Case
We report a 75 years old man case who underwent years ago an abdominal aortic aneurysm surgery through a transverse laparotomy approach. Inferior epigastric arteries were both ligatured during this previous surgery. Recently, this patient underwent an off-pump BIMA to coronary artery bypass, using a skeletonized harvesting technique, with favorable postoperative hemodynamics and cardiac output.
Nevertheless, he immediately developed a severe chest and upper abdominal walls ischemia (Figure 1a). The routine laboratory tests rapidly showed a metabolic acidosis with a minimal pH at 7.22 and maximal lactate level at 6.1. Maximal postoperative troponin I level was 1.85 µmol/l. The patient rapidly developed an acute renal failure with a maximal creatinin level at 338 µmol/l. Creatine kinase raised up to 4346 U/L on POD 5. An abdominal CT-scan didn’t show any digestive ischemia.
Wall necrosis was confirmed by clinical aspect at redo-surgery (Figure 1b) at POD 30. This intervention was motivated by a severe deep sternal wound infection. Microbiological agents involved were Morganella Morgani, Klebsiella Pneumonia BLSE and Enterococcus faecalis, and were treated by meropenem and amikacine for 8 weeks.
First redo surgery consisted in the debridement of necrotic tissues, iterative sternal osteosynthesis using the cabled butterfly sternal closure technique [4], and Vacuum Assisted Closure (V.A.C.) device for the upper abdominal defect. Therefore, eight weeks of concomitant V.A.C. and antibiotics therapy permitted to sterilize the wound, to obtain sternal consolidation and to reduce parietal defect (Fig 2a).
Secondary, the patient underwent a right pedicled pectoralis major muscle flap for parietal coverage (Fig 2b). At POD 15 of this third surgery, clinical examination showed sternal stability and satisfying parietal healing.