Background: Sternal wound infection (SWI) is a major complication occurring often after coronary artery bypass grafting (CABG) using bilateral internal mammary artery (BIMA) grafts. The aim of this study is to assess whether such a risk may be reduced by using incision negative pressure wound therapy (INPWT).
Methods: Data on patients undergoing isolated CABG using BIMA grafts at the Reims University Hospital, France, from 2013 to 2016 without or with INPWT was prospectively collected.
Results: INPWT was used in 161 patients and conventional sterile wound dressing was used in 266 patients. Propensity score matching resulted in 128 pairs with similar characteristics. SWIs were similarly distributed between the conventional sterile wound dressing (10.9%) and the INPWT cohorts (10.2%) (P = 1.00). Patients treated with INPWT had a lower rate of deep SWI/mediastinitis than patients who had conventional sterile dressing (5.5% versus 10.2%, P = .210), but the difference did not reach statistical significance. Tests for interaction confirmed these findings in different patient subgroups.
Conclusion: The routine use of INPWT may not significantly reduce the risk of SWI in patients undergoing BIMA grafting. In view of previous reports showing a benefit with the use of this method, a large randomized study is justified to assess the efficacy of INPWT in patients undergoing cardiac surgery.
Purpose
Obesity remains statistically associated with coronary artery disease, for which coronary artery bypass graft surgery (CABG) remains the standard of care. However, obesity is also associated with sternal wound infection (SWI) which is a severe complication of CABG despite advances in surgery and in infection prevention and control. Strategies to reduce the incidence of SWI are still being investigated, and we therefore conducted a retrospective study to revisit factors other than obesity associated with SWI after CABG.
Patients and Methods
Data were extracted from the medical records of 182 patients who underwent elective on-pump CABG using one or both pedicled internal mammary artery grafts in Reims University Hospital between May 2015 and May 2016. All preoperative or perioperative variables with a
p
value<0.10 in univariate analysis were entered into a stepwise logistic regression model.
Results
Among the 182 patients (145 male (79.6%), median age 68.0 [45.0–87.0] years), 138 (75.8%) underwent CABG using bilateral internal mammary artery grafts. Median BMI was 27.7 [18.7–50.5] kg/m
2
, and there were 51 (28.0%) and 79 (43.4%) patients with obesity and overweight, respectively. Twenty-three out of the 182 patients (12.6%) developed SWI. In-hospital mortality was not statistically different between patients with and without SWI but the median length of stay was (6.0 [2.0–38.0] versus 5.0[3.0–21.0] days in the intensive care unit, p=0.03, and 26.0 [9.0–134.0] versus 9.0 [7.0–51.0] days in hospital, p<0.0001). Obesity and preoperative anaemia were independently associated with SWI, as was the number of red blood cell (RBC) units transfused (OR 14.61 [2.64–80.75], OR 4.64 [1.61–13.34] and OR 1.27 [1.02–1.58], respectively).
Conclusion
The independent association of SWI with the number of RBC units transfused and the existence of preoperative anaemia and obesity suggests a mechanism of thoracic wall ischemia in SWI after CABG, thus leaving insufficient perfusion of the thoracic wall in patients with obesity. Medical strategies are warranted to try to prevent this costly complication.
We report the case of a 63-year-old man, admitted after a traffic accident. Clinical examination found chest trauma, mandibular and long bone fractures but there was no cerebral ischemic signs. The chest X-ray showed a widening of the mediastinum; therefore an aortography demonstrated a false aneurysm, an intimal flap of the left common carotid artery (LCCA) and a middle aortic arch disruption. Surgical reconstruction was accomplished by inserting Dacron prosthesis from the ascending aorta to the LCCA. The aortic arch wound was reconstructed by an autologous pericardial patch. In light of this surgical case, we discuss early methods of diagnosis and details of medical, surgical or endovascular treatments.
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