture with pledgets can partially occlude intrahepatic shunts in 23 dogs: evaluation of long-term survival The pledgets prevented the suture from cutting through the liver tissue, the same mechanical principle used in human cardiac surgery applied to a completely different organ in a different species. It is a good illustration of how versatile and transferable the basic pledget concept is across surgical contexts.
The Ongoing Debate Over Pledget Use
Despite their ubiquity, pledgets remain a subject of active discussion in surgical practice. The central tension is between their proven ability to prevent suture pull-through and the potential downsides of leaving foreign material in the body. In cardiac surgery, the evidence from matched comparisons suggests that pledgeted and nonpledgeted techniques produce similar clinical results over five years, which has emboldened some surgeons to move away from routine pledget use. Others argue that in high-risk tissue, such as heavily calcified aortic annuli or fragile connective-tissue-disorder patients, skipping pledgets is an unnecessary gamble.
The hemodynamic data adds another layer. If pledgets measurably increase the pressure gradient across a replacement valve, even modestly, that effect compounds over years of continuous cardiac output. For a young patient expected to live decades with a bioprosthetic valve, a small reduction in effective orifice area could eventually become clinically relevant. For an elderly patient with a limited life expectancy, the risk of suture dehiscence probably outweighs a minor hemodynamic penalty. There is no single right answer; the decision depends on the patient’s anatomy, tissue quality, expected lifespan, and the surgeon’s experience with pledgetless techniques.
Newer rapid-deployment and sutureless valve designs sidestep the question entirely by eliminating traditional sutures. These valves anchor themselves through a stent-like frame that expands against the annulus, so there are no sutures to reinforce and no pledgets to leave behind. Their adoption is growing, but conventional sutured valve replacement remains far more common worldwide, meaning pledgets will continue to be a routine part of cardiac surgery for the foreseeable future.