Clinical utilization of the coronary pressure wire

INTRODUCTION: Earlier studies have established the value of coronary pressure wires for diagnosing and monitoring the treatment of patients with coronary artery disease. In this study we demonstrated their usefulness in the daily clinical practice of a catheterization laboratory. MATERIAL AND METHODS: A retrospective study of the use of pressure wires in our laboratory between October 1998 and November 2000. The pressure wire was inserted whenever the interventional cardiologist considered it to be indicated. In all cases, pressures were recorded with a Waveguide Cardiometrics 0.014 guide (Endosonics) and hyperemia was induced by intracoronary adenosine. RESULTS: Two hundred fifty-three lesions were studied in 190 patients. Indications were functional evaluation of lesions of intermediate severity for 82% (9% intrastent restenoses); guidance of balloon PTCA for 5%; and fulfillment of a research protocol for 13%. Twenty-six percent of lesions considered to be of moderate severity based on angiography were treated as a consequence of the pressures measured by the wire. A decision to begin or continue a procedure was based on wire pressures in 24% and intervention was avoided in 60%. No major complications attributable to the wire were observed. A lesion was dissected in one patient (0.5%) but it was treated without consequences. Twenty pressure wires (11%) failed to work properly during the procedure, fourteen of them (7%) before insertion. The wire could not be advanced across the lesion in one case. CONCLUSIONS: The pressure wire is useful in the daily clinical practice of a catheterization laboratory. Its most common indication is the evaluation of lesions of intermediate or unknown severity, and use is associated with few complications.     

Angioplasty of coronary bifurcation stenoses: Immediate and long-term results of the protecting branch technique

Percutaneous transluminal angioplasty (PTCA) of coronary stenoses involving major bifurcations carries a small but significant risk of side branch occlusion which can be avoided by simultaneously using multiple dilatation systems. Among 1,275 PTCA procedures performed between 1984 and 1988 in 1,035 consecutive patients, 42 double wire procedures were applied (4%) to protect and/or dilate major coronary side branches. A total of 80 coronary stenoses were attempted of which 76 were located on a bifurcation and 4 on other segments. In the first 11 patients (group A), 2 guiding catheters were used and PTCA of each vessel was successfully performed by means of separate double lumen over-the-wire balloon catheters. In the next 31 patients (group B), 2 guidewires were advanced through a single guiding catheter and PTCA was attempted using “Monorail” balloon catheters sequentially advanced over the wires. In group B, a successful PTCA was obtained in 29 patients (93%) but twisting of the wires hampered balloon progression in 5 cases, such that dilatation could only be performed by stepping back to a single wire technique. The procedure time in group B was significantly shorter than in group A: 144 ± 30 versus 230 ± 52 minutes (p = .01). Repeat angiography was performed in 35 out of 40 patients (87%) after a mean of 180 ± 46 days following successful PTCA. Angiographic restenosis was present in 37% (24/65) of bifurcation segments which, in our experience, is not significantly different from the angiographic restenosis rate in less complex lesions (248/740; 34%; NS). It is concluded that 1) the need for using a protecting branch technique in PTCA practice is uncommon (4%); 2) among other approaches, the use of a “Monorail” system allows successful dilatation in 93% of cases with a shortened procedure time; 3) the restenosis rate at repeat angiography is similar to that of non-bifurcated lesions.     

经皮椎体后凸成形术治疗老年骨质疏松性椎体骨折: 单球囊与双球囊对比研究

目的 探讨单球囊与双球囊椎体后凸成形术治疗骨质疏松性椎体骨折的疗效。方法2008年4月～2010年2月,收治骨质疏松性椎体压缩骨折患者26例,累及椎体35个。随机分为单球囊组,15例,21个椎体,平均72（53～79）岁;双球囊组,11例,14个椎体。平均70．8（51～80）岁。手术于x线透视下完成,双球囊组应用双球囊在椎体内双侧同时扩张;单球囊组应用单球囊双侧穿刺在椎体内交替扩张。术后观察症状改善、椎体高度复位及后凸畸形矫正、并发症发生等情况。结果单球囊组平均每个椎体手术时间37．5（33～85）min;双球囊组平均每个椎体手术时间33．9（30～75）min;随访时间12～18个月,平均14．8个月。术后患者腰背痛症状均较术前明显缓解。VAS疼痛评分：单球囊组术前平均为7．6±2．2,术后为2．5±1．8,末次随访为3．1±2．0,手术前后差异有统计学意义（P〈O．05）;双球囊组术前平均为7．9±2．3,术后为2．4±2．0,末次随为2．9±2．1,手术前后差异有统计学意义（P〈0．05）;两组术后椎体前缘、中央高度均比术前有显著增加,且维持至末次随访,差异均有统计学意义（P〈0．05）。椎体后凸角单球囊组平均矫正（7．0°±4．5°）,双球囊组平均矫正（7．7°±3．9°）,各组手术前后比较,差异有统计学意义（P〈0．05）。而两组间上述各指标对应比较,差异无统计学意义。结论单球囊与双球囊椎体后凸成形术治疗老年骨质疏松性压缩骨折均可获得满意的治疗效果。     

