We describe an exceptional case of non-fatal septic rupture of the ascending aorta in a patient with sternal dehiscence, deep sternal wound infection (DSWI) and pleural empyema after aortocoronary bypass surgery. Routine follow-up computed tomography (CT) detected a mediastinal pseudoaneurysm originating from the ascending aorta. Thereby, massive and irregular sternal bone defects and contrast-enhancing mediastinal soft tissue suggest osteomyelitis and highly-active and aggressive DSWI as initial triggers. Urgent thoracotomy 1 day later included ascending aorta reconstruction, total sternum resection and broad wound debridement. Follow-up CT 1 year later showed a regular postoperative result in a fully recovered patient

AH Kiessling

Boris A Radeleff

C Schimmer

Christof M Sommer

CS Hollenbeak

D El-Ansary

Goetz M Richter

Hans U Kauczor

IK Toumpoulis

KH Orend

M De Feo

RF Di Marco Jr

Tobias Heye

Ulrike Stampfl

Ursula Tochtermann

Y Sugawara

English

PubMed

Abstract We describe an exceptional case of non-fatal septic rupture of the ascending aorta in a patient with sternal dehiscence, deep sternal wound infection (DSWI) and pleural empyema after aortocoronary bypass surgery. Routine follow-up computed tomography (CT) detected a mediastinal pseudoaneurysm originating from the ascending aorta. Thereby, massive and irregular sternal bone defects and contrast-enhancing mediastinal soft tissue suggest osteomyelitis and highly-active and aggressive DSWI as initial triggers. Urgent thoracotomy 1 day later included ascending aorta reconstruction, total sternum resection and broad wound debridement. Follow-up CT 1 year later showed a regular postoperative result in a fully recovered patient.</p

