Incidence Of Sternal Wound Complications Research Articles

Sternal wound infections after sternotomy: risk factors, prevention and management

A serious complication after cardiac surgery is sternal wound infection. Although incidence rates vary worldwide, this complication raises significant concern in a certain patient demographic. This article uses risk assessment strategies to identify a high-risk patient profile and draws parallels with positive predictors in the preoperative, intraoperative and postoperative setting. It describes the complexity of sternal wound infections and highlights guidelines on detection and treatment. The optimal goal of this article is to help minimise the incidence of sternal wound complications after sternotomy by discussing recommendations for preoperative, intraoperative and postoperative preventive measures.

Early Hospital Outcome of Using Both Internal Mammary Arteries in Cairo University Hospital

Background: Long-Using both mammary arteries in coronary artery bypass surgery has a good term results, but it is not recommended in old patients due to its technical difficulty and increased incidence of sternal wound complications. Several studies declared that bilateral internal mammary arteries (BIMA) grafting has a great benefit in patients aged 50–60 years, but this benefit does not extend to patients aged > 60 years. This study was designed to analyze the early hospital results, and experience in preventing sternal wound complications for BIMA grafting in patients 50–60 years old. Objective: To detect early outcome of using both internal mammary arteries in patients aged 50-60 years in Cairo University Hospital. Patients and Methods: Clinical data and echocardiographic and coronary angiography data of 100 patients who underwent BIMA grafting for coronary artery disease between 2017 and 2019 were analyzed retrospectively to detect the early hospital results. 100 patients aged 50 to 60 years. The operation time, aortic clamp time, and cardiopulmonary bypass time were studied to analyze the operation difficulty. The flow and P.I were studied to analyze the coronary artery graft function. The left ventricular end-diastolic dimension (LVEDD) and left ventricular ejection fraction (LVEF) were studied to detect heart function. Results: The operation time, aortic clamp time, and cardiopulmonary bypass time as well as the flow and pulsatility index were recorded. There was no incidence of sternal wound complications or graft occlusion. Furthermore, there was no significant difference in LVEF post-operation. Conclusions: Using both mammary arteries in coronary artery bypass surgery is safe and effective for patients 50– 60 years old similar to younger patients (< 50 years).

Early Hospital Outcome of Using Both Internal Mammary Arteries in Cairo University Hospital

Background: Long-Using both mammary arteries in coronary artery bypass surgery has a good term results, but it is not recommended in old patients due to its technical difficulty and increased incidence of sternal wound complications. Several studies declared that bilateral internal mammary arteries (BIMA) grafting has a great benefit in patients aged 50–60 years, but this benefit does not extend to patients aged > 60 years. This study was designed to analyze the early hospital results, and experience in preventing sternal wound complications for BIMA grafting in patients 50–60 years old. Objective: To detect early outcome of using both internal mammary arteries in patients aged 50-60 years in Cairo University Hospital. Patients and Methods: Clinical data and echocardiographic and coronary angiography data of 100 patients who underwent BIMA grafting for coronary artery disease between 2017 and 2019 were analyzed retrospectively to detect the early hospital results. 100 patients aged 50 to 60 years. The operation time, aortic clamp time, and cardiopulmonary bypass time were studied to analyze the operation difficulty. The flow and P.I were studied to analyze the coronary artery graft function. The left ventricular end-diastolic dimension (LVEDD) and left ventricular ejection fraction (LVEF) were studied to detect heart function. Results: The operation time, aortic clamp time, and cardiopulmonary bypass time as well as the flow and pulsatility index were recorded. There was no incidence of sternal wound complications or graft occlusion. Furthermore, there was no significant difference in LVEF post-operation. Conclusions: Using both mammary arteries in coronary artery bypass surgery is safe and effective for patients 50– 60 years old similar to younger patients (< 50 years).

Meta-Analysis Comparing Multiple Arterial Grafts Versus Single Arterial Graft for Coronary-Artery Bypass Grafting