Computed tomography-guided wire localization of pulmonary lesions before thoracoscopic resection: results in 101 cases

The authors determine the success rate, safety, and potential complications of computed tomography-guided preoperative hookwire localization of small peripheral pulmonary nodules. One hundred one consecutive wire localizations with addition of methylene blue injection were performed in 94 patients immediately before thoracoscopic resection of small lung lesions. Sixty-two patients had a known primary malignancy, whereas 32 had an asymptomatic nodule. Eighty-eight patients underwent single lesion localization, five underwent double localization, and one underwent triple wire placement. Five patients had previously undergone percutaneous biopsy that was nondiagnostic. The nodule was within the first wedge biopsy of lung tissue in 95 of 97 specimens (98%). A second wedge and an open lobectomy were required in one patient each. Three additional biopsies were intraoperatively deferred after the histologic diagnosis was established after removal of another nodule. The procedure was terminated before wire placement in one patient who was unable to successfully hold his breath. The wire dislodged with the tip in the pleural space rather than in the lung parenchyma in 22 cases; however, methylene blue tattoo allowed localization in 13 of these (59%). In the other nine cases, extra portals, digital palpation, or expanded wedge resection was required. Complications included pneumothorax in 48 cases, moderate pleuritic pain in five cases, seven small intercostal hematomas, and a 7-mm wire fragment retained in one patient's lung along the suture line. No patient required a preoperative drain for treatment of pneumothorax. Wire dislodgement occurred in 6 of 52 (12%) cases without an initial pneumothorax and in 16 of 48 (33%) cases if a pneumothorax occurred. Wires dislodged less frequently if placed either directly into or through the nodule in 11 of 64 (17%) cases than if placed adjacent to the nodule in 11 of 36 (31%) cases. Average wire tip depth from the visceral pleura was significantly less when the wire dislodged (11 mm) than when the wire remained in place (25 mm). Wire localization of small peripheral pulmonary nodules is a safe and effective procedure to assist thoracoscopic sublobectomy resection.     

Thrombus formation on guide wires during routine PTCA procedures: a scanning electron microscopic evaluation

BACKGROUND: Various coatings are used on catheters and guide wires to improve resistance to surface thrombus formation. However, little is known about the thrombogenicity of 0.014" angioplasty guide wires and the protection offered by these coatings. OBJECTIVES: To evaluate the thrombogenicity of five different guide wires used in coronary angioplasty. METHODS: Five different 0.014" guide wire types were evaluated in 50 consecutive angioplasty procedures. At the end of the procedure, the distal part of the guide wire was cut, put in formalin and prepared for scanning electron microscopic evaluation. The condition of each guide wire was then classified into one of three predefined categories: no thrombus, limited thrombus and significant thrombus formation. RESULTS: Silicone (n=10, Guidant, USA), phosphorylcholine polymer (n=8, Biocompatibles, Ireland), hydrophilic polymer (n=8, Scimed, USA) and two Teflon-based coatings (n=16, Schneider, USA; n=8, Cordis, USA) were evaluated. On microscopic examination, 48% of guide wires had a significant amount of thrombus, 18% had limited thrombus formation and 34% had no thrombus. The results were very dissimilar among the groups. Significant thrombus was found on 80% of Guidant guide wires, 69% of Schneider guide wires, 38% of Scimed guide wires and 25% of Cordis guide wires, while none was found on Biocompatibles guide wires (P<0.0001). CONCLUSIONS: Significant thrombus formation on angioplasty guide wires was a frequent finding, occurring in 48% of cases. Resistance to thrombus formation was very dissimilar among coatings, with only the Biocompatibles phosphorylcholine-coated guide wires showing no thrombus formation at all. Whether subclinical thromboembolization occurred in some patients is unknown, and the clinical implications of this study remain to be defined.     

