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Ann Thorac Surg 1999;68:2215-2219
© 1999 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Catastrophic hemorrhage on sternal reentry: still a dreaded complication?

^a Department of Cardiothoracic Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA

Address reprint requests to Dr Follis, Department of Cardiothoracic Surgery, University of New Mexico Health Sciences Center, 2211 Lomas Blvd NE, Albuquerque, NM 87131
e-mail: follis{at}unm.edu

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. To define the incidence of catastrophic hemorrhage (CH) during reoperations, the experience of the University of New Mexico was reviewed and compared with the practice of surgeons contacted by questionnaire.

Methods. At the University of New Mexico, 610 reoperations were reviewed and 210 deemed high risk because of multiple reoperation, aneurysm, patent grafts, chamber’s enlargement, conduit or previous mediastinitis. In the questionnaire, we asked about reentry technique, occurrence and outcome of CH, and precautions for high-risk patients.

Results. At the University of New Mexico there were 4 CH with 1 death, and in the questionnaire there were 2,046 CH with 392 deaths. Our rate per surgeon was lower than that of the questionnaire. Rate of CH according to the saw was 2.09 for reciprocating, 2.0 for sagittal, and 1.74 for stryker in the questionnaire. Our rate was lower (0.65) with a micro sagittal saw. High-risk category predicted CH during sternotomy (p = 0.01) but only conduit (p = 0.005) was significant by univariate analysis.

Conclusions. The risk of CH could be as high as 1%. The sagittal micro oscillating saw is the safest reported to date. Presence of a conduit increases the risk by 2.5 fold.

	Introduction

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Median sternotomy, popularized by Julian and associates [1] in the 1950s for rapid access to the heart, is the approach of choice for both congenital and acquired cardiac disease. As operative techniques evolve and survival after cardiac operations improves, the number of patients who have repeat sternotomy inevitably continues to rise. In the past decade, according to the report of the Society of Thoracic Surgeons, the number of redo coronary artery bypass has been averaging 8%. Likewise, the incidence of reoperation for aortic and mitral valve procedures has been 11% and 20%, respectively [2].

With 598,000 aortocoronary bypass, 50,000 aortic, and 29,000 mitral valve operations performed each year in the United States [3], approximately 58,000 redo operations should be expected. The exact number in the pediatric population is unknown but can be approximated at 15% of all procedures for congenital heart disease.

Division of the sternum is primarily a blind procedure and carries an increased risk of injury of major cardiac structures in the presence of adhesions between the posterior table and the innominate vein, right ventricle, and extracardiac conduits or grafts. After the provocative report of Dobell and Jain [4] in 1984, which summarized the experience of 224 surgeons in the country, a series of guidelines were developed, together with alternative techniques for sternal reentry [5–9].

Today, the exact incidence of catastrophic hemorrhage (CH), defined as exsanguination requiring blood trans-fusions, remains unknown. Although the experience gained with large volumes of cases has decreased its frequency and the number of poor outcomes, we believe this entity still occurs few times in the career of a thoracic surgeon and it goes unreported like any event secondary to technical failure.

In 1984, Akl and associates [10] described a technique using a micro sagittal oscillating saw in more than 50 reoperations without complications related to reentry. The purpose of this study was to review our experience with this technique between 1977 and 1995 in 610 reoperations and compare it with the practice of 1,116 surgeons contacted by questionnaire.

	Material and methods

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Clinical material
From September 1977 to December 1995 at three major hospitals, 568 patients, aged 1 month to 82 years, had 610 repeat sternotomies. All reoperations were done by a single group of surgeons using the technique described subsequently. To consider the procedure a reoperation, the previous sternotomy must have been performed at least 4 weeks previously. There were 503 adult patients (age 21 years or more) and 65 pediatric patients (age less than 21 years).

