Surgical Strategy for Sternal Closure in Patients with Surgical Myocardial Revascularization Using Mammary Arteries
Mircea Robu1,2, Bogdan Rădulescu1,2, Irina Margarint1
1Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania.
Insights
A novel sternal closure technique significantly reduced deep surgical site infections in patients undergoing bilateral mammary artery grafting for coronary artery bypass surgery. This method enhances sternal stability and wound healing, improving patient outcomes.
Area of Science:
- Cardiovascular Surgery
- Surgical Infection Prevention
- Biomedical Engineering
Background:
- Coronary artery bypass grafting (CABG) increasingly utilizes bilateral internal mammary arteries (BIMA) for improved long-term patency.
- Despite survival benefits, BIMA grafting is associated with a higher risk of deep sternal wound infections (DSWI), a critical complication.
- Existing literature highlights the challenge of preventing SWI in BIMA procedures.
Purpose of the Study:
- To evaluate the efficacy of a novel three-step sternal closure protocol in reducing surgical site infections (SSI) after total arterial myocardial revascularization.
- To assess the incidence of SSI, particularly DSWI, in patients undergoing BIMA grafting with the new closure technique.
Main Methods:
- A prospective study included 217 patients undergoing total arterial myocardial revascularization between January 2022 and December 2022.
- A three-step chest closure protocol involved BMI-adjusted sternal closure (butterfly technique or nitinol clips/hybrid ties), resorbable sutures for fat closure, and negative pressure wound therapy.
- Specific sternal closure methods were employed based on patient BMI (<35 kg/m² or >35 kg/m²).
Main Results:
- The study enrolled 217 patients, with 197 receiving BIMA grafts.
- A low incidence of SSI was observed: 13 (5.9%) superficial and only one (0.46%) deep SSI.
- Univariate analysis indicated that BIMA grafting was not significantly associated with increased SSI risk when using this closure protocol.
Conclusions:
- The implemented sternal wound closure strategy effectively minimizes the incidence of deep surgical site infections in CABG patients receiving BIMA grafts.
- This protocol offers a promising approach to mitigate the risk of DSWI, a "never event" in surgical care.
- The technique enhances sternal stability and wound healing, potentially improving overall patient safety in arterial grafting procedures.
Background:
Coronary artery bypass grafting has evolved from all venous grafts to bilateral mammary artery (BIMA) grafting. This was possible due to the long-term patency of the left and right internal mammary demonstrated in angiography studies compared to venous grafts. However, despite higher survival rates when using bilateral mammary arteries, multiple studies report a higher rate of surgical site infections, most notably deep sternal wound infections, a so-called "never event".
Methods:
We designed a prospective study between 1 January 2022 and 31 December 2022 and included all patients proposed for total arterial myocardial revascularization in order to investigate the rate of surgical site infections (SSI). Chest closure in all patients was performed using a three-step protocol. The first step refers to sternal closure. If the patient's BMI is below 35 kg/m2, sternal closure is achieved using the "butterfly" technique with standard steel wires. If the patient's BMI exceeds 35 kg/m2, we use nitinol clips or hybrid wire cable ties according to the surgeon's preference for sternal closure. The main advantages of these systems are a larger implant-to-bone contact with a reduced risk of bone fracture. The second step refers to presternal fat closure with two resorbable monofilament sutures in a way that the edges of the skin perfectly align at the end. The third step is skin closure combined with negative pressure wound therapy.
Results:
This system was applied to 217 patients. A total of 197 patients had bilateral mammary artery grafts. We report only 13 (5.9%) superficial SSI and only one (0.46%) deep SSI. The preoperative risk of major wound infection was 3.9 +/- 2.7. Bilateral mammary artery grafting was not associated with surgical site infection in a univariate analysis.
Conclusions:
We believe this strategy of sternal wound closure can reduce the incidence of deep surgical site infection when two mammary arteries are used in coronary artery bypass surgery.
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