股骨近端髓内钉InterTan治疗老年粉碎性。股骨转子间骨折疗效观察

目的评估InterTan治疗老年粉碎性股骨转子间骨折的临床疗效。方法采用InterTan治疗老年粉碎性股骨转子间骨折30例,对患者术中情况、术后Harris髋关节评分、骨折愈合时间、术后并发症等情况进行评估。结果30例患者中除2例失访,28例患者术后获平均6m随访,骨折均获愈合,愈合时间2～6m,平均愈合时间为（2．6±0．8）m。术后Harris髋关节评分评定结果：优10例,良14例,中3例,差1例,优良率为85．7％,未出现股骨颈颈部短缩,髋内翻,内固定断裂等并发症。结论股骨近端髓内钉INTERTAN是治疗老年粉碎性股骨转子间骨折较好的方法,其骨愈合率高,并发症少。     

Marked migration of sternotomy wires: a case report

This case report of sternal dehiscence, complicated by pronounced migration of fractured sternotomy wires, demonstrates the utility of computerized tomography (CT) in the precise localization of the wire fragments. Although CT is not typically used to evaluate sternal wire abnormalities, selected cases of sternal dehiscence can benefit from this detailed survey. A review of the literature regarding complications was also performed.     

Guía de presión encarcelada en el tratamiento percutáneo de las bifurcaciones coronarias: daño estructural y resultados clínicos

Introduction and objectivesThe use of a pressure wire as a jailed wire to evaluate side branch results during provisional stenting seems feasible. However, safety concerns exist due to the mechanical damage of the wire and the lack of prospective data evaluating the prognosis of patients treated using this technique. This study sought to evaluate the structural damage of the pressure wire in patients treated using the jailed pressure wire technique and to assess mid-term clinical outcomes.MethodsWe enrolled 99 patients with single bifurcation lesions and provisional stenting as the strategy of choice. A jailed pressure wire was used to guide side branch intervention according to the instantaneous wave-free ratio (iFR). A total of 114 patients and the respective nonpolymer-coated jailed wires were used as historical controls. Guidewire damage was evaluated by stereomicroscopy. The primary endpoint was significant microscopic damage. Major adverse cardiac events were evaluated at 2-year follow-up.ResultsSignificant microscopic damage was more frequent in pressure wires than in nonpolymer-coated wires (53.5% vs 22.8%, P < .001). There were no fractures in either group. There were fewer side branch interventions in the pressure wire group (postdilation/kissing balloon, 32.3% vs 56.1%, P = .001; stenting, 0.0% vs 2.6%, P = .104). The 2-year rate of major adverse cardiac events was similar between the 2 groups (HR_adj, 0.42; 95%CI, 0.10-1.73; P = .229).ConclusionsPressure wires were less resistant to jailing than conventional nonpolymer-coated wires. Patients treated with iFR-guided provisional stenting required fewer side branch interventions but had similar 2-year clinical outcomes than patients treated with the angiography-guided technique.     

Diaphragmatic pacemaker failure in congenital central hypoventilation syndrome: A tale of two twiddlers

Two patients with congenital central hypoventilation syndrome (CCHS) experienced phrenic nerve pacer failure due to deliberate manipulation of the internal receiver implant (“twiddling”). The patients, aged 7 and 12 years, presented with repeated episodes of pacer failure associated with local pain over a period of 18 months. They had progressively coiled the pacing wires to the point of breakage, which only became apparent at surgery. The breaks were not recognized radiologically, although in retrospect progressive twisting of the wires was evident on serial chest radiographs. Both patients required replacement of the internal receivers under general anesthesia. We recommend that the chest radiograph that is undertaken to investigate the cause of pacer dysfunction include the internal receiver. A plain chest radiograph that demonstrates progressive coiling of the subcutaneous pacing wire should raise suspicion of pacer wire breakage regardless of the patient's age. Pediatr Pulmonol. 1996; 22:319-321 . © 1996 Wiley-Liss, Inc.     