In the adult group, there were 402 men and 101 women ranging in age from 21 to 82 years (mean, 59.8 ± 11.7 years) for the men and 21 to 76 years (mean, 52.8 ± 14.1 years) for the women at the time of repeat sternotomy. Indications for reoperation included progression of atherosclerotic coronary artery disease in 353, progression of valvular heart disease or failed prosthesis in 192, sustained ventricular arrhythmias in 6, congestive heart failure secondary to constrictive pericarditis in 2, aortic aneurysms in 2, and atrial septal defect in 1. Three hundred forty patients had revascularization, 189 had redo valve operations (149 single and 40 double valve replacement). Combined bypass and valve procedures comprised 26 patients. Eight patients had placement of automatic defibrillator devices. One repeat sternotomy was done in 472 patients, two repeat sternotomies in 48 patients, and three repeat sternotomies in 12 patients. The time interval between sternotomies ranged from 1 to 610 months (mean, 134 ± 4.7 months).

In the pediatric group, there were 34 boys and 31 girls ranging in age from 1 month to 20 years for the boys (mean, 8.9 ± 5.7 years) and 3 months to 19 years for the girls (mean, 8.0 ± 5.1 years). Indications for reoperation included valve dysfunction after repair or replacement in 34 patients, persistent shunts in 5 patients and hemodynamic compromise from degenerative conduits or outflow tract obstruction in 34 patients. One repeat sternotomy was done in 61 patients, two repeat sternotomies in 14 patients, and three repeat sternotomies in 3 patients. The time interval between sternotomies ranged from 2 to 156 months (mean, 54 ± 4.8 months).

Two hundred ten patients were identified as high risk for reentry because of second or third reoperation (n = 76), ascending aortic aneurysm (n = 9), patent mammary graft (n = 18), enlargement of right chambers (n = 111), the presence of a conduit (n = 34), or a history of sternal infection with mediastinitis (n = 16).

None of the patients had history of mediastinal radiation. At the discretion of the surgeon, 16 patients had the femoral vessels exposed before reentry in the event of emergent bypass for CH.

Operative technique
After removal of the sternal wires, two penetrating towel clamps were placed in the fascia and periosteum at the lateral borders of the midsternum. With upward traction on the clamps, the microsagittal saw was used to divide the anterior table from xiphoid to suprasternal notch. The saw operates by vibrating action allowing cutting in the same sagittal plane as the long axis of the handle, differently from the stryker saw which operates at a 90-degree angle from the long axis of the handle. The posterior table was penetrated in a controlled perpendicular fashion by resting the heel of the hand on the sternum (Fig 1). Because of the small weight of the saw, a characteristic feel is appreciated when division through bone is complete. All tilting of the saw is in the sagittal plane which avoids beveling and irregularity of the cut edges. As cutting progressed cephalad, traction on the clamps allows gradual separation of the two sternal halves eliminating the need for instruments to pry open the sternum.

View larger version (87K): [in this window] [in a new window]   Fig 1. Division of the sternum with the micro oscillating sagittal saw.

Statistical analysis
Fisher exact test was used to analyze differences in mortality rates according to the number of reoperations (first reoperation versus second or third), and to assess the predictive impact of the high-risk category on the occurrence of injury during and after sternotomy. Posthoc analysis of the variables defining the high-risk category was done with univariate and stepwise logistic regression analysis. In absence of the number of reoperations per year among the respondents to the questionnaire, the number of events per surgeon per 10 years was calculated and compared with that of our institution. Additionally, the number of events per surgeon per 10 years was compared between types of saw used. Rates were compared using a normal approximation for the Poisson model with the variance of rate equal to rate per sample size.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Clinical data
Four injuries, two in adults and two in pediatric patients, were attributed to the use of the saw. Structures damaged included a saphenous vein graft, the right ventricle, and two conduits. The injury to the vein graft required emergency cardiopulmonary bypass and the patient died on postoperative day 2 in cardiogenic shock. In the second patient, after repair of the right ventricle, dissection of the heart was difficult and required institution of cardiopulmonary bypass via femoral cannulation. A double valve replacement was done, but the patient required intra-aortic balloon pump and left ventricle assist device and died 24 hours later in cardiogenic shock. The outcome was believed to be secondary to the magnitude of the operation and to global left ventricular dysfunction rather than the initial right ventricular injury. One of the two conduit injuries required emergency cardiopulmonary bypass. The other conduit injury was repaired and the operation proceeded uneventfully. All injuries occurred in the high-risk group. Overall there was one death related to CH in this group.