Observational studies and randomized controlled trials (RCTs) have shown conflicting outcomes for multiple arterial graft (MAG) coronary artery bypass graft surgery compared with single arterial grafts (SAGs). The predominant evidence supporting the use of MAGs is observational. The aim of this meta-analysis of RCTs is to compare outcomes following MAG and SAG. We searched multiple databases for RCTs comparing MAG versus SAG. The clinical outcomes studied were all-cause mortality, cardiac mortality, myocardial infarction (MI), revascularization, stroke, sternal wound complications, and major bleeding. We used hazard ratio (HR), relative risk (RR), and corresponding 95% confidence interval (CI) for measuring outcomes. Ten RCTs (6392 patients) were included. The average follow-up in the studies was 4.2 years. The average age of the patients in the studies ranged from 56.3 years to 74.6. No significant difference was seen between MAG and SAG groups for all-cause mortality (11.8% vs 12.7%, HR 0.94, 95% CI 0.81 to 1.09, p 0.36), cardiac mortality (4.1% vs 4.5%, HR 0.96 95% CI 0.74 to 1.26, p 0.77), MI (3.5% vs 5.1%, HR 0.87 95% CI 0.67 to 1.12, p 0.28), and major bleeding (3.3% vs 4.9%, RR 0.85 95% CI 0.64 to 1.13, p 0.26). Repeat revascularization in MAG showed a lower RR than SAG when one of the confounding studies was excluded (RR 0.63, 95% CI 0.4 to 0.99, p 0.04). The incidence of stroke was lower in MAG than SAG (2.9% vs 3.9%, RR 0.74 95% CI 0.56 to 0.98, p 0.03). MAG had higher incidence of sternal wound complications than SAG (2.9% vs 1.7%, RR 1.75 95% CI 1.19 to 2.55, p 0.004). In conclusion, MAG does not have a survival advantage compared with SAG but is better in revascularization and risk of stroke. This benefit may be set off by a higher incidence of sternal wound complications in MAG.

Sternal Wound Complications: Objective Reclassification and Surgical Reconsideration.

Sternal wound complications pose a tremendous challenge post-cardiac surgery. There’s no consensus or clear guidelines to deal with them. We propose that simple and more objective classification helps to organize the range of sternal wound complications and suggest a relevant treatment strategy. One-hundred-sixteen cases of sternal wound complications retrospectively were reviewed out of 2,391 adult patients, who underwent full sternotomy during cardiac surgery from 2006 to 2018. Eighty-six cases conservatively were managed and the remaining 30 cases required surgical intervention. More objective classification was proposed and less invasive fasciocutaneous flap was considered for nearly all reconstructive procedures. The incidence of sternal wound complications was 4.8%. Conservative management was adopted for 86 cases, mean duration was 11.19 ± 9.8 days. Surgical management was performed in 30 patients (25.86%); 28 (93.3%) of whom recovered with good outcomes with less invasive fasciocutaneous flap done for 13 cases. Two cases had recurrence; one conservatively was managed and other was reoperated and healed well. The most common organisms in recurrent infections were N. coagulase (29.8%), Klebsiella (12.5%), pseudomonas (10.5%), and MRSA (10.5%). We had 4 mortalities. None of the mortalities were related to sternal wound complications; one was related to the cardiac surgery. Sternal wound complications are grave events. Objective classification and proper management selection will gain better outcomes.

Short-term results of bilateral internal mammary arterial grafting for patients aged 60\u201375 years \u2013 a retrospective study

BackgroundBilateral internal mammary artery (BIMA) grafting has a good long-term survival rate and graft patency rate, but it is only recommended in young patients due to its high technical requirements and high incidence of sternal complications. Previous studies indicated that BIMA grafting has a significant benefit in patients aged 50–59 years, but this benefit does not extend to patients aged > 60 years. Thus, this study was designed to analyse the immediate artery graft function, short-term (3 months) results, and experience in preventing sternal complications for BIMA grafting in elderly patients (60–75 years old).MethodsClinical records and echocardiographic and coronary artery computed tomography angiography data of 155 patients who underwent BIMA grafting for coronary artery disease between 2015 and 2017 in our hospital were analysed retrospectively to summarise the operative experience and short-term (3 months) results. Patients were divided into two groups: Group A (n = 95), aged < 60 years and Group B (n = 60), aged 60–75 years. The operation time, aortic clamp time, and cardiopulmonary bypass time of these two groups were compared to analyse the operation difficulty and the flow and pulsatility index were compared to analyse the immediate artery graft function. The left ventricular end-diastolic dimension (LVEDD) and left ventricular ejection fraction (LVEF) of these two groups were compared to analyse heart function.ResultsThere were no significant differences in the operation time, aortic clamp time, and cardiopulmonary bypass time as well as the flow and pulsatility index between these two groups (P > 0.05). There was no significant difference in the incidence of sternal wound complications, graft occlusion, and other common complications 3 months post-BIMA grafting between these two groups (P > 0.05). Furthermore, there was no significant difference in LVEDD and LVEF between the groups 3 months post-operation (P > 0.05).ConclusionsBIMA grafting was safe and effective for older patients (60–75 years). Similar to younger patients (< 60 years), BIMA grafting in elderly patients (60–75 years) can also achieve a satisfactory short-term (3 months) result. Thus, advanced age (60–75 years) should not be a contraindication for BIMA grafting.

