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Ann Thorac Surg 2000;69:1338-1340
© 2000 The Society of Thoracic Surgeons

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Original articles: Cardiovascular

Anterior thoracotomy wound complications in minimally invasive direct coronary artery bypass

^a Division of Cardiothoracic Surgery, Department of Surgery, East Carolina University School of Medicine, Greenville, North Carolina, USA

Address reprint requests to Dr Elbeery, Division of Cardiothoracic Surgery, East Carolina University School of Medicine, 600 Moye Blvd, Greenville, NC 27858
e-mail: elbeery{at}brody.med.ecu.edu

Presented at the Forty-sixth Annual Meeting of the Southern Thoracic Surgical Association, San Juan, Puerto Rico, Nov 4–6, 1999.

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. The minimally invasive anterior thoracotomy for beating heart coronary bypass offers a modest 10-cm incision and avoids the morbidity of extracorporeal circulation. This study examines minimally invasive direct coronary artery bypass (MIDCAB) wound complications and contributing comorbid factors.

Methods. A retrospective, single-institution review of 165 consecutive MIDCAB cases performed between March 1996 and August 1999 examined all wound abnormalities. Two surgeons performed all cases.

Results. Wound complications occurred in 15 patients (9.1%), including three (1.8%) incisional hernias, four (2.4%) superficial dehiscences, three (1.8%) wound infections, three (1.8%) chronic pain syndromes, and two (1.2%) seromas. Two patients with incisional hernias required operative repair. The remaining wound abnormalities responded to conservative therapy. Two chronic pain syndrome cases resolved spontaneously, but the third required advanced pain management. In contrast to MIDCAB, the sternotomy wound complications proved significantly less prevalent (n = 5259, 1.1% vs 9.1%, p < 0.005).

Conclusions. Although MIDCAB offers several advantages over standard approaches, these data suggest that anterior thoracotomy wound complications are not insignificant and may be underestimated by those exploring minimally invasive options.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
The small left anterior thoracotomy is commonly used for beating heart coronary artery bypass to the anterior coronary circulation. First reported in 1995 by Robinson and associates [1], this approach offers select patients a modest incision and avoids the morbidity of extracorporeal circulation and median sternotomy. Clinical data support minimally invasive direct coronary artery bypass (MIDCAB) as a reliable and effective technique with high anastomotic patency, reduced hospital costs, and shortened length of stay [2, 3]. Moreover, short-term reports demonstrate a reproducibly low overall morbidity and mortality with this minimally invasive technique [4, 5]. While various case reports of infection, lung herniation, wound dehiscence, and pain syndromes related to this approach have been published, no large study has directly addressed the issue of wound-associated morbidity [6–8]. This study is designed as a retrospective review of MIDCAB cases, subsequent wound complications, and contributing comorbid factors.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
A retrospective, single-institution review examined MIDCAB cases performed between March 1996 and August 1999, recording all postoperative wound abnormalities and subsequent therapy. Two surgeons performed all cases. The collected data included the following comorbid factors: diabetes, smoking, preoperative steroid use, chronic obstructive pulmonary disease (COPD), and morbid obesity. The primary inclusion criteria for MIDCAB included persons with single-vessel coronary artery disease involving the left anterior descending (LAD), particularly ostial or complex lesions not optimally treated by percutaneous therapies. Previous left thoracotomy, multi-vessel or significant distal coronary disease, or previous left internal mammary artery (LIMA) harvest excluded patients from MIDCAB consideration. The surgical technique utilized an 8- to 10-cm left anterior thoracotomy incision at the fourth intercostal space, pectoralis major muscle division, and chest entrance without rib resection. The LIMA was harvested under direct vision using the Limavator retractor (Genzyme Corporation, Cambridge, MA). The ribs were spread the minimal amount necessary for adequate visualization with great care taken to avoid dislocation of the fourth costal cartilage from the sternum. After mammary graft exposure to the level of the subclavian vein, a commercially available MIDCAB retractor and heart stabilizer (Genzyme Corporation) were positioned, and the LIMA to LAD revascularization was completed. Wound closure included reapproximation of the costal cartilages using absorbable pericostal interrupted sutures, as well as separate layer closures for the pectoralis muscles, deep dermal, and subcuticular layers with running absorbable sutures. Subcutaneous drains were not utilized. A single thoracostomy tube was placed through a separate stab incision. Patients were followed up as outpatients at 2 weeks after discharge.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
The study evaluated 165 consecutive patients. Demographic data are presented in Table 1. The average age was 60.2 ± 11.6 years (range 30 to 88 years) with a 70% male predominance. Average ejection fraction equaled 0.55 ± 0.08 (range 0.30 to 0.70). The average operative time was 144.4 ± 51.2 minutes, and the postoperative length of stay was 3.2 ± 1.5 days. No mortality occurred within this group. One perioperative myocardial infarction occurred. Follow-up at 2 weeks for wound inspection was 100%. The incidence of comorbid factors includes: diabetes (25.4%), smoking (42.4%), preoperative steroid use (1.8%), COPD (3.6%), and morbid obesity (2.4%), as represented in Table 1. No comorbid factors correlated with an increased risk of wound complication by univariate or multivariate analysis.

