Arteriovenous Loop–Independent Free Flap Reconstruction of Sternal Defects after Cardiac Surgery

Abstract

Background Sternal defects following deep wound infections are predominantly reconstructed using local and regional flaps. The lack of appropriate recipient vessels after cardiac surgery may explain the minor role of free flaps. To date, arteriovenous loops have been the leading solution to enable microsurgical closure of these defects. However, the related surgical effort and the risk of flap failure are increased. We reviewed our experiences with the right gastroepiploic vessels as alternative recipient vessels for free flap reconstructions. Methods Between September 2010 and July 2015, 12 patients suffering deep wound infection after cardiac surgery underwent sternal reconstruction with free flaps anastomosed to the right gastroepiploic vessels. Gracilis flaps (n = 8) and anterolateral thigh perforator flaps (n = 4) were used for sternal reconstruction. Recipient vessels were harvested by laparoscopic dissection in five patients. Half of the free flaps were variably combined with omental flow-through flaps. Results Healing of all flaps was uneventful with no partial or total flap loss. Simultaneous interdisciplinary harvesting of recipient vessels by laparoscopy significantly shortened mean operative time from 313 to 216 minutes (p = 0.018). One incisional hernia was observed in the laparotomy group. Revision of a gracilis donor site was necessary in another patient due to postoperative bleeding. No recurrent sternal infection occurred during a mean follow-up of 20 months (range, 3-59 months). Conclusions The concept of gastroepiploic recipient vessels allows reliable free flap reconstructions of sternal defects in such high-risk patients without the need for arteriovenous loops.

Sternal reconstruction after post-sternotomy mediastinitis

“…There was a 47% survival, with postoperative renal failure requiring dialysis and septic shock requiring vasopressors the greatest risk factors for death [ 56 ]. Dorseifer et al looked beyond the pedicled local and regional grafts and arteriovenous microsurgical loops and reported 12 patients with DSWIs who underwent gracilis ( n = 8) and anterolateral thigh perforator free flaps ( n = 4) anastomosed to the right gastroepiploic vessels harvested in 42% patients laparoscopically with uneventful healing [ 57 ]. Kaul et al described a chronic encapsulated anterior mediastinal abscess presenting with remote cutaneous fistulisation 12 years after redo aortic valve replacement for prosthetic valve endocarditis.…”

Extending the Indication of the Superior Thyroid Artery as a Recipient Vessel for Complex Upper Body Defects

“…While studies have positively commented on the advantages of its use, and although it has been shown to be an adequate alternative for an AV loop, vessel harvesting requires laparoscopy or laparotomy. 31 Although severe chest defects already cause comprised respiratory biomechanics, laparotomy further hinders respiration. 32 Additionally, this procedure bears the risk of intestinal injuries or development of incisional hernias.…”

“…These include preparation of the right gastroepiploic vessel as a recipient for free tissue transfer. While studies have positively commented on the advantages of its use, and although it has been shown to be an adequate alternative for an AV loop, vessel harvesting requires laparoscopy or laparotomy 31 . Although severe chest defects already cause comprised respiratory biomechanics, laparotomy further hinders respiration 32 .…”

Free Flaps in Sternal Osteomyelitis After Median Sternotomy: A Center's 12-Year Experience

“…18 There have also been a number of reports on the application of free flaps for the defect coverage after DSWI, such as the free LD, free tensor fascia lata, and free rectus abdominis flap with an ongoing debate on the optimal recipient vessels. [19][20][21][22][23][24][25] Further, there is a continuing discussion regarding the timing of reconstruction of these wounds, with several reports favoring early reconstruction over delayed, [26][27][28] as well as the use of open and incisional negative-pressure wound therapy. 6,29 Another aspect in the discussion of a preferred flap in sternal wound reconstruction is the type of flap tissue.…”