Total arterial myocardial revascularization using bilateral internal mammary arteries and the role of postoperative sternal stabilization to reduce wound infections in a large cohort study.

Total arterial myocardial revascularization using bilateral internal mammary arteries shows improved results for mortality, long-term survival and superior graft patency. It has become the standard technique according to recent guidelines. However, these patients may have an increased risk of developing sternal wound infections, especially obese patients or those with diabetes. One reason for the wound complications may be early sternum instability. This situation could be avoided by using a thorax support vest (e.g. Posthorax® vest). This retrospective study compared the wound complications after bilateral internal mammary artery grafting including the use of a Posthorax vest. Between April 2015 and May 2017, 1613 patients received total arterial myocardial revascularization using bilateral internal mammary artery via a median sternotomy. The Posthorax support vest was used from the second postoperative day. We compared those patients with 1667 patients operated on via the same access in the preceding 26 months. The end points were the incidence of wound infections, when the wound infection occurred and how many wound revisions were needed until wound closure. The demographic data of both groups were similar. A significant advantage for the use of a thorax support vest could be seen regarding the incidence of wound infections (P = 0.036) and the length of hospital stay when a wound complication did occur (P = 0.018). As seen in this retrospective study, the early perioperative use of a thorax stabilization vest, such as the Posthorax vest, can reduce the incidence of sternal wound complications significantly. Furthermore, when a wound infection occurred, and the patient returned to the hospital for wound revision, patients who were given the Posthorax vest postoperatively had a significantly shorter length of stay until wound closure.

Does using Jackson-Pratt drain affect the incidence of sternal wound complications after open cardiac surgery?

TThis study aims to investigate the effect of the Jackson-Pratt drain on sternal wound complications in patients with a Body Mass Index of ≥30 kg/m2 undergoing open cardiac surgery via median sternotomy. A total of 174 patients (124 males, 50 females; mean age 58.2±10.4 years; range, 33 to 78 years) with a Body Mass Index of ≥30 kg/m2 undergoing cardiac surgery via median sternotomy between January 2011 and December 2015 in our institution were retrospectively analyzed. Of the patients, 94 were inserted a Jackson-Pratt drain (JP group) following median sternotomy, while 80 patients received no drain (non-JP group). Pre-, intra, and postoperative outcomes of both groups including type of operation, length of hospital stay, and complications were compared. No significant difference in the age, gender, Body Mass Index, and potential risk factors was found between the groups. The median of stay in the intensive care unit was two days and the median time from operation to discharge was seven days in both groups. There was a statistically significant difference in the rate of sternal wound complications between the groups. Sternal wound complications occurred in two patients (2.1%) in the drained group, compared to nine patients (11.25%) in the non-drained group (p=0.01). Our study results show that Jackson-Pratt drain insertion after median sternotomy in patients with a Body Mass Index of ≥30 kg/m2 undergoing open cardiac surgery is a simple and reliable method to reduce the risk of postoperative sternal wound complications, compared to the conventional closure technique.

Sternal Application of Vancomycin Greatly Reduces the Incidence of Sternal Wound Complications in Patients undergoing Cardiosurgical Procedures

Sternal Application of Vancomycin Greatly Reduces the Incidence of Sternal Wound Complications in Patients undergoing Cardiosurgical Procedures

Pedicled and skeletonized single and bilateral internal thoracic artery grafts and the incidence of sternal wound complications: Insights from the Arterial Revascularization Trial

