Coronary artery bypass grafting via manubrium-sparing sternotomy in a patient with total laryngectomy and a permanent tracheostoma

Abstract

For patients who have previously undergone total laryngectomy and a permanent tracheostomy, median full sternotomy is not the ideal surgical approach because of the substantially increased risk of sternal wound complications and tracheal injuries. We present a case in which conventional coronary artery bypass grafting using bilateral internal thoracic arteries was performed safely via a manubrium-sparing sternotomy in a patient who had undergone total laryngectomy and a permanent tracheostoma. We also discuss the appropriate surgical approach for patients with total laryngectomy and a permanent tracheostoma.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-021-01309-8.

Introduction

For patients who have undergone total laryngectomy and a permanent tracheostomy, median full sternotomy is not an ideal surgical approach because of the high risk of sternal infection and lethal mediastinitis. To avoid these risks, reports have been published on several surgical approaches, including manubrium-sparing sternotomy (MSS) [1–3], transverse bilateral thoracotomy [4, 5], and left anterior thoracotomy (LAT) [6]. Herein, we report the case of a patient who underwent conventional coronary artery bypass grafting (CABG) using the bilateral internal thoracic arteries (ITAs) via MSS.

Case report

The patient was a 69-year-old man who had symptoms of chest pain during exertion. He had previously undergone total laryngectomy and permanent tracheostomy. He was transferred to our institution for surgical revascularization. His initial electrocardiogram (ECG) showed normal sinus rhythm with ST-segment depression in leads II, III, aVF, and V2–5, and ST-segment elevation in lead aVR. Transthoracic echocardiography showed normal left ventricular (LV) function (ejection fraction, 67%) with no asynergy in LV wall motion. Coronary angiography revealed severe triple-vessel disease with significant stenosis in the ostial portions of the diagonal branch of the left anterior descending (LAD) artery and the LAD itself (90% and 90%, respectively), the ostial and mid portions of the left circumflex artery (99% and 90%, respectively), and the proximal portion of the right coronary artery (75%), which were unsuitable for percutaneous coronary interventions (Fig. 1).

Fig. 1.

Preoperative coronary angiography. Panel A shows the left coronary artery and corresponds to the left anterior 40 and cranial 30° oblique images. Panel B shows the left coronary artery, which corresponds to the right anterior 30 and caudal 25° oblique images. Panel C shows the right coronary artery and corresponds to the caudal 25° oblique image

Preoperatively, three-dimensional (3D) computed tomography scans was obtained to examine the positional relation between the sternum and ITAs.

Under general anesthesia, the patient’s tracheostoma was intubated with an endotracheal tube and completely isolated from the surgical field with a plastic, sterile drape. The patient was placed in the supine position. A longitudinal skin incision was made from 2 cm below the sterno-manubrial junction, down to approximately 2 cm below the xiphoid process. After that, the sternum was divided in the midline from the bottom to the top, sparing the manubrium, and then transected at the level of the second intercostal space (Supplementary Video 1). To make a transverse cut in the second intercostal space, we used a sagittal oscillating saw, which was smaller than the width of the sternum. The sternum was pulled up using two blunt pronged Kocher retractors by the surgical assistant, and the left ITA was harvested. Moreover, we did not use an ITA retractor because opening an ITA retractor has significant risk of traction injury in the proximal aspect of both ITAs. Great care was taken to avoid excessive traction over half of the sternum due to the risk of the injury to the proximal portion of the left ITA and, likewise, the right ITA was harvested. The proximal portions of both ITAs were adequately dissected in the surgical field by retracting the manubrium towards the cranium. The entire lengths of both ITAs were harvested by the skeletonized technique using an ultrasonic vibration scalpel (Harmonic Scalpel, Ethicon Endo-Surgery Inc., Cincinnati, OH, USA). A sternal retractor was placed, the pericardium was opened, and a five-vessel conventional CABG (right ITA to the left descending artery, left ITA to diagonal branch, radial artery to the obtuse marginal artery and left posterolateral branch (sequential bypass), and saphenous vein to the posterior descending artery). The intact manubrium did not interfere with the procedure (Supplementary Videos 2 and 3). To close the sternum, the sternal body was reapproximated in the midline with four stainless steel wires, and a sternal lock cable (Biomet Microfixation, Inc., Jacksonville, FL, USA) was placed between the manubrium and the body of the sternum.