Comparative study of tibial (single) and tibiofemoral (double) osteotomy for osteoarthrosis and rheumatoid arthritis.

Osteotomies on 101 knees in 79 patients were assessed either prospectively or retrospectively. High tibial osteotomy was performed in 54 knees (27 with rheumatoid arthritis (RA) and 27 with osteoarthrosis (OA)) and double (tibiofemoral) osteotomy in 47 knees (25 RA and 22 OA), and were assessed prospectively in 46 and retrospectively in 55. Using a subjective assessment, 65% showed some improvement--70% of the single and 60% of the double osteotomies. Of the four groups (OA single or double, RA single or double), OA knees having a single osteotomy improved most frequently (74%), and OA knees having a double osteotomy least frequently (50%). Significant improvements in pain score and angular deformity were recorded. The mean range of movement of the operated knee was significantly reduced, and was particularly evident in those knees having a double osteotomy. We conclude that double osteotomies tend to have a higher incidence of complications, including impaired movement, and are not more efficient in relieving pain than single osteotomies in either OA or RA.     

经胰管预切开联合胰管支架置入法在困难胆管插管中的应用

目的 探讨经胰管预切开联合胰管支架置入法在经内镜逆行性胰胆管造影术(endoscopic retrograde cholangiopancreatography,ERCP)乳头困难插管中的应用价值。方法 纳入2017年1月—2019年12月在海军医科大学第三附属医院行ERCP治疗的169例乳头插管困难病例,其中137例采用双导丝法,32例患者采用经胰管预切开联合胰管支架置入法,观察两组的插管成功率、插管时间以及术后并发症等。结果 双导丝组和经胰管预切开联合胰管支架置入组的插管成功率分别为98.54％(135／137)和100.00％(32／32)(P>0.05);两组的插管时间分别为(15.69±9.07)min 和(17.06±5.79)min(P>0.05);术后并发症发生率分别是25.55％(35／137)和 9.38％(3／32)(P<0.05),其中胰腺炎发生率分别是5.8％(8／137)和0。结论 ERCP乳头插管困难时采用经胰预切开联合胰管支架置入法,具有与双导丝技术相似的成功率,同时更加安全,值得临床推广应用。     

Recanalization of Chronic Total Coronary Occlusions Using a Laser Guide Wire: A Pilot Study

Objectives. This study sought to prospectively evaluate the performance of a laser guide wire in crossing chronic total coronary occlusions in patients with a failed previous mechanical guide wire attempt.Background. Despite continued refinement of mechanical hardware available for coronary angioplasty, restoration and maintenance of blood flow through a chronically occluded coronary artery remains a true challenge.Methods. Fifty patients with a chronic total coronary occlusion and a previous failed attempt at recanalization using mechanical guide wires were included. A mechanical attempt to cross the occlusion was repeated. In case of failure, an additional attempt was made with the laser guide wire.Results. The median age of occlusion was 22 weeks (range 5 to 200), and the occlusion length was 23 ± 11 mm (mean ± SD). A repeat mechanical attempt was successful in six cases (12%). Dissection occurred in five other cases, and device crossover was not attempted. Thus, in 39 patients an attempt was made with the laser guide wire, with successful recanalization in 23 (59%). Thereby the overall success rate increased from 12% to 58% (29 of 50 patients). The amount of contrast medium used was 515 ± 154 ml, fluoroscopy time was 99 ± 43 min, and total procedure time was 2 h 48 min (±55 min). Procedural success was achieved in 26 cases and clinical success (procedural success without in hospital events) in 24. In-hospital events were two non–Q wave myocardial infarctions related to subacute reocclusion. In one patient, a balloon dilation after laser guide wire perforation resulted in tamponade requiring pericardiocentesis. After a successful procedure, the angina class decreased from 2.9 ± 0.2 to 1.4 ± 0.7 at 3 months of clinical follow-up. Six-month angiographic follow-up was completed in all 24 eligible patients and showed vessel patency in 20 (80%).Conclusions. The use of the laser guide wire for recanalization of chronic total coronary occlusions refractory to treatment with mechanical guide wires is feasible and relatively safe and was successful in 59% of cases. This device must thus be considered a valuable addition to the interventional armamentarium and accordingly will be evaluated in a randomized clinical trial.     

