Coronary bypass by complete sternotomy in a patient with a tracheostoma

Abstract

Patients with a laryngectomy pose a challenge when they require cardiac surgery. Dissection of the manubrium and sternal notch from surrounding soft tissues can be hazardous, as it may result in troublesome bleeding and inadvertent tracheal injury, especially in those patients, in whom the trachea is displaced anteriorly, or lies close to the sternal notch, as a result of a 'low' tracheal stoma. Performing a median sternotomy in such patients is believed to substantially increase the risk of sternal wound complications, mediastinitis, stoma necrosis and tracheal injuries, leading to several modifications of conventional median sternotomy, including bilateral thoracotomy incisions and limited median sternotomy approaches. There is only one case reported in the literature wherein cardiac surgery was done in such a patient, through a full sternotomy. This report describes a successful coronary artery bypass grafting through a complete median sternotomy, with no complications. This approach permitted adequate operative exposure and separated the stoma from the operative field. We also review alternative modalities of access, in these patients.

Minimally Invasive Coronary Artery Bypass Grafting in a Patient With Chronic Tracheostoma: Alternative to Reduce Sternal Wound Complication Risk

“…Similarly, a preexisting tracheostoma theoretically imposes a considerable risk for infection in patients undergoing sternotomy for myocardial revascularization. 2 Previously, authors have attempted to maintain the distance from the tracheostomy site, using alternative approaches including the “T-modified” manubrium-sparing median sternotomy 3 or the “Figure L approach,” which consists of an anterior thoracotomy extended vertically downward to the peritoneal cavity. 4 …”

“…Similarly, a preexisting tracheostoma theoretically imposes a considerable risk for infection in patients undergoing sternotomy for myocardial revascularization. 2 Previously, authors have attempted to maintain the distance from the tracheostomy site, using alternative approaches including the "T-modified" manubrium-sparing median sternotomy 3 or the "Figure L approach," which consists of an anterior thoracotomy extended vertically downward to the peritoneal cavity. 4 Minimally invasive coronary artery bypass grafting (MICS CABG) via a small anterior thoracotomy is a robust technique that allows complete surgical revascularization, providing excellent outcomes, 5 while circumventing the risk of sternal wound complications.…”

Pneumomediastinum Causing Distortion on Transesophageal Echocardiography as a Result of Tracheal Injury After Sternotomy

“…Increased risk factors include when the trachea is displaced anteriorly or lies close to the sternal notch or as a result of a "low" tracheal stoma. 1 Subsequent repair of this injury includes suturing the site and then confirming an airtight seal by flooding the space with saline.…”