ObjectivesThe question of whether skeletonized internal thoracic artery harvesting reduces the incidence of sternal wound complications in comparison with the pedicled technique, in the context of single or bilateral internal thoracic arteries, remains controversial. We studied the impact of the internal thoracic artery harvesting strategy on sternal wound complication in the Arterial Revascularization Trial. MethodsPatients enrolled in the Arterial Revascularization Trial (n = 3102) were randomized to coronary artery bypass grafting with single or bilateral internal thoracic arteries. Sternal wound complication rates were examined according to the harvesting technique that was documented in 2056 patients. The internal thoracic artery harvesting technique, based on the surgeon's preference, resulted in 4 groups: pedicled single internal thoracic artery (n = 607), pedicled bilateral internal thoracic artery (n = 459), skeletonized single internal thoracic artery (n = 512), and skeletonized bilateral internal thoracic artery (n = 478). Propensity scores weighting was used to estimate the impact of the harvesting technique on sternal wound complications. ResultsA total of 219 of 2056 patients (10.6%) experienced a sternal wound complication within 1 year from the index operation. Of those, only 25 patients (1.2%) required sternal wound reconstruction. Pedicled bilateral internal thoracic artery (odds ratio [OR], 1.80; 95% confidence interval [CI], 1.23-2.63) but not skeletonized bilateral internal thoracic artery (OR, 1.00; 95% CI, 0.65-1.53) or skeletonized single internal thoracic artery (OR, 0.89; 95% CI, 0.57-1.38) was associated with a significantly increased risk of any sternal wound complications compared with pedicled single internal thoracic artery. ConclusionsThe present Arterial Revascularization Trial substudy suggests that, with a skeletonization technique, the risk of sternal wound complication with bilateral internal thoracic artery grafting is similar to that after standard pedicled single internal thoracic artery harvesting, whereas skeletonized single internal thoracic artery harvesting did not add any further benefit when compared with pedicled single internal thoracic artery harvesting.

The Use of Nitinol Clips for Primary Sternal Closure in Cardiac Surgery

Deep sternal wound complications after cardiac surgery have an incidence of 2 to 8% and carry a significant mortality. The aim of this study was to evaluate the effect of thermo-reactive Nitinol clips on the incidence of postoperative deep sternal wound complications. We retrospectively reviewed 1119 consecutive patients that underwent major cardiac surgery via median sternotomy in our centre. Sternal closure was performed using Nitinol clips in 235 patients (Group I) and standard stainless steel wires in 884 patients (Group II). The risk factors that were identified between the two groups were age, EuroSCORE, body mass index, diabetes and pulmonary comorbidity. The overall incidence of deep sternal wound complications was 2.2% (25/1119).The incidence was higher in Group II (2.3%) compared to Group I (1.7%) (p = 0?8).Mechanical sternal dehiscence occurred in 2 patients in Group II. Mortality related to sternal wound complications was 8% (2/21) in Group II whereas in Group I was 0%. The incidence of sternal wound complications and the mortality related to them were lower in patients undergoing sternal closure with Nitinol clips. A randomized study to further evaluate the possible advantages of Nitinol clips is warranted.

Indications and Risks of Delayed Sternal Closure After Open Heart Surgery in Neonates and Early Infants

Delayed sternal closure (DSC) has been an essential part of neonatal and infant heart surgery. Here, we report our single institution experience of DSC for eight years. The successive 188 patients were analyzed retrospectively. Sternum was closed at the end of the operation in 97 (51.6%) patients (primary sternal closure [PSC] group). Sternum was left open in 91 (48.4%) patients. Among them, 45 (23.9%) had only skin closure (DSCs group) and 46 (24.4%) had membrane patch closure (DSC membrane [DSCm] group). Median age was higher in PSC group (90 days) than DSCs (11 days) and DSCm groups (9.5 days). Mortality was 1%, 11.1%, and 28.2% in PSC, DSCs, and DSCm groups, respectively (P < .05). Univariate analysis recognized the neonatal age (odds ratio [OR] = 4.2), preoperative critical condition (OR = 5.3), cardiopulmonary bypass time >180 minutes (OR = 4), and cross clamp time >99 minutes (OR = 3.9) as risk factors for mortality. Total morbidity rate was higher in DSCm group (73.9%) than DSCs group (51.1%) and PSC group (23.7%; P < .001). Mechanical ventilation time, intensive care unit stay, and hospital stay were longer in DSCs and DSCm groups than PSC group (P < .001). The incidence of hospital infection was also higher in DSCs (43.5%) and DSCm (33.3%) groups than PSC group (20.6%; P < .05). But there was no difference in the incidence of sternal wound complications, including both deep and superficial (4.1%, 8.8%, and 4.4%, respectively). Although the risk of sternal wound complications is not different, patients who necessitate DSC (using both skin and membrane closure techniques) have more complicated postoperative course than patients with PSC.