Processing,Structural Characterization and Comparative Studies on Uniaxial Tensile Properties of a New Type of Porous Twisted Wire Material

A self-developed rotary multi-cutter device cuts stainless steel wire ropes into segments to fabricate twisted wires. Stainless steel porous twisted wire materials (PTWMs) with a spatial composite intertexture structure are produced by the compaction and subsequent vacuum solid-phase sintering of twisted wires. The stainless steel PTWMs show two types of typical uniaxial tensile failure modes, i.e., a 45° angle fracture mode and an auxetic failure mode (the PTWMs expand along the direction perpendicular to the tension). The effects of the sintering parameters, porosities, wire diameters, and sampling direction on the tensile properties of the PTWMs are carefully investigated. By increasing the sintering temperature from 1130 °C to 1330 °C, the tensile strength of the PTWMs with 70% target porosity increased from 7.7 MPa to 28.6 MPa and the total failure goes down to 50%. When increasing the sintering time from 90 min to 150 min, the tensile strength increases from 12.4 MPa to 19.1 MPa and the total failure elongation drops to 78.6%. The tensile strength of the PTWMs increases from 28.9 MPa to 112.7 MPa with decreasing porosity from 69.5% to 46.0%, and the total failure elongation also increases from 14.8% to 40.7%. The tensile strength and the failure strain of the PTWMs with fine wires are higher than those of the PTWMs with coarse wires under the same porosity. Sampling direction has a small influence on the tensile properties of the PTWMs.     

Improved recanalization of chronic total coronary occlusions using an optical coherence reflectometry-guided guidewire.

Successful percutaneous therapy of chronic total occlusions is limited predominantly by the inability to cross the lesion. We report our experience of 29 chronic total occlusions (CTOs) that could not be crossed with conventional wires and subsequently underwent attempted recanalization facilitated using a wire navigated with optical coherence reflectometry. Mean length of occlusion was 22.1 mm (range, 4.5-88.7 mm). Successful recanalization was achieved in a further 15 (51.7%), with no complications of tamponade, myocardial infarction, or death. These results demonstrate that this wire can be a useful tool in addition to conventional wires in the treatment of CTO.     

One,two, three … breakdance and twist

Wire breakage during percutaneous coronary intervention is a rare event. It occurs especially when treating complex lesions, and it should be prevented with careful planning of each procedural step. We reported a case in which wire breakage occurred when treating the left anterior descending (LAD)/first diagonal bifurcation with the T‐stenting technique. After careful evaluation of all the available retrieval techniques and failure of the balloon–catheter trapping, the twin‐twisting wires technique (TTWT) was applied. This technique allows the retrieval of a foreign body thanks to its entrapment in the spiral made by two twisting wires. At the first attempt, the broken wire was only withdrawn and not retrieved, while the two twisting wires went broken. The second attempt was performed using stronger wires as twisting wires. The two recently broken fragments were successfully retrieved together with a long proximal remnant of the initially broken wire, which distal tip was further withdrawn. The broken wire was successfully retrieved with the third attempt, together with the previously implanted LAD stent that was accidentally entrapped in the twist. This is the first report of TTWT implementation for the retrieval of a broken wire from a two‐stent bifurcation, both proximal and distal wire remnants and a total of three broken wires. The improvements we made to the technique, tips and tricks, caveats, and suggestions for successful wire retrieval and avoidance of the complications that we experienced are described in detail.     

Percutaneous transluminal coronary angioplasty for chronic total coronary occlusion in patients with stable angina. Relationship between lesion anatomy, procedure technique and efficacy

