Risk Factors for Sternal Complications After Cardiac Operations: A Systematic Review

doi:10.1016/j.athoracsur.2016.05.047

The Annals of Thoracic Surgery

Volume 102, Issue 6, December 2016, Pages 2109-2117

https://doi.org/10.1016/j.athoracsur.2016.05.047 Get rights and content

Early detection of patients at risk of sternal complications is essential to facilitate prevention and optimize timely intervention. A systematic review and meta-analysis was conducted to identify risk factors associated with sternal complications. The review included 17 full-text studies, of which 10 were entered into meta-analyses. Female gender, diabetes mellitus, obesity, bilateral internal mammary artery grafts, reoperation for postoperative complications, and blood product requirement were reported as significant predictors of sternal infection. The compilation of these risk factors may help to screen and stratify patients at risk of impaired sternal healing and warrants further investigation.

Section snippets

Material and Methods

The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines [18].

Results

The primary literature search identified 1,983 studies, of which 425 were duplicates. After the application of the primary and secondary screening criteria, 17 full-text studies were included in the final review, of which 10 were entered into meta-analyses (Fig 1). The κ statistics for agreement between the 2 independent assessors for the primary and secondary screening processes were 0.90 (91% percentage agreement) and 0.81 (82% percentage agreement), respectively. The Supplementary Material

Comment

This is the first study to systematically analyze and critically appraise the literature pertaining to risk factors for sternal complications in patients after cardiac operations. It included a subgroup analysis for risk factors associated with sternal instability and infection as separate clinical entities as well as meta-analyses to identify the significance of these risk factors.