Radeleff Boris A

Tochtermann Ursula

Stampfl Ulrike

Heye Tobias

Sommer Christof M

Kauczor Hans U

Richter Goetz M

Directory of Open Access Journals

Journal of Cardiothoracic Surgery

Septic rupture of the ascending aorta after aortocoronary bypass surgery

Springer - Publisher Connector

BioMed CentralJournal of Cardiothoracic Surgery
ssOpen AcceCase report
Septic rupture of the ascending aorta after aortocoronary bypass 
surgery
Christof M Sommer*1, Tobias Heye1, Ulrike Stampfl1, Ursula Tochtermann2, 
Boris A Radeleff1, Hans U Kauczor1 and Goetz M Richter1
Address: 1Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany and 2Department of 
Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
Email: Christof M Sommer* - christof.sommer@med.uni-heidelberg.de; Tobias Heye - tobias.heye@med.uni-heidelberg.de; 
Ulrike Stampfl - ulrike.stampfl@med.uni-heidelberg.de; Ursula Tochtermann - ursula.tochtermann@med.uni-heidelberg.de; 
Boris A Radeleff - boris.radeleff@med.uni-heidelberg.de; Hans U Kauczor - hu.kauczor@med.uni-heidelberg.de; 
Goetz M Richter - goetz.richter@med.uni-heidelberg.de
* Corresponding author    
Abstract
We describe an exceptional case of non-fatal septic rupture of the ascending aorta in a patient with
sternal dehiscence, deep sternal wound infection (DSWI) and pleural empyema after
aortocoronary bypass surgery. Routine follow-up computed tomography (CT) detected a
mediastinal pseudoaneurysm originating from the ascending aorta. Thereby, massive and irregular
sternal bone defects and contrast-enhancing mediastinal soft tissue suggest osteomyelitis and
highly-active and aggressive DSWI as initial triggers. Urgent thoracotomy 1 day later included
ascending aorta reconstruction, total sternum resection and broad wound debridement. Follow-up
CT 1 year later showed a regular postoperative result in a fully recovered patient.
Background
Sternal dehiscence is a frequent complication after aorto-
coronary bypass surgery with an incidence estimated at
1% to 6% in a normal population [1]. When complicated
by sternum osteomyelitis and DSWI, prolonged hospital-
ization and increased cost of care, morbidity and mortal-
ity as high as 20% is reported [2]. Broken wire fixations
and displaced bone fragments with non-physiological
sternal movement seem to be essential in its pathogenesis
[3]. Obesity, diabetes mellitus, chronic obstructive pul-
monary disease and previous sternotomy make up the
major risk factors [4]. Despite antibiotic therapy and
aggressive surgical interventions, the prognosis is serious
[5]. In this case report, we describe a patient developing
non-fatal septic rupture of the ascending aorta with medi-
astinal pseudoaneurysm triggered by sternum osteomyeli-
tis and extensive DSWI after aortocoronary bypass
surgery.
Case presentation
A 65-year-old male white was referred to our department
for routine follow-up CT for sternal dehiscence, DSWI and
pleural empyema developing after aortocoronary bypass
operation 9 months before. His history included congen-
ital portal vein stricture with recurrent ascites, acute myo-
cardial infarction 4 months ago, systemic hypertension,
hypercholesteremia, renal insufficiency, penicillin allergy
and methicillin-resistant staphylococcus aureus in the
blood culture. Medication consisted of spironolactone,
metoprolol succinate, furosemide, ramipril, acetylsali-
cylate, zinc aspartate and zolpidem tartrate. Physical
examination was carried out in the Department of Cardiac
Published: 16 December 2008
Journal of Cardiothoracic Surgery 2008, 3:64 doi:10.1186/1749-8090-3-64
Received: 17 July 2008
Accepted: 16 December 2008
This article is available from: http://www.cardiothoracicsurgery.org/content/3/1/64
© 2008 Sommer et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 3
(page number not for citation purposes)
Journal of Cardiothoracic Surgery 2008, 3:64 http://www.cardiothoracicsurgery.org/content/3/1/64Surgery right before the CT and revealed pressure-like pec-
toral pain and non-physiological sternal movement. Lab-
oratory showed elevated c-reactive protein (58 mg/l),
ferritin (1450 μg/l) and gamma-glutamyl transferase (77
U/l), whereas choline esterase (3110 U/l) and hemo-
globin (12.5 g/dl) were reduced. Electrocardiogram and
tropoine T were unremarkable. CT detected massive ster-
nal bone defects, inhomogenous bone matrix and irregu-
lar sternotomy edges as evidence for long-lasting chronic
osteomyelitis (Figure 1). Clearly contrast-enhancing soft
tissue in the upper and anterior mediastinum documeted
highly-active and aggressive DSWI (Figure 2A, B). An oval-
shaped massive contrast-enhancing retrosternal mass
directly within the DSWI with narrow connection to the
ascending aorta indicated a mediastinal pseudoaneurysm
(Figure 2). Because hyperacute aortic rupture was unlikely
due to postoperative mediastinal scarring, the patient
underwent urgent thoracotomy 1 day later. Ascending
aorta reconstruction with insertion of a pericardial patch,
total sternum resection, broad wound debridement inclu-
sive of soft tissue reconstruction with a pectoralis plastic
was carried out. Intraoperative mediastinal bacterial
smear tests verified existence of methicillin-resistant sta-
phylococcus aureus. Postoperative CT 2 days later demon-
strated a proper thoracic aorta. 12 days later, the patient
was transferred from intensive care unit to ward. Another
8 days later, he was admitted to a peripher hospital in
good clinical condition. Outpatient routine follow-up CT
1 year later documented a regular postoperative result in a
fully recovered patient.
Conclusion
Midline sternotomy is by far the most common surgical
approach in cardiac surgery. One disadvantage of this
technique is the relatively frequent occurence of sternal
dehiscence with instability [1]. It is described as non-
physiological sternal movement after disruption of wire
fixations [3]. Because of its decreased blood supply, espe-
cially the lower sternal third is affected. Moreover, utiliza-
tion of the internal mammary artery for coronary artery
bypass grafting leads to additional and acute reduction of
the sternal blood supply [6]. When this situation is com-
plicated by infection, which occurs especially in patients
with immunosuppression, sternum osteomyelitis and
DSWI might develop as devastating complications despite