BACKGROUND: In spite of continuing progress in percutaneous coronary interventions (PCI), recanalisation of chronic total coronary occlusion (CTO) still remains a challenge for invasive cardiologists. AIM: To analyse the results of PCI of CTO and to assess the relationship between lesion anatomy, procedural technique and efficacy of PCI in patients with stable angina. METHODS: The study group consisted of 460 consecutive patients (81% males, age 25-80 years, 68% with a history of myocardial infarction [MI]), who underwent CTO recanalisation in our institution between 1996 and 2003. Duration of CTO ranged between 1 and 3 months in 5.9% of patients, 3-6 months -- in 12.4%, more than 6 months -- in 51.7% and was undefined in 30% of patients. RESULTS: The overall average success rate was 65%; it increased from 60% in 1996 to 75% in 2003. The most frequent (92%) cause of failure was the inability to pass a guide wire through the occlusion. The use of soft or standard guide wire was associated with a 68.7% success rate. In those in whom standard methods failed, the use of special guide wire was associated with the efficacy of 61.2%, and the Magnum system -- of 28.6%. Stents were implanted in 34.5% of patients (from none in 1996 to 55% in 2003). Serious peri-procedural complications included one death (0.2%), MI in one (0.2%) patient, repeated urgent PCI in 5 (1.1%) patients, urgent CABG in one (0.2%) patient, perforation of coronary artery requiring pericardiocentesis in one (0.2%) patient, and complications at the site of artery puncture in 14 (3%) patients. Univariate analysis showed that longer duration of occlusion, TIMI flow grade 0, lengthy occlusion, abrupt vessel stump, small vessel diameter, presence of bridge collaterals, branching off at the site of occlusion, and massive calcifications were the factors adversely affecting the outcome. Multivariate analysis revealed that tapered end of the stump, lack of calcifications and TIMI flow grade 1 were the factors independently associated with a favourable outcome. CONCLUSIONS: The overall average efficacy of PCI of CTO is 75% and the risk of peri-procedural complications is low (1.7%). Clinical factors and the anatomy of lesion should be taken into account when planning the procedure. Special guide wires designed for recanalisation of CTO are effective in more than half of patients in whom standard guide wires failed.     

Hemoptysis due to migration of a fractured Kirschner wire

We report a rare complication related to the insertion of Kirschner wires for stabilization of an acromioclavicular separation. Five years after placement of the Kirschner wires, the patient presented with hemoptysis. On review of chest radiographs, a fractured wire was found to have migrated from the acromioclavicular joint, through the hemithorax and into the trachea.     

Short- and long-term follow-up of percutaneous coronary intervention for chronic total occlusion through transradial approach: tips for successful procedure from a single-center experience

Background: There are limited data regarding transradial percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). Objective: To assess the feasibility and safety of transradial coronary intervention (TRI) for CTO lesions, we analyzed our experience in PCI treatment of CTO lesion through transradial approach for the past 6 years. Methods: From January 2003 to May 2009, among 134 CTO lesions, on which we performed PCI, 120 lesions were performed from transradial approach. Results: Technical success for transradial CTO was 80%. Complication of access bleeding was zero. The most commonly selected guiding wire was Wave 3 for right coronary artery (RCA) lesions (82%) and Voda left for Left Coronary Artery (LCA) lesions (91%). The average number of wires used during procedure was 2.2 ± 0.8. Tapered wire was used in 8% of the cases, Rotablator was performed in 4.1% of cases, and Tornus catheter was performed in 12.5% of cases. The mean procedure time was 83 ± 39 minutes. The mean volume of contrast medium used was 228 ± 92 mL. There were two coronary artery perforations during procedure and one in‐hospital cardiac death. Patients were followed up for 36 ± 21 months; restenosis rate was 19.5%–26.7% for bare metal stent (BMS) and 9.8% for drug‐eluting stents (DES). Overall major adverse cardiac events (MACE) rate was 11.7%. Conclusion: It was demonstrated that transradial PCI for CTO lesions is safe, minimizing vascular complications without increasing procedural time and contrast use. (J Interven Cardiol 2011;24:137–143)     

Sternal bands for closure of midline sternotomy leads to better wound healing

Midline sternotomy is the most common incision for cardiac surgery, but problems of wound healing and sternal instability are still matters of concern. The use of stainless steel wires only was compared with the use of wires plus sternal bands for closure of midline sternotomy wounds in a 2-year period. Of 370 patients in whom only stainless steel wires were used, 14 (3.78%) required re-operation for dehiscence. Only 3 (0.76%) of 395 patients in whom sternal bands were also used, required re-operation for dehiscence. The difference was highly significant. It was concluded that use of sternal bands leads to a more stable union.     

Reinforced sternal closure: the bilateral straight longitudinal wire technique

Sternal dehiscence and mediastinitis are among the most severe complications of median sternotomy. A simplified technique of reinforced closure is described. A straight wire is inserted longitudinally on each side of the sternum, placed within the transverse wires when the latter are approximated. Using this technique in 112 patients with a precarious sternum, no cases of sternal dehiscence or mediastinitis have been seen.