View larger version (119K): [in this window] [in a new window]   Fig 1. Left anterior thoracotomy with superficial dehiscence and subsequent chronic draining sinus.

	Comment

Top Abstract Introduction Material and methods Results Comment References

The left anterior thoracotomy approach to beating heart bypass appears to provide both a safe and effective alternative for LAD revascularization. MIDCAB offers not only improved cosmesis but, more importantly, avoidance of extracorporeal circulation, which may lower overall hospital costs, complications, and length of stay. This series of patients supports the efficacy of the procedure and demonstrates comparable cardiac morbidity and mortality rates compared with standard CABG. At the same time, these data also demonstrate significant differences in wound morbidity. Other series report similar findings. Pagni and associates [8] suggested an increased wound infection risk associated with submammary incisions, reporting a 9% incidence, particularly in morbidly obese females (100%). Our overall wound morbidity rate also equaled 9.1% but with no significant association with obesity. In fact, no specific factor proved to predispose MIDCAB patients to wound problems with respect to diabetes, smoking, steroid use, COPD, or morbid obesity.

The sternotomy infection rate at our institution is consistent with those published on large cohort studies [9]. While patient selection, limited sample size, and the retrospective analysis limits direct comparison of MIDCAB with standard CABG in this study, the difference in wound complication rates prove significant, emphasizing that anterior thoracotomy is not a completely benign approach.

Alternative incisions have been utilized for minimally invasive LIMA to LAD operations. The most common of these involves a lower hemisternotomy, which is "T’ed" off to the left in the second intercostal space. The major advantage of this approach is that it allows LIMA harvest using traditional instruments in a manner with which all cardiothoracic surgeons are comfortable. The major disadvantage is the fact that the patient’s recovery involves healing of the sternum, which (like standard sternotomy) limits the ability to do strenuous physical activity for 6 to 8 weeks. Furthermore, in the authors’ experience, this incision does not afford exposure of the LIMA cephalad to the second intercostal space because the manubrium remains fixed and cannot be retracted superiorly.

Theoretical considerations for wound problems in MIDCAB anterior thoracotomies include the lack of collateral blood supply to the intercostal muscles. This may account for the difference in morbidity between the median sternotomy and anterior thoracotomy. DeJusu and Acland [10] describe a high incidence of tissue ischemia noted in the thoracic interspaces after interruption of the internal thoracic artery branch collaterals during mammary harvest. Local ischemia may then contribute to poor or delayed wound healing resulting in wound complications. Other factors that may also contribute to wound morbidity in the anterior thoracotomy include fracture or avulsion of the costal cartilages from the sternum resulting in chest wall instability and possible lung herniation. In addition, large pendulous breasts or obese body habitus may contribute to intertriginous infection. Hematoma or seroma formation in the large subcutaneous space created in this procedure may also lead to compromised wound healing and subsequent infection.

Despite the significant wound morbidity rate, the anterior thoracotomy MIDCAB approach remains a successful and effective method of coronary revascularization. The procedure is especially suited to very young patients seeking to avoid a full CABG procedure as well as those who are poor candidates for standard CABG due to comorbidities. In all cases, however, the risk of subsequent wound complications is not insignificant, and patients must be counseled accordingly.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Robinson M.C., Gross D.R., Zeman W., et al. Minimally invasive coronary artery bypass grafting. J Cardiovasc Surg 1995;10:529-536.
2. Gulielmos V., Knaut M., Cichon R., et al. Experiences with a minimally invasive surgical technique for the treatment of coronary artery multivessel disease in 100 patients. Eur J Cardiothorac Surg 1998;14:347-352.[Abstract/Free Full Text]
3. Zenati M., Domit T., Saul M., et al. Resource utilization for minimally invasive direct and standard coronary artery bypass grafting. Ann Thorac Surg 1997;63:S84-S87.
4. Calafiore A.M., Teodori G., Di Giammarco G., et al. Minimally invasive coronary artery bypass grafting on a beating heart. Ann Thorac Surg 1997;63:S72-S75.
5. Subramarian V.A., McCabe J.C., Geller C.M. Minimally invasive direct coronary artery bypass grafting. Ann Thorac Surg 1997;64:1648-1655.[Abstract/Free Full Text]
6. Deeik R., Memon M., Sugimoto J. Lung herniation secondary to minimally invasive direct coronary artery bypass grafting. Ann Thorac Surg 1998;65:1772-1774.[Abstract/Free Full Text]
7. Hei E., Deal C. Intercostal lung hernia subsequent to harvesting of the left internal mammary artery. Ann Thorac Surg 1995;59:1579-1580.[Abstract/Free Full Text]
8. Pagni S., Salloum E., Tobin G., VanHimbergen D., Spence P. Serious wound infections after minimally invasive coronary bypass procedures. Ann Thorac Surg 1998;66:92-94.[Abstract/Free Full Text]
9. Borger M.A., Rao V., Weisel R.D., et al. Deep sternal wound infection. Ann Thorac Surg 1998;65:1050-1056.[Abstract/Free Full Text]
10. DeJusu R., Acland R. Anatomic study of the collateral blood supply of the sternum. Ann Thorac Surg 1995;59:163-168.[Abstract/Free Full Text]

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