strict sterility and antibiotic prophylaxis [7]. In case of
aggressive mediastinal propagation, cardiac suture lines
might be eroded with septic shock or hemorrhage as fatal
Sternum osteomyelitisFigure 1
Sternum osteomyelitis. CT 3D-reconstruction shows 
massive sternal bone defects, inhomogenous bone matrix 
and irregular sternotomy edges (white arrows) as evidence 
for long-lasting chronic osteomyelitis
DSWI with pseudoaneurysmFigure 2
DSWI with pseudoaneurysm. CT axial (A) and sagittal 
(B) reconstructions show clearly contrast-enhancing soft tis-
sue in the upper and anterior mediastinum (areas encirceled 
by white lines); ascending aorta (Ao), pseudoaneurysm 
(asterisk), left ventricle (LV) and massive sternal bone defects 
(white arrows).Page 2 of 3
(page number not for citation purposes)
Journal of Cardiothoracic Surgery 2008, 3:64 http://www.cardiothoracicsurgery.org/content/3/1/64Publish with BioMed Central   and  every 
scientist can read your work free of charge
"BioMed Central will be the most significant development for 
disseminating the results of biomedical research in our lifetime."
Sir Paul Nurse, Cancer Research UK
Your research papers will be:
available free of charge to the entire biomedical community
peer reviewed and published immediately upon acceptance
cited in PubMed and archived on PubMed Central 
yours — you keep the copyright
Submit your manuscript here:
http://www.biomedcentral.com/info/publishing_adv.asp
BioMedcentral
complications [7]. It is well known, that continuous bac-
terial spread from or within a soft tissue compartment
might cause vascular infection characterized as bacterial
aortitis, infected aorta, ruptured mycotic aneurysm or
spontaneous non-aneurysmal suppurative vascular rup-
ture [8]. Sugawara et al. described a ruptured abdominal
aorta secondary to klebsiella pneumonia psoas muscle
abscess [9]. The typical mechanism of aortic rupture,
which is expansion of an atherosclerotic aneurysm, is vir-
tually impossible in our patient. Neither the short period
of only 9 months nor pseudoaneurysm configuration
directly within the DSWI support this. Much more proba-
ble is chronic septic vascular erosion resulting in aortic
rupture with pseudoaneurysm formation. Aggressive sur-
gical interventions with broad wound debridement, plas-
tic reconstruction, bone removal and mediastinal
irrigation with antiseptic solutions in combination with
intravenous antibiotic therapy seem to be the only chance
to control extensive sternal osteomyelitis with DSWI and
to prevent even worse complications [5]. Accomplished in
our patient, admission to a peripher hospital was possible
in good clinical condition 22 days later and outpatient
routine follow-up CT 1 year later documented a regular
postoperative result in a fully recovered patient.
Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
CMS conceived the study. TH prepared the figures. CMS
and TH performed the CT-examination. CMS and US did
the background literature search and drafted the manu-
script. UT was the cardiac surgeon. BAR participated in
study design and coordination. HUK and GMR were
involved in the conception of the study and the critical
review of the intellectual content of the manuscript. All
authors have read and approved the final manuscript.
References
1. Kiessling AH, Isgro F, Weisse U, Moltner A, Saggau W, Boldt J:
Advanced sternal closure to prevent dehiscence in obese
patients.  Ann Thorac Surg 2005, 80:1537-1539.
2. Hollenbeak CS, Murphy DM, Koenig S, Woodward RS, Dunagan WC,
Fraser VJ: The clinical and economic impact of deep chest sur-
gical site infections following coronary artery bypass graft
surgery.  Chest 2000, 118:397-402.
3. El-Ansary D, Waddington G, Adams R: Measurement of non-
physiological movement in sternal instability by ultrasound.
Ann Thorac Surg 2007, 83:1513-1516.
4. Schimmer C, Reents W, Elert O: Primary closure of median ster-
notomy: a survey of all German surgical heart centers and a
review of the literature concerning sternal closure tech-
nique.  Thorac Cardiovasc Surg 2006, 54:408-413.
5. De Feo M, Renzulli A, Ismeno G, Gregorio R, Della Corte A, Utili R,
Cotrufo M: Variables predicting adverse outcome in patients
with deep sternal wound infection.  Ann Thorac Surg 2001,
71:324-331.
6. Di Marco RF Jr, Lee MW, Bekoe S, Grant KJ, Woelfel GF, Pellegrini
RV: Interlocking figure-of-8 closure of the sternum.  Ann Thorac
Surg 1989, 47:927-929.
7. Toumpoulis IK, Anagnostopoulos CE, Derose JJ Jr, Swistel DG: The
impact of deep sternal wound infection on long-term sur-
vival after coronary artery bypass grafting.  Chest 2005,
127:464-471.
8. Orend KH, Storck M, Brandl R, Becker HM: Non-aneurysmal sup-
purative aortic rupture.  Eur J Vasc Endovasc Surg 1995,
10:118-121.
9. Sugawara Y, Sato O, Miyata T, Kimura H, Yamaoka M, Uozaki H, Oka
T, Makuuchi M: Ruptured abdominal aorta secondary to psoas
muscle abscess due to Klebsiella pneumoniae in an alcoholic.
J Infect 1997, 35:185-188.Page 3 of 3
(page number not for citation purposes)


Crossref

Advanced sternal closure to prevent dehiscence in obese patients. Ann Thorac Surg

Cotrufo M: Variables predicting adverse outcome in patients with deep sternal wound infection. Ann Thorac Surg

Elert O: Primary closure of median sternotomy: a survey of all German surgical heart centers and a review of the literature concerning sternal closure technique. Thorac Cardiovasc Surg

HM: Non-aneurysmal suppurative aortic rupture. Eur J Vasc Endovasc Surg

Measurement of nonphysiological movement in sternal instability by ultrasound. Ann Thorac Surg

Ruptured abdominal aorta secondary to psoas muscle abscess due to Klebsiella pneumoniae in an alcoholic.

RV: Interlocking figure-of-8 closure of the sternum. Ann Thorac Surg

Swistel DG: The impact of deep sternal wound infection on long-term survival after coronary artery bypass grafting. Chest

VJ: The clinical and economic impact of deep chest surgical site infections following coronary artery bypass graft surgery. Chest

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2614984

Septic rupture of the ascending aorta after aortocoronary bypass surgery

Abstract

Similar works

Full text

Available Versions

Directory of Open Access Journals

Springer - Publisher Connector

Crossref