Case Report
A 78-year-old man with severe coronary artery disease was referred to
our hospital for coronary artery bypass grafting (CABG). He had
undergone total arch replacement for an aortic arch aneurysm 9 years
prior at another hospital. At that time, he underwent postoperative
urgent debridement and an omental flap procedure for deep sternal wound
infection during hospitalization. The split sternum was closed without
wire banding. He recovered without recurrence of infection and was
discharged.
Since then, he was treated for hypertension and diabetes mellitus at a
local hospital. Three years prior, he received surgery for right-sided
lung cancer. Six months prior, he underwent percutaneous catheter
intervention due to severe triple-vessel disease. Follow-up coronary
angiography revealed multiple in-stent restenoses despite strict medical
treatment. Computed tomography (CT) showed funnel chest at the lower
part of the sternum, with limited space between the sternum and omentum
(Figure 1). There were also atheromatous changes in the descending
aorta.
Considering his coexistent comorbidities, CABG with re-sternotomy was
scheduled. Partial cardiopulmonary bypass was established through the
right subclavian artery and right femoral vein for safe re-sternotomy by
decompression of the cardiac volume. Re-sternotomy was safely performed
using a circular electric sternum saw. The omentum functioned as a
cushioning material between the sternum and mediastinal organs and
appeared viable (Figure 2a); then, the left internal mammary artery was
harvested. The space above the ascending aorta for proximal anastomosis,
shown in Figure 2b, was dissected using an ultrasonic scalpel (Harmonic
Scalpel®; Ethicon Endo-Surgery, Cincinnati, OH, USA).
The degree of adhesion in the pericardium was not severe; therefore, the
targeted coronary arteries were easily detected. On-pump beating CABG
was then performed using the left internal mammary artery to left
anterior descending artery and saphenous vein grafts to obtuse marginal
branch and distal site of the right coronary artery (Figure 2b). After
proximal anastomosis of the coronary artery bypass at the native
ascending aorta using a suture device, the viable omentum was
reimplanted and covered the ascending aorta.
Weaning from cardiopulmonary bypass was uneventful, and the patient
fully recovered without wound complications. Postoperative CT showed
patency of all coronary artery bypass grafts and no remarkable
infectious signs. The reimplanted omental flap was detected in the
anterior mediastinum (Figure 3). The patient experienced no major
adverse cardiac and infectious events for 3 months postoperatively.
The patient has provided permission to publish the features of his case.
The identity of the patient has been protected.