First Patient

In January 2019, a 69-year-old female patient with a history of coronary artery disease and type 1 diabetes was admitted to our hospital and underwent coronary artery bypass grafting (CABG) revascularization. The surgical procedure and the early postoperative period were uneventful. Three weeks following the surgery, the patient was readmitted due to a presternal infection, which was treated conservatively using systemic antibiotics. After one month, a negative microbiological culture was discovered, and debridement with pectoral plastic was performed. The postoperative phase was uneventful, and the patient was released home.

Several weeks later, the patient was admitted again, this time with a SCF in the lower part of the sternal wound filled with pus. Pseudomonas aeruginosa and Staphylococcus aureus were isolated from the wound swab. Debridement and excision of the fistula in the xiphoid part of the sternum were done, while the newly created defect was filled with vancomycin paste and extracellular matrix patch (ProxiCor®) (Figure 1A). The place of the defect was covered with fibrine glue, and the wound was closed by anatomic layers with single PDS® stitches (Figure 1B). Postoperative period and one-month local findings were both regular. Five-year follow-up has shown no recidivism after treatment.

Fig. 1 - Surgical reconstruction of sternocutaneous fistula in the first patient. A) Debridement and excision of the fistula, defect filled with vancomycin paste and extracellular matrix patch. B) Defect covered with fibrine glue.

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Fig. 1 - Surgical reconstruction of sternocutaneous fistula in the first patient. A) Debridement and excision of the fistula, defect filled with vancomycin paste and extracellular matrix patch. B) Defect covered with fibrine glue.

Second Patient

In September 2018, a 47-year-old male patient was admitted to our hospital and underwent CABG revascularization. The patient had a previous history of myocardial infarction and coronary artery disease and a low ejection fraction (35%). The surgical technique, early postoperative phase, and subsequent evaluations were unremarkable.

In June 2023, two SCFs developed in the sternal region with Staphylococcus aureus in microbiological culture. Additionally, the patient acquired grade 5 renal failure and required daily hemodialysis therapy. He was hospitalized, and several days later, we performed surgical procedures for SCFs. Following the typical preoperative protocol and surgical preparation, the incision was opened through all anatomical layers of the presternal region, revealing metal osteosynthesis stitches and two fistulas in the median portion of the sternum (Figure 2A). Metal stitches were removed, the presternal wound was debrided, and the fistula was resected. Extracellular matrix patches (ProxiCor®) and vancomycin paste were used to fill newly formed defects (Figure 2B). The extracellular matrix patch was sutured to the surrounding tissue (Figure 2C). The filled defects were covered using BioGlue®, and the wound was sutured with single PDS® stitches across anatomical layers (Figure 2D). The postoperative course was regular. Two months later, an examination showed that the wound was healing adequately. Six-month after-treatment follow-up has shown no recidivism, but unfortunately, eight months after treatment, the patient died because of multiple myeloma.

Fig. 2 - Surgical reconstruction of sternocutaneous fistula in the second patient. A) Detecting fistulas in the median portion of the sternum. B) Debridement of wound and resection of fistula, defect filled with extracellular matrix patch and vancomycin paste. C) Extracellular matrix patch sutured to the surrounding tissue. D) Defects covered with BioGlue®.

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Fig. 2 - Surgical reconstruction of sternocutaneous fistula in the second patient. A) Detecting fistulas in the median portion of the sternum. B) Debridement of wound and resection of fistula, defect filled with extracellular matrix patch and vancomycin paste. C) Extracellular matrix patch sutured to the surrounding tissue. D) Defects covered with BioGlue®.

Third Patient

In March 2023, a 66-year-old male patient was admitted to our hospital undergoing an elective CABG procedure. The medical history revealed developed coronary artery disease and diabetes mellitus type 2. We used both right and left mammary arteries and one venous saphenous graft for coronary revascularization. The CABG treatment followed a standard postoperative course, and the patient was discharged to home recovery.

The patient was readmitted in August 2023 due to wound dehiscence and SCF in the upper sternum. Following the typical preoperative protocol, the surgical reconstruction was performed. Following presternal debridement, the lower half of the incision was sutured with single PDS® stitches by anatomical layers (Figure 3A). We identified a fistula in the upper section of the incision that extended to the left pectoralis muscle (Figure 3B). We excised the fistulous tissue and filled the defect with vancomycin paste and an extracellular matrix patch (ProxiCor®) (Figure 3C). The rest of the incision was sutured with single PDS® stitches through anatomical layers. The postoperative course was regular, and examination controls after two weeks and one month showed a regular healing process (Figure 3D). Eight-month after-treatment follow-up has shown no signs of recidivism.

Fig. 3 - Surgical reconstruction of sternocutaneous fistula in the third patient. A) The lower half of the incision was sutured with single PDS® stitches. B) Identification of a fistula in the upper section of the incision. C) The defect is filled with vancomycin paste and an extracellular matrix patch. D) Examination control after one month.

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Fig. 3 - Surgical reconstruction of sternocutaneous fistula in the third patient. A) The lower half of the incision was sutured with single PDS® stitches. B) Identification of a fistula in the upper section of the incision. C) The defect is filled with vancomycin paste and an extracellular matrix patch. D) Examination control after one month.