Massive hemorrhage from the posterior intercostal artery following lower partial sternotomy

Background Median sternotomy remains the most common approach in cardiovascular surgery. Recently, minimally invasive procedures, such as minimally invasive cardiac surgery, robot surgery, and catheter therapy have been developed in cardiovascular surgery. However, all these surgeries cannot be performed by minimally invasive approaches. Several complications associated with median sternotomy have been reported, although post-sternotomy hemorrhage from the posterior intercostal artery is extremely rare. Case presentation We present a case of posterior intercostal artery bleeding following lower partial sternotomy. A 79-year-old man underwent aortic valve replacement using lower partial median inverted L-shaped sternotomy that cut into the right second intercostal space. A postoperative chest radiograph indicated a hematoma in the right upper chest wall and pleural effusion. Hence, we inserted a drainage tube immediately. Approximately 2 hours after the surgery, his blood pressure gradually decreased. Blood drainage was observed from the tube, and the amount of blood drainage was not large. Contrast-enhanced computed tomography revealed a huge hematoma and hemorrhage from the fourth right posterior intercostal artery. Immediately, we performed emergency surgery. The lower partial sternotomy was repeated. We detected the origin of the bleeding that was identified in the right fourth posterior intercostal artery, and the bleeding was stopped. The postoperative course was uneventful. Conclusions This case highlights the possibility of intraoperative bleeding from the intercostal artery, even in the absence of clearly rib fracture. In our case, we did not identify the cause of bleeding, although we suggest the inhomogeneous stress on the posterior ribs upon attaching the sternal retractor for lower partial sternotomy may have affected the posterior intercostal artery.

Superior mediastinal tumour excision through upper partial sternotomy and chamberlain incision

Superior mediastinal mass excision can be performed by various approaches such as partial sternotomy, mini trapdoor incision, anterior cervical transsternal approach and lateral thoracotomies. However, adequate exposure especially of superior surface seems to be difficult. Total four patients of superior mediastinal mass were admitted in the department of cardiothoracic and vascular surgery, Safdarjung hospital, New Delhi between June 2019 to May 2021. All of them were operated by upper partial sternotomy with right or left chamberlain extension of incision. It is safe and effective in terms of exposure with early recovery as well as cosmesis. Hence, we advocate the use of upper partial sternotomy with left or right chamberlain incision which provides good exposure in addition to ease of patient position, vascular control and emergency institution of cardiopulmonary bypass.

Aortopexy for Tracheomalacia Via Partial Sternotomy

Tracheomalacia (TM) is a disease that causes the airway obstruction of the tracheal lumen as a result of the structural disorder of the tracheal cartilage. We present a 4-month-old patient who developed ventilator depended TM after repair of esophageal atresia with tracheoesophageal fistula. Aortopexy and intraoperative flexible bronchoscopy were first performed via partial sternotomy in Turkey for this patient. He was weaned from ventilatory support and extubated at the first and discharged at the 8th post-operative day. Partial sternotomy is performed in the supine position, thus it allows for intraoperative flexible bronchoscopy permitting to check for the adequacy of the aortopexy.

Tricuspid valve repair via partial sternotomy for traumatic valve insufficiency

Tricuspid valve insufficiency rarely follows a blunt chest trauma. When the tricuspid valve is solely injured, the cardiac trauma may stay asymptomatic and tolerable, which often makes it difficult to determine the indication for surgery. We report a case of a patient with tricuspid regurgitation secondary to trauma due to a motorcycle accident. The patient was initially asymptomatic, but shortness of breath emerged two years after the accident. He underwent the tricuspid valve repair with chordae reconstruction and annuloplasty via lower partial sternotomy. We advocate that early surgical intervention prevents right heart failure, atrial fibrillation, and valve replacement.

Massive Hemorrhage From the Posterior Intercostal Artery Following Lower Partial Sternotomy: a Case Report

Background: In recent years, partial sternotomy has been adopted as an approach for minimally invasive cardiac surgery. Lower partial sternotomy is considered a superior approach compared to full sternotomy in terms of postoperative sternum fixation. We reported a very rare complication of posterior intercostal bleeding after aortic valve replacement with lower partial sternotomy.Case presentation: A 79-year-old man underwent aortic valve replacement using lower partial sternotomy involving the right second intercostal space. The surgery was completed without any problem. However, a postoperative chest radiograph indicated a hematoma in the right upper chest wall and pleural effusion. Therefore, we inserted a drainage tube immediately. His blood pressure gradually decreased despite not having much drainage from the chest tube. Contrast-enhanced computed tomography revealed a huge hematoma and hemorrhage from the fourth right posterior intercostal artery. Immediately, we performed an emergency lower partial sternotomy again. We detected the origin of the bleeding in the right fourth posterior intercostal artery and obtained hemostasis with direct suture. The postoperative course was uneventful.Conclusions: This case highlights the possibility of intraoperative bleeding from the intercostal artery, even in the absence of a clear rib fracture. In our case, we did not identify the cause of the bleeding. However, we suggest that the inhomogeneous stress on the posterior ribs upon attaching the sternal retractor for lower partial sternotomy may have affected the posterior intercostal artery.

KẾT QUẢ DÀI HẠN PHẪU THUẬT CẦU NỐI ĐỘNG MẠCH CHỦ NGỰC - ĐỘNG MẠCH CẢNH - DƯỚI ĐÒN

Objectives: The complex stenosis of the branches of the aortic arch is rare, it was the challenge for vascular surgeon to manage. The purpose of thisstudy was review our experience with diagnosis and surgical treatment for complex stenosis of the branches of the aortic arch .Methods: Prospective. Eveluate the clinical characteristics of complex stenosis of the branches of the aortic arches. Diagnosis was based on Dupplex scanning, MSCT and angiography. Intrathoracic bypass was indicated for all cases. Results: From 10/1999 to 10/2011, twelve patients with complex stenosis of the branches of the aortic arch were treated in Choray hospital and Thong nhat hospital. 4 cases stenosis of the carotid and the subclavian artery; 4 cases have stenosis the branchiocephalic artery; and 4had stenosis all of the branches of the aortic arch. 10 cases admission because of chronic upper extremity ischemia. 12 cases had TIA. Takayashu’s disease affected in 6 cases, atherosclerosis was the cause of 6 patients. All patients were diagnosed by Duplex scan, MSCT and arteriography. 2 cases with 99 percent stenosis, the others were completely occluded.Upper partial sternotomy were performed in all cases.; Aorto carotido-subclavian bypass in 7 cases; Aorto bi-carotid bi-subclavian bypass were performed in 4 cases; Branchiocephalo carotid and subclavian bypass in 1 case, PTFE prothesis graft was used in 2 cases. Dacron prothesis was used in the rest .No procedure-related mortality was observed. No stroke. There are 1 wound infection, No restenosis after 12 years follow up.Conclusions: Upper partial sternotomy is a very good approach for ascending aorto carotidosubclavian bypass operation. Ascending aorto carotido subclavian bypass should be done for stenosis of multi-branches.