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Citation Excerpt :
Our results suggest that BMI, HbA1c, female sex, PVD, current smoking status, and creatinine level all represent significant risk for the development of DSW after median sternotomy. Although this generally agrees with the previous literature,4,13,14 our study is the first to further stratify adjusted risk according to specific BMI and HbA1C categories. On the basis of our model, factors that appear to be most strongly associated with DSW are either nonmodifiable, such as female sex or PVD, or difficult to modify, such as smoking status, extreme BMI, or HbA1c.
Severe deep sternal wound (DSW) complications after cardiac surgery are a source of cost, morbidity, and mortality. Our objective was to develop and validate a clinical risk score for predicting risk of DSW requiring operative bone debridement, the most severe form of sternal dehiscence.
A retrospective review was conducted of patients who underwent open cardiac surgery at a single institution between October 2007 and March 2019. Primary outcome was DSW requiring sternal bone debridement. Potential risk factors were screened using Least Absolute Shrinkage and Selection Operator (LASSO) and significant covariates were included in a logistic regression prediction model. Interval validation was performed using 10-fold cross-validation. A novel sternal wound dehiscence risk score was derived from the relative parameterization estimates.
One hundred thirty-four of 8403 patients (1.6%) were identified as having a DSW. Female sex (odds ratio [OR], 2.75; 95% CI, 2.58-2.93), body mass index (OR, 1.0946; 95% CI, 1.09-1.09), percent glycated hemoglobin (OR, 1.31; 95% CI, 1.28-1.33), peripheral vascular disease (OR, 2.38; 95% CI, 2.2005-2.5752), smoking (OR, 1.66; 95% CI, 1.53-1.79) and elevated creatinine level (OR, 1.20; 95% CI, 1.18-1.22) were independent predictors of DSW. Patients were categorized as minimal risk (0%-1%), low risk (2%-3%), intermediate risk (4%-7%), and high risk (9%-64.0%) on the basis of risk score.
This risk stratification model for DSW requiring operative debridement might provide individualized estimates of risk, and guide counseling and potential risk mitigation strategies.
Coronary artery bypass grafting using bilateral internal thoracic arteries in patients with diabetes and obesity: A systematic review and meta-analysis
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Patients with diabetes and obesity are at higher risk of adverse long-term outcomes following coronary artery bypass grafting. The use of bilateral internal thoracic arteries (BITA) can potentially offer survival benefit in higher risk patients compared to single internal thoracic artery (SITA), but BITA is not routinely used due to lack of clear evidence of efficacy and concerns over sternal wound complications.
Medline, Embase and the Cochrane Library were searched for studies comparing the efficacy and safety of BITA and SITA grafting in patients with diabetes and obesity. Meta-analysis of mortality and sternal wound complications was performed.
We identified eight observational and ten propensity matched studies, and one RCT, comparing BITA and SITA which included patients with diabetes (n = 19,589); two propensity matched studies and one RCT which included patients with obesity (n = 6,972); mean follow up was 10.5 and 11.3 years respectively. Meta-analysis demonstrated a mortality reduction for BITA compared to SITA in patients with diabetes (risk ratio [RR] 0.79; 95% confidence interval [CI] 0.70–0.90; p = 0.0003). In patients with obesity there was a non-significant reduction in mortality in the BITA group (RR 0.73, 95% CI 0.47–1.12; p = 0.15). There was a significantly higher rate of sternal wound complications following BITA observed in patients with diabetes (RR 1.53, 95% CI 1.23–1.90; p = 0.0001) and obesity (RR 2.24, 95% CI 1.63–3.07; p < 0.00001).
BITA is associated with better long-term survival in patients with diabetes. The effects of BITA grafting in patients with obesity are uncertain. BITA is associated with higher rates of sternal wound complications compared to SITA in both patients with diabetes and obesity.
Risk factors for post sternotomy wound complications across the patient journey: A systematised review of the literature
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Citation Excerpt :
Risk scoring or stratification has been widely adopted as a method of predicting outcome within cardiac surgery. Using risk assessment tools to assist in the identification of patients at risk of developing an SSI is beneficial; highlighting patients to facilitate prevention and optimize timely intervention.13 There are a number of risk tools, such as the widely used Society of Thoracic Surgeon's (STS) risk calculator,24 or the Toronto Risk Score.47
Around 36,000 cardiac operations are undertaken in the United Kingdom annually, with most procedures undertaken via median sternotomy. Wound complications occur in up to 8% of operations, with an associated mortality rate of around 47% in late or undetected cases.
To undertake a systematised literature review to identify pre-operative, peri-operative and post-operative risk factors associated with sternal wound complications.
Healthcare databases were searched for articles written in the English language and published between 2013 and 2021. Inclusion criteria were quantitative studies involving patients undergoing median sternotomy for cardiac surgery; sternal complications and risk factors.
1360 papers were identified, with 25 included in this review. Patient-related factors included: high BMI; diabetes; comorbidities; gender; age; presenting for surgery in a critical state; predictive risk scores; vascular disease; severe anaemia; medication such as steroids or α-blockers; and previous sternotomy. Peri-operative risk increased with specific types and combinations of surgical procedures. Sternal reopening was also associated with increased risk of sternal wound infection. Post-operative risk factors included a complicated recovery; the need for blood transfusions; respiratory complications; renal failure; non-diabetic hyperglycaemia; sternal asymmetry and sepsis.
Pre, peri and post-operative risk factors increase the risk of sternal wound complications in cardiac surgery. Generic risk assessment tools are primarily designed to provide mortality risk scores, with their ability to predict risk of wound infection questionable. Tools that incorporate factors throughout the operative journey are required to identify patients at risk of surgical wound infection.
Non-Tumorous Diseases of the Sternum and Its Articulations: At the Front Gate of the Chest
2022, Current Problems in Diagnostic Radiology
Abnormalities of the sternal and peri-sternal regions are commonly seen in clinical practice and may be one of the important causes of chest pain particularly anterior chest wall pain. While reading computed tomography (CT) of the chest for evaluation of chest pain, the sternal region is either easily overlooked or its abnormality is often detected incidentally. This article will provide an overview of normal sternal anatomy and congenital variants as well as a variety of non-tumorous pathologic conditions of the sternum and adjacent joints, with emphasis on CT, to help radiologists, particularly thoracic radiologists, to make an accurate diagnosis in their daily practice. Non-tumorous abnormalities include trauma (fractures and dislocations), infection (osteomyelitis, septic arthritis), degenerative (osteoarthritis) and inflammatory conditions (rheumatoid arthritis, seronegative arthritides), and metabolic disorders (Paget's disease and renal osteodystrophy) as well as treatment related changes such as poststernotomy and its complications (dehiscence, nonunion) and postradiation changes of the sternum.
Coronary Artery Bypass Surgery After Transradial Catheterization: Implementing 2021 ACC/AHA/SCAI Revascularization Guidelines Into Clinical Practice
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The 2021 ACC/AHA/SCAI coronary artery disease revascularization guideline recommends radial artery (RA) access for coronary angiography and RA grafting over saphenous vein grafting in patients referred for coronary artery bypass grafting. We present a case of a patient who underwent coronary angiography via both RAs and therefore could not receive RA bypass grafts. (Level of Difficulty: Advanced.)

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ReviewRisk Factors for Sternal Complications After Cardiac Operations: A Systematic Review

Section snippets

Material and Methods

Results

Comment

Arch Phys Med Rehabil

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Epilepsy Res

J Thorac Cardiovasc Surg

Chest

Ann Thorac Surg

Semin Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Plast Reconstr Aesthet Surg

Am J Infect Control

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Am J Med

Am J Kidney Dis

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

A biomechanical study of median sternotomy closure techniques

Eur J Cardiothorac Surg

Sternal instability after midline sternotomy

J Thorac Cardiovasc Surg

Disruption and infection of median sternotomy: a comprehensive review

Eur J Cardiothorac Surg

Sternal reconstruction with titanium plates in complicated sternal dehiscence

Eur J Cardiothorac Surg

Sternal precautions: is it time for change? Precautions versus restrictions- a review of literature and recommendations for revision

Cardiopulm Phys Ther J

Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care

Ann Thorac Surg

Review
Risk Factors for Sternal Complications After Cardiac Operations: A Systematic Review