Prostaglandin E 2 EP4 receptor–selective agonist facilitates sternal healing after harvesting bilateral internal thoracic arteries in diabetic rats

Sternal wound complications are devastating events occurring in coronary artery bypass surgery, particularly in patients with diabetes. Prostaglandin E2 receptors have 4 subtypes, and the activation of the EP4 receptor induces bone regeneration. The present study investigated the utility of a prostaglandin E2 EP4 receptor-selective agonist in sternal healing after median sternotomy with the removal of the bilateral internal thoracic arteries in diabetic rats. Diabetic Wistar rats with blood glucose levels of greater than 400 mg/dL were established by means of a single intraperitoneal injection of streptozotocin. After median sternotomy and bilateral internal thoracic artery removal in 16 diabetic rats, 8 rats were administered the EP4 agonist (300 microg) on the posterior table of the sternum (EP4 group), whereas 8 did not receive any treatment (control group). Sternal healing and incidence of sternal wound complications were evaluated 4 weeks after the operation. Sternal wound complications developed in 5 rats in the control group but in only 1 rat in the EP4 group (P < .01). Histologic examination revealed an almost completely healed sternum filled with regenerated bone tissue only in the EP4 group. Both bone mineral content and bone mineral density, as assessed with dual-energy x-ray absorptiometry, were higher in the EP4 group than in the control group (71.7 +/- 12.1 vs 48.9 +/- 11.7 mg for bone mineral content [P < .01] and 66.8 +/- 14.6 vs 47.9 +/- 6.3 mg/mm2 for bone mineral density [P < .05]). The prostaglandin E2 EP4 agonist accelerated the sternal healing and decreased the incidence of sternal wound complications in the diabetic ischemic sternum. This method might help in decreasing sternal necrosis in high-risk patients or permit wider application of bilateral internal thoracic arteries in coronary artery bypass surgery, even in patients with diabetes.

Pectoralis major muscle flap for deep sternal wound infection in neonates

Background. Deep sternotomy wound infections during the neonatal period, their management utilizing the pectoralis major muscle flap (PMF), and their follow-up are reported.Methods. Seven hundred-twenty consecutive pediatric cardiac operations performed from 1995 to mid 1998 in 108 neonates and 612 infants are reviewed. Nine children (1.25%), 6 neonates and 3 infants, developed deep sternotomy wound infections and underwent PMF reconstruction. The 6 neonates are reviewed. Their follow-up includes growth and development reports, physical examination, and computerized tomographic scans of the chest.Results. The incidence of sternal wound complications in our neonatal patients (5.5%, 6 of 108) was significantly higher than in the infantile group (0.5%, 3 of 612), (p = 0.0001, odds ratio = 11.94). Five neonates were treated with a unilateral, turnover PMF reconstruction. One patient was treated by a bilateral rotational PMF. All sternal wounds healed successfully, and all patients survived. In a follow-up period, ranging from 6 to 31 months (mean 16.5 months), the growth and development of all operated neonates was as expected for their age. There were no signs of chronic sternal infection in any of them.Conclusions. Early recognition of sternal wound complications should facilitate surgical treatment. Utilizing the PMF promotes rapid wound healing and preservation of life in these severely ill neonates, with minimal developmental problems.

A Review of Sternal Wound Complications in a Military Hospital

A retrospective review of sternal wound complications was conducted during a recent 13-month period at the Naval Hospital, San Diego. These complications developed in 5 (3.0%) of 168 patients after they underwent coronary artery bypass with saphenous vein grafts. Three or more of these patients were male, obese, and hypertensive, with a significant smoking history. All these factors have been previously reported to be associated with an increase in the incidence of sternal wound complications. All patients had prolonged postoperative intensive care treatment, and ultimately all patients recovered and were discharged from the hospital. Interestingly, as opposed to other reviews, we were unable to show an association of sternal wound complications with the use of internal mammary artery harvesting.

The effects of different techniques of internal mammary artery harvesting on sternal blood flow

We investigated chest wall blood flow in a canine model to determine if the technique used to harvest the mammary artery has a differential effect on residual chest wall blood flow. Eight dogs underwent bilateral internal mammary artery mobilization; one artery was harvested as a pedicle and the other was harvested as a skeletonized vessel. Residual blood flow to the chest wall distribution of each artery was measured with radioactive microspheres. Chest wall blood flow was significantly decreased from preharvest levels after internal mammary artery mobilization regardless of the technique used. Tissue blood flows decreased to 46.9%, 22.1%, and 41.2% of baseline values for the manubrium (p < 0.01), sternum (p < 0.001), and ribs (p < 0.05), respectively. Residual sternal blood flow on the side of the skeletonized vessel was significantly greater than on the side of the pedicle graft (2.60 +/- 0.68 versus 1.27 +/- 0.27 cm3/min/100 gm, p < 0.001). We conclude that minimization of tissue mobilization during internal mammary artery harvesting may reduce sternal devascularization. This finding may have clinical significance with respect to lowering the incidence of sternal wound complications in coronary bypass surgery using the internal mammary artery as a bypass conduit.