Patrique Segers

Major bleeding during negative pressure wound/V.A.C.® - therapy for postsurgical deep sternal wound infection - a critical appraisal

Negative-pressure wound therapy, commercially known as vacuum-assisted closure (V.A.C.®) therapy, has become one of the most popular (and efficacious) interim (prior to flap reconstruction) or definite methods of managing deep sternal wound infection. Complications such as profuse bleeding, which may occur during negative-pressure therapy but not necessarily due to it, are often attributed to a single factor and reported as such. However, despite the wealth of clinical experience internationally available, information regarding certain simple considerations is still lacking. Garnering information on all the factors that could possibly influence the outcome has become more difficult due to a (fortunate) decrease in the incidence of deep sternal wound infection. If more insight is to be gained from fewer clinical cases, then various potentially confounding factors should be fully disclosed before complications can be attributed to the technique itself or improvements to negative-pressure wound therapy for deep sternal wound infection can be accepted as evidence-based and the guidelines for its use adapted. The authors propose the adoption of a simple checklist in such cases.

Randomized clinical trial comparing two options for postoperative incisional care to prevent poststernotomy surgical site infections

Surgical site infection (SSI) remains an important complication of cardiac surgery. Prevention is important, as SSI is associated with high mortality and morbidity rates. Incisional care is an important daily issue for surgeons. However, there is still scant scientific evidence on which guidelines can be based. A randomized clinical trial was performed to compare two options for postoperative incisional care. Patients undergoing sternotomy for cardiothoracic surgery were eligible. To protect an incision from exogenous contamination or direct inoculation by endogenous pathogens, the study group received an adhesive drape, impermeable to water and air. The control group was treated with a water‐ and air‐permeable absorbent dressing. Primary outcome measure was SSI. Between March 2003 and January 2005, 1,185 patients were included. Both groups were comparable for base‐line characteristics. No significant difference was found in the incidence of sternal SSI between groups (2.6 vs. 3.3%). In our study, an incisional‐care program using a sterile, impermeable adhesive drape did not perform better than an absorbent dressing in reducing SSI after cardiothoracic surgery. In our view, future studies in the field of prevention of SSI should concentrate on other areas of interest.

Kawasaki disease causing saccular aneurysms of the coronary arteries

A 22-year-old man was referred for treatment of a 45 mm saccular aneurysm of the right coronary artery (RCA) and a 15 mm saccular aneurysm of the left anterior descending artery (LAD). The patient developed Kawasaki disease in 1998. The aneurysms were diagnosed in 2002. The RCA showed thrombus formation. Until now the patient had remained asymptomatic. He now presented with effort angina. On coronary angiography and magnetic resonance imaging, an occluded aneurysm of the proximal RCA (45 mm) was seen with a second aneurysm more distally (22 mm).