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      Tremendous bleeding complication after vacuum-assisted sternal closure

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          Abstract

          Vacuum-assisted closure (VAC) of complex infected wounds has recently gained popularity among various surgical specialties. The system is based on the application of negative pressure by controlled suction to the wound surface. The effectiveness of the VAC System on microcirculation and the promotion of granulation tissue proliferation are proved. No contraindications for the use in deep sternal wounds in cardiac surgery are described. In our case report we illustrate a scenario were a patient developed severe bleeding from the ascending aorta by penetration of wire fragments in the vessel. We conclude that all free particles in the sternum have to be removed completely before negative pressure is used.

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          Mechanisms governing the effects of vacuum-assisted closure in cardiac surgery.

          Johan Sjögren, Malin Malmsjö, Richard Ingemansson (2007)
          : Vacuum-assisted closure has been adopted as the first-line treatment for poststernotomy mediastinitis as a result of the excellent clinical outcome achieved with its use. Scientific evidence regarding the mechanisms by which vacuum-assisted closure promotes wound healing has started to emerge, although knowledge regarding the effects on heart and lung function is still limited. The organs in the mediastinum are hemodynamically crucial, and in patients with poststernotomy mediastinitis, vulnerable bypass grafts and reduced cardiac function must be taken into consideration during vacuum-assisted closure therapy. This article provides an overview of the effects of vacuum-assisted closure on heart and lung function and summarizes the current knowledge on the mechanisms by which vacuum-assisted closure therapy promotes wound healing.
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            Management of poststernotomy mediastinitis: experience and results of different therapy modalities.

            O Elert, R Leyh, M Bensch … (2008)
            Different primary treatment modalities have been utilized to treat poststernotomy mediastinitis (PM) following cardiac surgery. A literature survey using the key phrases "treatment of deep sternal wound infection" and "poststernotomy-mediastinitis" was performed. Furthermore, a questionnaire regarding the primary treatment of PM was distributed to all 79 German heart surgery centers. The review of the literature shows that the current understanding is based purely on retrospective studies, not on evidence-based medicine. All 79 German heart centers replied to the questionnaire. Vacuum-assisted closure therapy (V. A. C.(R)) is used in 28/79 (35 %) heart centers as the "first-line" treatment, 22/79 (28 %) perform primary reclosure in conjunction with a double-tube irrigation/suction system, and in 29/79 (37 %) German heart centers both treatment options were used according to the intraoperative conditions. As a primary treatment for PM two treatment modalities are currently in use: primary reclosure coupled with a double-tube suction/irrigation system versus V. A. C.(R) therapy. Since prospective randomized studies have not yet been performed, controlled clinical trials comparing both treatment modalities are pivotal to define the evidence for patients presenting with PM.
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              Sternal wound infections following cardiac surgery: risk factor analysis and interdisciplinary treatment.

              Raymund E. Horch, Ulrich Kneser, Johannes Rösch … (2006)
              Sternal wound infections are a serious complication after cardiac surgery. Although a variety of treatment algorithms has been published, the ideal operative treatment of complicated median sternotomy wounds is the subject of ongoing controversy. In a retrospective review, 3016 consecutive open-heart surgery patients between January 2003 and June 2006 were evaluated: 65.6% underwent coronary artery bypass surgery (CABG), 16.3% cardiac valve replacement, 13.5% combined CABG and valve replacement, 2.8% aortic reconstruction or replacement, 0.6% artificial heart implantation, and 1.2% cardiac transplantation. Sixty-three patients (2.1%) developed sternal wound infections. Fifty-six wounds were treated with débridement, irrigation, and re-wiring. Thirty-four patients were treated using vacuum-assisted closure therapy. Nineteen of these patients eventually required plastic surgical coverage with either rectus abdominis or pectoralis major flaps. Diabetes mellitus, rethoracotomy, duration of operation and, interestingly, the time of operation (morning versus afternoon) presented significant risk factors for development of sternal wound infections (P <.05). Three patients developed partial flap necrosis and required a second flap. Eventually, all defects were successfully reconstructed and there was no recurrent ostemyelitis noticed over the entire observation period (follow-up, 23 +/- 13 months). Patients at risk for development of sternal wound infections may be preferably operated in the morning at first position. Vaccuum-assisted closure therapy acts as a link between radical débridement and definitive plastic coverage. The type of flap is individually chosen based on location of the defect and availability of certain vascular axis. The presented interdisciplinary approach with radical surgical débridement, application of subatmospheric pressure dressings, and early involvement of the plastic surgical team allows efficient treatment of infected median sternotomy wounds.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Cardiothorac Surg
                Title: Journal of Cardiothoracic Surgery
                Publisher: BioMed Central
                ISSN (Electronic): 1749-8090
                Publication date Collection: 2011
                Publication date (Electronic): 9 February 2011
                Volume: 6
                Page: 16
                Affiliations
                [1 ]Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
                [2 ]Department of Cardiac Surgery, Klinikum Ludwigshafen, 67069 Ludwigshafen, Germany
                [3 ]Anaesthesiology and Operative Intensive Care, Klinikum Ludwigshafen, 67069 Ludwigshafen, Germany
                Article
                Publisher ID: 1749-8090-6-16
                DOI: 10.1186/1749-8090-6-16
                PMC ID: 3044101
                PubMed ID: 21306630
                SO-VID: 49d9a30e-9866-45e2-af23-c3b61f7eef07
                Copyright © Copyright ©2011 Kiessling et al; licensee BioMed Central Ltd.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 13 October 2010
                Date accepted : 9 February 2011
                Categories
                Subject: Case Report

                ScienceOpen disciplines: Surgery
                Data availability:
                ScienceOpen disciplines: Surgery

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