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.