The overall mortality rate was 8.2% (50 of 610) with the rate increasing with the number of reoperations. Thus, 8% (37 of 472) died after first reoperation, 14.6% (7 of 48) after second reoperation, and 33.3% (4 of 12) after third reoperation. The difference in mortality rates between first and third reoperations was statistically significant (p = 0.01 by Fisher exact test). The mortality rate directly related to sternal reentry was 1 patient, with 210 deemed to be high-risk patients by the criteria described earlier.

The high-risk category predicted injury during sternotomy (p = 0.01). Moreover, among the variables included in the high-risk category, ie, open internal mammary artery, right ventricular or right atrial enlargement, ascending aortic aneurysm, more than one reoperation, multivalvular disease, history of mediastinitis, and presence of a conduit, only the latter (p < 0.005) was identified as a significant variable by univariate analysis. Likewise, stepwise logistic regression analysis did not identify additional variables as predictors.

Table 1 lists the odd ratios, 95% confidence limits, and p values for the high-risk category variables for injuries during sternotomy using univariate logistic regression. The presence of a conduit increased the risk of injury by a factor of at least 2.5. The overall incidence of CH in our series was 0.6% (4 of 610).

	Comment

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The present study confirmed our initial suspicion that CH on sternal reentry is underreported. The questionnaire sent to the members of The Society of Thoracic Surgeons disclosed 2,046 events resulting in 392 deaths (19%). The most commonly involved structures were right ventricle, vein grafts, aorta, ITA, and innominate vein, in decreasing order of frequency. Likewise, review of our experience with a micro oscillating sagittal saw in our institution over 18 years yielded four injuries with one death (25%).

The technique of resternotomy plays a crucial role in the occurrence CH, so a review of the available methods is appropriate. In 1979, Culliford and Spencer [6] reported a method where 8 to 10 cm of the retrosternal space was cleared by retracting laterally on the costal arch and superiorly on the xiphoid process. The heart was displaced posteriorly with a sponge stick, and all adhesions along the posterior table were divided sharply. Sternal division was done with a Lebshe knife or reciprocating stryker saw.

In a similar fashion, Grunwald [7] elevated the costal arch to allow direct vision of restosternal space. Division with the cautery was done up to the angle of Louis, and dissection in the retromanubrial area was done from above with a finger or right-angle clamp. The Sarns saw was used to divide the length of sternum that was freed. Among the 227 repeat sternotomies over 18 years, the overall mortality rate was 1.3% with none of the deaths related to complications of sternal reentry.

In 1989, Garrett and Matthews [8] described a simple technique used in 50 consecutive patients without incident. The previously placed sternal wires were cut and untwisted but not removed. An oscillating saw was used to divide the sternum while upward traction was applied to the wires. The wires provided a barrier to the saw while the posterior table of the sternum was being divided.

Anterior sternal retraction using a modified Rultract retractor (Rultract, Inc, Cleveland, OH) was described by Eddy and associates [5] and resulted in only minor injury in 0.4% of 224 cases. After excising the xiphoid process and placing the patient in Trendelenburg position, adhesions were taken down with the cautery up to the sternal notch. A reciprocating sternal saw was then used to divide the sternum. A more contemporary variation of this technique is done with the Mayfield redo sternotomy retractor (Genzyme Surgical Products, Cambridge, MA), a low profile retractor with endoscope and suction or cautery electrode. The device is advanced cephalad behind the sternum starting at the xyphoid process while adhesions are taken down with the cautery. Although the system is appealing, to our knowledge no clinical series has been published in the literature.

