Ann Thorac Surg 1998;65:553
© 1998 The Society of Thoracic Surgeons
Case Reports
Partial Breast Necrosis After MIDCABG via Small Anterolateral Thoracotomy
Yaron Har-Shai, MD,
Roni Ammar, MD,
Amir Taran, MD,
Ami Barak, MD,
Shraga Mayblum, MD,
Gideon Uretzky, MD
Plastic Surgery Unit, Carmel Medical Center, Haifa, Israel
Department of Cardiothoracic Surgery, Carmel Medical Center, Haifa, Israel
Accepted for publication September 24, 1997.
Dr Har-Shai, Plastic Surgery Unit, Carmel Medical Center, 7 Michal St. Haifa 34362, Israel.
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Abstract
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We report a case in which partial breast necrosis developed after minimally invasive direct coronary artery bypass grafting using an IMA Retractor (Cardio-Thoracic Systems Inc, Cupertino, CA). We suggest that during minimally invasive direct coronary artery bypass grafting in the presence of a large breast, it is advisable to reduce the intraoperative additive forces of pressure and traction caused by the retractor arm on the breast tissue, thus avoiding further excessive compression on the partially compromised blood circulation of the breast.
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Introduction
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Minimally invasive direct coronary artery bypass grafting has recently been introduced into cardiac surgery and has been shown to cause less trauma and pain than cardiopulmonary bypass, and to reduce the risks of wound infection and blood loss [1] [2] [3] [4]. Recovery is more rapid and the cosmetic results are better. In a recent study, the main complications of minimally invasive direct coronary artery bypass grafting consisted of bleeding and graft failure [5]. The following describes a case in which partial breast necrosis developed after direct coronary grafting without cardiopulmonary bypass via a small anterolateral thoracotomy using an IMA Retractor (Cardio-Thoracic Systems Inc, Cupertino, CA).
The patient, a healthy 59-year-old woman with marked bilateral breast hypertrophy was scheduled for minimally invasive direct coronary artery bypass grafting because of a severe proximal occlusion of the left anterior descending artery.
The patient was intubated in a supine position and a small rubber cushion was inserted underneath her left scapula. A horizontal skin incision, 8 cm long, over the fifth intercostal space was made on the halfway of an imaginary line extending between the sternal notch and the lower left border of the chest cage. A specially adapted retractor (IMA Retractor) was inserted into the fifth intercostal space and gently opened to avoid fracturing the ribs. The particular shape of the arms of this retractor creates a "tunnel" facing the left internal mammary artery (LIMA) (Fig 1). The pedicled LIMA was harvested from the first rib down to the seventh intercostal space. The distal part of the LIMA was made visible by rotating the retractor arms 180 degrees. After LIMA harvesting was completed, the retractor was replaced by another spreader (Access Platform; Cardio-Thoracic Systems Inc), which includes a coronary artery stabilizer (Stabilizer; Cardio-Thoracic Systems Inc). Heparin was administered intravenously and the anastomosis was completed. The small thoracotomy incision was sutured in layers, leaving a pleural tube for drainage.
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Intraoperative view demonstrating the retractor apparatus in place. The upper arm of the retractor compresses the large left breast (arrow).
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The overall operating time was 150 minutes. After the removal of the retractor, a vertical rectangular hyperemic zone distending from the left inferior mammary fold to the areola gradually appeared.
The postoperative period was uneventful and the patient was discharged on the 5th postoperative day. The hyperemic area did not resolve. Two days later the patient noticed purulent discharge from the surgical wound. Her body temperature was elevated to 38.9°C. On physical examination the previously hyperemic zone was necrotic (Fig 2) and dehiscence of the surgical wound was evident. At bedside, the surgical wound was completely opened and a large volume of purulent necrotic material was evacuated.
Under general anesthesia, the necrotic skin and the inferior portion of the left pectoralis major muscle, as well as devitalized fat and breast tissue consisting of the whole inferior half of the left breast, were debrided. Two nondisplaced fractures at the anteromedial portions of the fifth and sixth ribs were noticed.
The surgical wound was left wide open and copious irrigations with antibacterial solutions were initiated. After 3 weeks, granulation tissue proliferated in the surgical wound. Clinically no active infection was noticed.
Again under general anesthesia, the lateral and medial skin edges of the left lower breast wound were debrided and approximated, leaving a small inferior middle opening for drainage. The cavity that remained in the lower pole of the left breast was considerably large.
After 5 months of conservative daily treatment with Kaltostat Cavity (ConvaTec Limited, E.R. Squibb & Sons, Inc, Uxbridge, England), the inner space was filled with granulation tissue and eventually the surgical wound healed completely. The patient’s left breast, which became small, conical, and ptotic, caused marked breast asymmetry, resulting in extreme aesthetic discomfort (Fig 3). The patient refused any corrective breast operation.
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Comment
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Minimally invasive direct coronary artery bypass grafting operations, which have undoubtedly opened a new era in the treatment of isolated disease of the left anterior descending coronary artery, are facilitated by the development of suitable instrumentation. The use of a rib spreader that permits optimal exposure of the LIMA through a small incision with effective reduction of heart motility is key to the success of this surgical approach. Although the results are encouraging, surgeons must be aware of the possible harmful side effects that may appear when executing this new technique.
Approximately 60% of the breast receives blood from the anterior and posterior perforating branches of the internal mammary artery [6]. The sternocostal segment of the pectoralis major is supplied by the internal mammary branches emerging through the cranial five or six intercostal spaces, whereas its dominant blood supply is derived from the thoracoacromial artery. When the LIMA is mobilized and ligated, musculocutaneous arterial perforators are severed, reducing blood supply to the medial and posterior left breast. In addition, in the presence of a large breast, 40 minutes of unrelieved pressure of the IMA Retractor, the mean time required for LIMA harvesting, further compresses the already compromised overlaying and intervening tissues. As a result, reduction of blood supply to the breast ensues and ischemic necrosis may develop.
There is no evidence available in the current literature documenting a case of breast necrosis after standard coronary artery bypass grafting; therefore, minimally invasive direct coronary artery bypass grafting via a small anterolateral thoracotomy may not be the approach of choice in women with large breasts. During the operation direct compression force of the retractor arms on the breast should be reduced by supplying appropriate padding or by periodically relieving the pressure and removing the retractor from the breast tissue. Alternatively, modifications in the design of the retractor arms, intended to avoid possible pressure points during its application, are warranted.
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References
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- Benetti FJ, Ballester C Use of thoracoscopy and minimal thoracotomy, in mammary–coronary bypass to left anterior descending artery, without extracorporeal circulation. J Cardiovasc Surg 1995;36:159-161.[Medline]
- Buffold E, Andrade JCS, Branco JNR, et al. Coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 1996;61:63-66.[Abstract/Free Full Text]
- Acuff TE, Landreneau RJ, Griffith BP, Mack MJ Minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1996;61:135-137.[Abstract/Free Full Text]
- Calafiore AM, Angelini GD, Bergsland J, Salerno TA Minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1996;62:1545-1548.[Abstract/Free Full Text]
- Calafiore AM, Di Giammarco G, Teodori G, et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1658-1665.[Abstract/Free Full Text]
- McCary KS, Jr, Carpenter SA, Georgiade GS The breast: embryology, anatomy, and physiology. In: Georgiade NG, Georgiade GS, Riefkohl R., eds. Aesthetic surgery of the breast. Philadelphia: Saunders, 1990:6-7.
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Abstract
Introduction
