# Modified Cabral



## jbnewlife77 (Oct 30, 2012)

Does anyone know how to code a modified Cabral procedure?

OPERATIONS/PROCEDURES PERFORMED: 
1.  Emergency salvage repair of Type A dissection with the tear 
    initiating at the non-coronary sinus. 
2.  Re-do sternotomy, excision of #25 mechanical valve, fem-fem cannulation 
    converted to right atrial venous cannulation. 
4.  Modified Cabral with #25 St.Jude valve conduit/ 10 mm hemashield graft to Lt 
    main anastomosis. R coronary artery button directly anastomosed to conduit 
    graft.
5.  Hemi-arch repair of the distal ascending aorta/proximal arch, utilizing 
    circulatory arrest at 15 degrees Centigrade for 19 minutes.

PROCEDURE IN DETAIL:  The patient was emergently taken to surgery after informed 
consent was obtained. Utilizing a two team approach, nurse practitioner Carmen 
Lopez and I opened the sternum as Dr. Larson and fourth year resident, Dr. 
Waylan Clark, cannulated the right CFA and CFV for fem-fem cannulation.  Once 
the groin vessels were exposed we opened the sternum, dissected the 
diaphragmatic surface of the heart, proceeded along the right atrium which was 
adhered to the pericardial wall as well as the aneurysm. We dissected cephalad 
to the level of the innominate vein which was also adhered to the aneurysm. 
Dissection of the innominate vein continued. During the initial opening of the 
sternum with the retractor, it was obvious that the innominate vein was 
unfortunately contracted from adhesions and markedly stretched. Because of the 
need to  appropriately open the sternum and the  aortic dissection extended into 
the arch  the innominate vein was transected with a vascular  endo-GIA stapler. 
This allowed us to open the sternum normally wihout fear of tearing the 
Inonimate vein. Dissection continued circumferentially around the aneurysm, at 
the  level of the innominate artery so that we could  potentially cross clamp 
the aorta. During this period of time, Dr. Larson and Dr. Clark cannulated the 
right common femoral artery with a #18 Edwards cannula. The right common femoral 
vein was cannulated under TEE guidance with the wire extending into the right 
atrium. However, because the large aneurysm was impinging  on both the SVC and 
right atrium, the venous cannula was only able to be advanced  into the  right 
atrium. .It could not be advanced into the SVC. Of note, anesthesia
was unable to place the Swan beyond the RA because of the aneurysms impingement 
on the right atrium-vena cava juncture. Once an appropriate ACT was obtained, he 
was placed on cardiopulmonary bypass with flows of approximately 4 liters per
minute.  To achieve optimal CP bypass flowa we rapidly converted from femoral 
venous cannulation to right atrial cannulation with a 3 stage venous cannula. We 
then continued to dissect the right atrium, the right diaphragmatic surface all 
the way around the LV to the level of the left atrial appendage. We placed a 
retrograde catheter from the right atrium into the coronary sinus. Dissection
continued, peeling the right atrium off of the pericardial surface down
onto the level of the right superior pulmonary vein, where the previois LV sump
had been placed.  This was further dissected and new pledgeted sutures were 
placed along the right superior pulmonary vein to insert a LV  sump through the 
right superior pulmonary vein into the LV. We then continued to cool.  We 
carefully attempted to dissect the aneurysm off the Main pulmonary artery. 
However, it was quite evident that the right pulmonary artery as it coursed 
posterior to the aorta was markedly adhered to the posterior surface of the 
aneurysm.  This dissection was aborted to avoid injury to the right pulmonary 
artery.  At the level cephalad to the right pulmonary artery and just at the 
level of the innominate artery, we were able to dissect around the aorta to 
place a cross clamp.  Once the patient was cooled to 28 degrees, he fibrillated, 
a crossclamp was placed  and retrograde cardioplegia was administerd.  The heart 
arrested nicely in diastole. LV temperature was moniored. Cold hyperkalemic 
cardioplesia was administered  intermitently every 15 minutes. The aorta was 
transected completely just above the level of the right pulmonary artery and 
both lumen were visualized. The aneurysm at the level of the transverse sinus 
was then transected. The right pulmonary artery was adhered to that aorta and 
hence we did not further dissect the right pulmonary artery off the posterior 
surface of the aneurysm wall.