The patient had an uneventful postoperative course without any evidence of wound infection or mediastinitis (Fig. 2). Postoperative multidetector computed tomography showed that all bypass grafts were patent (Fig. 3). The patient was discharged on postoperative day 12.

Fig. 2.

The midline incision is away from the tracheostoma

Fig. 3.

Postoperative MDCT image. All grafts were patent. The MDCT image corresponds to the left anterior oblique 60 (A) and the right anterior oblique 40° (B), respectively. Dx, diagonal branch; LAD, left anterior descending artery; LITA, left internal thoracic artery; MDCT, multidetector computed tomography; RA, radial artery; RITA, right internal thoracic artery; SVG, saphenous vein graft

Discussion

Median full sternotomy in patients who had previously undergone total laryngectomy and permanent tracheostomy may lead to wound infection, osteomyelitis, mediastinitis, bleeding, and tracheal injury. Therefore, MSS [1–3], transverse bilateral thoracotomy [4, 5], and LAT [6] have been suggested as alternatives. In coronary artery disease (CAD) involving multiple vessels, transverse bilateral thoracotomy may sometimes need to be supplemented with an additional incision (e.g., inferior sternotomy) [5]. Although it is difficult to expose the posterior descending branch in multivessel CAD using LAT in off-pump CABG, on-pump CABG via LAT can achieve complete revascularization in patients with multivessel CAD [7]. When off-pump CABG is challenging or difficult, on-pump CABG via LAT is an effective technique to achieve complete revascularization in all patients, except patients with porcelain aorta [8]. On the other hand, the right ITA in CABG via LAT would be difficult to harvest under direct vision. Moreover, intricate instruments such as endoscopic assist device, special retractors, or long surgical instruments are needed to achieve complete revascularization in CABG via LAT. We prefer to use bilateral ITAs to improve survival after CABG in multivessel CAD [9]. We hesitated to use on-pump CABG via LAT because of the technical difficulty of harvesting the right ITA. However, this approach has the potential to become an alternative standard for surgical coronary revascularization. Hybrid myocardial revascularization (HCR) is another alternative approach for the treatment of high-risk patients with CAD [10]. HCR may reduce in-hospital complications and length of hospital stay and improve patient satisfaction compared with conventional CABG. Moreover, HCR may offer durability and surgical advantages when using the left ITA. However, the safety, efficacy, and cost-effectiveness of HCR remain unknown [10]. Appropriately powered randomized trials are required to prove the effectiveness of HCR.

Ricci et al. described a case of off-pump CABG in a patient with MSS without skin flaps [1]. Freeland et al. proposed the use of transverse skin flaps because of the retraction limitation for ITA harvesting [2]. In this case, with gentle elevation of the sternum, or the manubrium, using two blunt pronged Kocher retractors by the surgical assistant, we obtained sufficient exposure of the proximal ITA without skin flaps. We did not use an ITA retractor because of the significant risk of traction injury in the proximal aspect of both ITAs. Kasai et al. previously described the usefulness of off-pump CABG in MSS, as it eliminates the need to place the aortic cannula and the aortic cross-clamp [3]. However, in this case, the intact manubrium did not interfere with harvesting the bilateral ITAs, cannulation of the ascending aorta, cross-clamping of the aorta, and anastomosis of several grafts to target vessels.

In conclusion, we performed conventional CABG with bilateral ITAs via MSS in a patient who had undergone total laryngectomy and permanent tracheostomy. We believe that this approach is safe for patients with total laryngectomy and permanent tracheostoma.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contribution

Writing—original draft preparation: KI. Writing—review and editing: TO, RN, TF, YH, SM, and AS. Supervision: KI.

Funding

None.

Declarations

Ethics approval

This study complied with the principles of the Declaration of Helsinki and was approved by the institute ethics committee.

Consent to participate

Written informed consent was obtained from the patient.

Consent for publication

The authors affirm that human research participants provided informed consent for publication of the image in Figs. 1, 2, and 3 and supplementary video 1, 2, and 3. The participant has consented to the submission of the case report to the journal.

Conflict of interest

The authors declare no competing interests.