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KEY FACTS
Terminology
Imaging
Clinical Issues
Diagnostic Checklist
TERMINOLOGY
Abbreviations
- Median sternotomy (MS)
- Clamshell sternotomy (CS)
Synonyms
- CS: Transverse sternotomy, cross-bow incision
Definitions
- MS: Vertical incision through manubrium and sternum
- Access to heart and anterior/prevascular mediastinum
- Limited access to hila, lungs, pleura
- Indications
- Cardiac and aortic surgery
- Coronary artery bypass graft (CABG) most common
- Ascending aortic aneurysm or dissection
- Cardiac valve repair or replacement
- Chest trauma exploration
- Pulmonary embolectomy
- Resection of anterior/prevascular mediastinal mass
- Double lung transplant in some cases
- Cardiac and aortic surgery
- Closure with cerclage or "figure 8" steel sutures
- 2-3 wires in manubrium, 4-5 in sternum body
- Heals quickly with stable closure and minimal pain
- Stainless-steel wire sutures: Single wire, double wire, figure-of-eight, Robicsek weave
- Other
- Sternal bands
- Polymer cable ties
- Sternal plates
- Transverse rigid sternal plate fixation: May improve outcomes in patients at high risk for dehiscence, such as morbidly obese patients
- Access to heart and anterior/prevascular mediastinum
- CS: Broad transverse incision across sternum and 4th anterior intercostal spaces
- Excellent access to heart and both hemithoraces
- Disrupts sternal pericardial attachments
- Pleural spaces may communicate anteriorly
- Chest tube may cross midline anteriorly
- Indications
- Double lung or heart-lung transplantation
- Resection of large mediastinal or cardiac mass
- Resection of bilateral lung metastases (rare)
- Disrupts sternal pericardial attachments
- Closure with steel "figure 8" sternal sutures
- Extensive disruption of chest wall musculature
- Increased risk of sternal complications
- Excellent access to heart and both hemithoraces
- MS: Vertical incision through manubrium and sternum
IMAGING
General Features
Radiographic Findings
CT Findings
Imaging Recommendations
CLINICAL ISSUES
Presentation
Natural History & Prognosis
Treatment
DIAGNOSTIC CHECKLIST
Consider
Image Interpretation Pearls
Selected References
- Madjarov JM et al: Median sternotomy after sternal reconstruction with bilateral longitudinal plating in a patient with osteoporosis. Heart Surg Forum. 23(1):E058-60, 2020
- Shudo Y et al: Impact of surgical approach in double lung transplantation: median sternotomy vs clamshell thoracotomy. Transplant Proc. 52(1):321-5, 2020
- Cataneo DC et al: New sternal closure methods versus the standard closure method: systematic review and meta-analysis. Interact Cardiovasc Thorac Surg. 28(3):432-40, 2019
- Foldyna B et al: Computed tomography improves the differentiation of infectious mediastinitis from normal postoperative changes after sternotomy in cardiac surgery. Eur Radiol. 29(6):2949-57, 2019
- Nenna A et al: Sternal wound closure in the current era: the need of a tailored approach. Gen Thorac Cardiovasc Surg. 67(11):907-16, 2019
- Valente T et al: MDCT prior to median re-sternotomy in cardiovascular surgery: our experiences, infrequent findings and the crucial role of radiological report. Br J Radiol. 92(1101):20170980, 2019
- Wang B et al: Analysis of sternal healing after median sternotomy in low risk patients at midterm follow-up: retrospective cohort study from two centres. J Cardiothorac Surg. 14(1):193, 2019
- Allen KB et al: Sternotomy closure using rigid plate fixation: a paradigm shift from wire cerclage. Ann Cardiothorac Surg. 7(5):611-20, 2018
- Losanoff JE et al: Primary closure of median sternotomy: techniques and principles. Cardiovasc Surg. 10(2):102-10, 2002
- Macchiarini P et al: Clamshell or sternotomy for double lung or heart-lung transplantation? Eur J Cardiothorac Surg. 15(3):333-9, 1999
- Bains MS et al: The clamshell incision: an improved approach to bilateral pulmonary and mediastinal tumor. Ann Thorac Surg. 58(1):30-2; discussion 33, 1994