 We noted that the dissection initiated from a tear  right above the 
level of the non-coronary sinus. The actual root at the level 
of the sinus was at least 7 to 7.5 cm in size. Unfortunately, this patient
could not be repaired just with a simple tube  graft and we had to perform a
modified Cabral to repair this dissection. We then proceeded to construct a 
large rectangular button of the right coronary os. We noted that the left 
coronary os was amenable to do a modified Cabral with a 10 mm graft.  We decided 
first to excise his old valve from the annulus. We carefully incised
his sutures and removed the valve from the annulus. We irrigated the LV.
We then used our 10 mm graft, beveled it, and performed an end-to-end 
anastomosis of the 10 mm graft to the left main coronary os with a #5-0 Prolene
suture. This graft was then attached to the antegrade cardioplegia octopus
and antegrade cardioplegia was administered into the graft. At a pressure of 
100mm Hg there was no bleeding from this anastomosis.  I was then  able to give 
plegia directly into the left coronary os. We turned our attention to
performing the actual valve conduit anastomosis. We placed 19 sutures, 1
mm or less apart, around the annulus of the valve. These were then
placed through the valve conduit that had previously been sized to a #25
St. Jude valve conduit. The valve conduit seated nicely. The sutures were
tied starting from the lowest level of each sinus along the  middle scallop and 
then outward toward the commisures. We believe that this anastomosis was 
excellent and water tight.

We then turned our attention to performing the distal anastomosis of the 
graft to the aortic arch/ascending aorta. The patient had been cooled to 
15 degrees Centigrade. The fibrin glue was obtained and the felt strips had been 
previously cut to approximately 1.5 cm diameter. The patient was placed in 
Trendelenburg position, the head was packed in ice,steroids and pheno barbital 
were given, and Hypothermia circulatory arrest was initiated  at 15 degrees 
Centigrade. The ascending aorta/arch at the level of the innominate artery
was then transected and beveled  posteriorly into the arch. Fibrin glue was then 
used to glue the false lumen.  We then used a felt strip to go anastomose the 
felt strip around the external aspect of the arch with a #5-0 Prolene suture. We 
measured our graft, beveled it appropriately and then performed an end-to-end 
anastomosis of the graft to the arch. The  cross clamp was removed,  the graft 
was de-aired and we  noted that the anastomosis was water tight. Circulatory 
arrest lasted for 19 minutes. We then marked on the conduit graft where both the 
right coronary button and our 10 mm graft would be anastomosed.  The 10 mm graft 
ran underneath the conduit and we marked the area of anastomosis along the right 
aspect of the conduit at approximately 10 o'clock. Similarly we marked the area 
of the RCA button anastomosis. We then placed the crossclamp on the graft and 
performed the end-to-side anastomosis of the right coronary artery button to the 
graft with a #5-0 Prolene suture. We then probed this anastomosis and confirmed 
patency.  The end-to-side anastomosis of the 10 mm graft to the 
valve conduit was then performed also with #5-0 Prolene suture. During 
this period of time, the patient was warmed. At 32 degrees Centigrade, the
cross clamp was removed and the patient was de aired through both the conduit 
graft as well as the LV sump. We came off bypass after we warmed to 37
degrees Centigrade.  Hemostasis was obtained  with sutures placed were 
necessary.  Several sutures were placed along the distal anastomosis. He came 
off bypass without diffulculty. Good LV function.  The patient was given blood
products,  and Factor 7. However, we felt that the patient was still oozy with
no active bleeding, due to the long pump run, mild hypothermia, as well
as an INR of 4.0 prior to the operation. We then decided to pack the patient for 
hemostasis  and return to the OR in the AM.  The patient was hemodynamically 
stable. He was packed in the OR and  a wound vacuum was placed on top of the 
wound. Four CT were placed in the mediastinum. There were no sponge, needle
and instrument counts since the patient was packed open  and would require a 
return to the OR in the AM for definitive closure. The patient returned to 
recovery in stable condition. 

The patient's family, and wife, were then made aware of the details of the 
operation. 


I was thinking of 33863 but not sure, any help appreciated. Thanks


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