No deaths related to sternotomy were reported by Temeck and colleagues [9] in a series of 113 reoperations. Preoperative assessment included chest x-ray, computed tomography, echocardiography, and partial femoral bypass in high-risk patients. The oscillating saw was used with an up and down motion to divide the outer table of the sternum. The inner table was then slowly incised using the closed tip of the heavy scissors as a wedge between the sternal edges.

Speculations have been made regarding the ideal direction of force to be used to divide the sternum to spare the underlying structures. Thus, a horizontal force, parallel to the sternum would appear more selective in dividing the bone while leaving intact the structures that are just few millimeters deep. Machiraju [11] described this technique in 100 patients with no incidence of injury.

Although the literature is rich in the description of "innovative" methods, all have been tested in relatively small groups of patients (100 to 200 patients). Given the low incidence of CH, it is difficult to prove the superiority of a single technique with a small series; only a large randomized study could provide a definite answer. Our study, although based on larger group of patients, has the same drawbacks (retrospective design, one technique compared with data collected from a questionnaire, and no randomization). Furthermore, the comparisons of the rate of events per surgeon and of the rate of events per surgeon according to the type of saw used, between our series and the questionnaire, are indicative at best, because the survey inquired about catastrophic events that occurred in the past 10 years but did not take into account how long the surgeon had been in practice. The data were based on recollection, and the number of reoperations per year was missing. Because of these limitations, we could not prove without reservation that the use of a micro sagittal saw is superior to any other technique previously reported. We remain convinced, however, that this method is one of the safest because of the unique characteristics of the saw.

The relative distribution of anatomic structures injured reflects their most common location in relationship with the midline. Two special situations, however, are associated with the conduct of the previous operation and merit a separate discussion, namely, the presence of an open conduit in children and of patent saphenous vein grafts and ITA in adults.

Management of open conduits during reoperations in children
In 1991 DeLeon and associates [12] reported a resternotomy series of 22 patients with valved conduits adherent to the sternum. There were three injuries that required initiation of cardiopulmonary bypass with a rate of CH of 13% (three of 22). The technique of reentry consisted of chiseling the inner table in order to leave a thin layer attached to the conduit. Another series [13] had a higher rate of injury of 18% (18 of 100).

In the present series there were 34 conduits with two injuries (6%), of which only one required initiation of cardiopulmonary bypass. The presence of a conduit was the only variable that increased the risk of injury, by univariate analysis.

Reoperations in patients with an open vein graft or internal thoracic artery
In the subset of patients with an open vein graft or the ITA pedicle near or across the midline, sternal reentry might be a formidable problem. Prevention of this scenario at the first operation with coverage or placement of the ITA away from the immediate retrosternal space is essential.

In patients with open grafts, this surgeon’s trap should always be investigated during the preoperative evaluation even at the cost of repeating catheterization with additional injections and special views. Any area of the saphenous vein graft or the ITA that does not move with either cardiac or respiratory cycles must be assumed to be adherent to the ribcage. If the ITA crosses the midline and is adherent to the posterior table of the sternum, alternative options should be considered, such as drug treatment, left thoracotomy approach, or minimally invasive procedures through a right or left small thoracotomy or subxyphoid incisions.

In some of these instances where an internal thoracic artery or a patent vein are adherent to the sternum (Fig 2) , one of the authors (S.P.) has chosen to bevel the sternal osteotomy in the area of the jeopardized ITA. Using the sternal wires as landmarks, the exact location of the ITA can be plotted on the anterior-posterior chest x-ray film, and the area requiring a beveled sternal osteotomy can be established. After exposing the sternum, the predetermined course of the osteotomy is marked on the periostium using the retained wires as a guide. The wires are then removed and, with a small oscillating sagittal saw, three separate incisions are made (two sagittal and one oblique; Fig 3). The two midline anterior-posterior sagittal incisions are placed in the sternum on the superior and inferior sides of the area of ITA jeopardy. These two preliminary incisions are carried through both anterior and posterior tables. The third oblique or beveled cut is then placed. The cut enters the sternum at the left lateral aspect of the anterior table and exits the right lateral aspect of the posterior sternal table thus leaving the undisturbed ITA attached to the posterior table. With two penetrating towel clips, progressive upward traction is placed on the right sternal table, and the three separate sternal osteotomies are connected by cutting the residual bone with Mayo scissors. With the sternum divided, the ITA can be sharply dissected off the posterior sternal table. This technique has been used on three occasions without injuring the ITA, disrupting the sternum, or causing a wound infection.

