Migration of fractured sternal wires after CABG in a smoker

A 74-year-old white male smoker with chronic obstructive pulmonary disease and marked coughing experienced a transmural, anterior myocardial infarction two years prior to the current visit. Because of postinfarction angina, he underwent elective coronary artery bypass grafting including the use of the left internal mammary artery at our institution (fig. 1a). His postoperative course was complicated by persistent smoking and coughing. Three months after operation, he presented to our outpatient clinic with cough-induced pain at the proximal end of the sternum. The thoracic X-ray showed fracture of the proximal sternal wire (fig. 1b). One and a half year later, the patient presented again with pain on coughing and moving, now expanding all over his sternum. He experienced no pain with normal breathing. His physical examination revealed a median thoracic scar without signs of inflammation nor palpable wires, but abnormal sternal mobility with cracking. The thoracic X-ray showed fracture of all sternal wires (fig. 1c). In addition, fractured parts of the proximal wire have migrated at the dorsal side of the sternum from its proximal to its distal end. A conservative management with regular controls was chosen given the minor complaints of the patient. The decision against reoperation based on the increased risk of injuring the bypasses (in particular the mammary graft to the left anterior descending coronary artery), the likelihood of postoperative infection as well as recurrence of postoperative pseudoarthrosis given the patient’s ongoing smoking and coughing.