Successful Life-Saving Repair of Innominate Vein Injury Secondary to Primary Sternotomy for CABG: A Case Report

Background: Iatrogenic injury to the innominate vein during primary sternotomy for open heart surgery is rare but potentially life-threatening. Prompt recognition and structured management are essential to prevent catastrophic hemorrhage and cerebral venous congestion. Case Presentation: We report a patient undergoing primary coronary artery bypass grafting (CABG) who sustained a catastrophic rupture of the innominate vein at its confluence with the superior vena cava during sternal retraction. Immediate hemorrhage control was achieved with digital compression and intermittent venous clamping. Temporary decompression was facilitated using a saphenous vein patch to the left brachiocephalic vein. Definitive reconstruction was then performed using prosthetic Dacron grafts: the right brachiocephalic vein was reconstructed in an end-to-end fashion to the distal superior vena cava, while the left brachiocephalic vein was anastomosed to the main graft in a side-to-end configuration. Venous reconstruction was completed prior to the initiation of cardiopulmonary bypass (CPB). CPB was subsequently established to complete CABG, with a total bypass time of 74 minutes and an aortic cross-clamp time of 52 minutes. The postoperative course was favorable. Therapeutic anticoagulation with heparin bridging to warfarin (target INR 2.0– 3.0) was instituted. At follow-up, the patient demonstrated no neurological deficits, no clinical evidence of venous congestion, and no signs of graft thrombosis. Conclusion: Although exceedingly rare during primary sternotomy, innominate vein avulsion represents a critical intraoperative event. This case illustrates that rapid hemorrhage control, structured venous reconstruction using prosthetic grafts, and appropriate postoperative anticoagulation can result in favorable outcomes. Awareness of mediastinal venous anatomy and careful sternal technique remain essential preventive measures.