View larger version (153K): [in this window] [in a new window]   Fig 2. Injection of the internal thoracic artery crossing the midline. The lateral projection confirmed a retrosternal position.

View larger version (97K): [in this window] [in a new window]   Fig 3. Diagram of the osteotomies in relationship to the left internal thoracic artery (LITA) crossing the midline.

This study allowed us to establish few facts of which any cardiothoracic surgeon should be cognizant when embarking in redo operations. (1) The risk of catastrophic hemorrhage on sternal reentry is estimated at 0.5% to 1% with an associated mortality rate of 21%. (2) The use of a micro oscillating sagittal saw has proved safe in 610 repeat sternotomies, the largest series reported in the literature to date. (3) Presence of a conduit is the only risk factor that has been conclusively demonstrated to increase the risk of catastrophic hemorrhage by at least 2.5 fold. (4) In patients with open grafts, a saphenous vein or ITA crossing the midline should be sought in each case and alternative approaches should be considered when such a situation is identified.

	Footnotes

 
This article has been selected for the open discussion forum on the STS Web site: http://www.sts.org/section/atsdiscussion/

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Julian O.C., Lopez-Belio M., Dye W.S., Javid H., Grove W.J. The median sternal incision in intracardiac surgery with extracorporeal circulation. Surgery 1957;42:753-761.[Medline]
2. Data Analysis of The Society of Thoracic Surgeons National Cardiac Surgery Database, January 1998.
3. Detailed diagnoses and procedures. National Hospital Discharge Survey, Vital And Health Statistics. Series 13. National Health Survey, Hyattsville, MD: U.S. Department of Health and Human Services, 1998.
4. Dobell A.R.C., Jain A.K. Catastrophic hemorrhage during redo sternotomy. Ann Thorac Surg 1984;37:273-278.[Abstract/Free Full Text]
5. Eddy A.C., Miller D., Johnson D., et al. Anterior sternal retraction for reoperative median sternotomy. Am J Surg 1991;161:556-559.[Medline]
6. Culliford A.T., Spencer F.C. Guidelines for safely opening a previous sternotomy incision. J Thorac Cardiovasc Surg 1979;78:633-638.[Abstract]
7. Grunwald R.P. A technique for direct-vision sternal reentry. Ann Thorac Surg 1985;40:521-522.[Abstract/Free Full Text]
8. Garrett H.E., Jr, Matthews J. Reoperative median sternotomy. Ann Thorac Surg 1989;48:305.[Abstract/Free Full Text]
9. Temeck B.K., Katz N.M., Wallace R.B. An approach to reoperative median sternotomy. J Cardiac Surg 1990;5:14-25.[Medline]
10. Akl B.F., Pett S.B., Wernly J.A. Use of a sagittal oscillating saw for repeat sternotomy. Ann Thorac Surg 1984;38:646-647.[Abstract/Free Full Text]
11. Machiraju V.R. Technical complications during redo cardiac surgery. In: Machiraju V.R., ed. Redo cardiac surgery in adults. Southampton, New York: CME Network, 1997:1-5.
12. DeLeon S.Y., Ilbawi M.N., Tubeszewski K., et al. Resternotomy in patients with valved conduits adherent to the sternum. Ann Thorac Surg 1991;52:569-571.[Abstract/Free Full Text]
13. Schaff H.V., Orszulak T.A., Gersh B.J., et al. The morbidity and mortality of reoperation for coronary artery disease and analysis of late results with use of actuarial estimate of event-free interval. J Thorac Cardiovasc Surg 1983;85:508-515.[Abstract]

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