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References
Tables
Tables
KEY FACTS
Terminology
Imaging
Clinical Issues
Diagnostic Checklist
TERMINOLOGY
Abbreviations
- Median sternotomy (MS)
- Clamshell sternotomy (CS)
Synonyms
- CS: Transverse sternotomy, cross-bow incision
Definitions
- MS: Vertical incision through manubrium and sternum
- Access to heart and anterior/prevascular mediastinum
- Limited access to hila, lungs, pleura
- Indications
- Cardiac and aortic surgery
- Coronary artery bypass graft (CABG) most common
- Ascending aortic aneurysm or dissection
- Cardiac valve repair or replacement
- Chest trauma exploration
- Pulmonary embolectomy
- Resection of anterior/prevascular mediastinal mass
- Double lung transplant in some cases
- Cardiac and aortic surgery
- Closure with cerclage or "figure 8" steel sutures
- 2-3 wires in manubrium, 4-5 in sternum body
- Heals quickly with stable closure and minimal pain
- Stainless-steel wire sutures: Single wire, double wire, figure-of-eight, Robicsek weave
- Other
- Sternal bands
- Polymer cable ties
- Sternal plates
- Transverse rigid sternal plate fixation: May improve outcomes in patients at high risk for dehiscence, such as morbidly obese patients
- Access to heart and anterior/prevascular mediastinum
- CS: Broad transverse incision across sternum and 4th anterior intercostal spaces
- Excellent access to heart and both hemithoraces
- Disrupts sternal pericardial attachments
- Pleural spaces may communicate anteriorly
- Chest tube may cross midline anteriorly
- Indications
- Double lung or heart-lung transplantation
- Resection of large mediastinal or cardiac mass
- Resection of bilateral lung metastases (rare)
- Disrupts sternal pericardial attachments
- Closure with steel "figure 8" sternal sutures
- Extensive disruption of chest wall musculature
- Increased risk of sternal complications
- Excellent access to heart and both hemithoraces
- MS: Vertical incision through manubrium and sternum
IMAGING
General Features
Radiographic Findings
CT Findings
Imaging Recommendations
CLINICAL ISSUES
Presentation
Natural History & Prognosis
Treatment
DIAGNOSTIC CHECKLIST
Consider
Image Interpretation Pearls
Selected References
- Madjarov JM et al: Median sternotomy after sternal reconstruction with bilateral longitudinal plating in a patient with osteoporosis. Heart Surg Forum. 23(1):E058-60, 2020
- Shudo Y et al: Impact of surgical approach in double lung transplantation: median sternotomy vs clamshell thoracotomy. Transplant Proc. 52(1):321-5, 2020
- Cataneo DC et al: New sternal closure methods versus the standard closure method: systematic review and meta-analysis. Interact Cardiovasc Thorac Surg. 28(3):432-40, 2019
- Foldyna B et al: Computed tomography improves the differentiation of infectious mediastinitis from normal postoperative changes after sternotomy in cardiac surgery. Eur Radiol. 29(6):2949-57, 2019
- Nenna A et al: Sternal wound closure in the current era: the need of a tailored approach. Gen Thorac Cardiovasc Surg. 67(11):907-16, 2019
- Valente T et al: MDCT prior to median re-sternotomy in cardiovascular surgery: our experiences, infrequent findings and the crucial role of radiological report. Br J Radiol. 92(1101):20170980, 2019
- Wang B et al: Analysis of sternal healing after median sternotomy in low risk patients at midterm follow-up: retrospective cohort study from two centres. J Cardiothorac Surg. 14(1):193, 2019
- Allen KB et al: Sternotomy closure using rigid plate fixation: a paradigm shift from wire cerclage. Ann Cardiothorac Surg. 7(5):611-20, 2018
- Losanoff JE et al: Primary closure of median sternotomy: techniques and principles. Cardiovasc Surg. 10(2):102-10, 2002
- Macchiarini P et al: Clamshell or sternotomy for double lung or heart-lung transplantation? Eur J Cardiothorac Surg. 15(3):333-9, 1999
- Bains MS et al: The clamshell incision: an improved approach to bilateral pulmonary and mediastinal tumor. Ann Thorac Surg. 58(1):30-2; discussion 33, 1994
