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.