# Replacement of ascending aorta with 22 mm Hemashield graft



## sandy06 (Jul 18, 2012)

PREOPERATIVE DIAGNOSIS:
Acute type A aortic dissection with arch dissection.

POSTOPERATIVE DIAGNOSIS:
Chronic type A aortic dissection with acute tear at the mid arch with
rupture.

OPERATION:
1. Replacement of ascending aorta with 22 mm Hemashield graft.
2. Reimplant of innominate and left carotid artery with a 14 mm
   bifurcating Hemashield graft and a right axillary artery
   cannulation and repair with retrograde cerebral perfusion and
   selective antegrade cerebral perfusion via the Hemashield graft
   with hypothermic circulatory arrest.
3. Repair of left femoral artery.
4. Repair of right axillary artery.

SURGEON:  A, M.D.

ASSISTANTS:

ANESTHESIA:
General endotracheal tube anesthesia.

ESTIMATED BLOOD LOSS:

SPECIMENS REMOVED:

INDICATIONS:

DESCRIPTION OF PROCEDURE/FINDINGS:
Briefly, patient was identified in the holding area after being
transported by helicopter from the Lower Keys Medical Center with an
acute type A dissection. CAT scan was reviewed and the patient was
urgently taken to the operating room. Once placed to the operating
room, the patient was given general endotracheal tube anesthesia and
preoperative antibiotics. All appropriate monitors were placed which
included a right and left radial A-lines, with a right internal
jugular Swan-Ganz catheter, and Foley catheters were placed. All
appropriate monitors were placed and a transesophageal echo was
performed.

Once the patient was prepped and draped, a transesophageal echo
verifies an arch dissection with a tear just proximal to the left
subclavian artery, with true and false luminal flow in basal artery
on the transesophageal echocardiogram. The patient had no aortic
insufficiency and dissection starting at the sinotubular junction. So
at this point, since the patient had an arch dissection with the
possibility of selective antegrade cerebral perfusion, we decided to
perform a right axillary artery cannulation.

So, at this point, an incision was made in the right subclavicular
region. We were able to cut down the subcutaneous tissue with the
Bovie cautery, achieving hemostasis. At this point, the pulsatile
subclavian artery was identified and we were able to isolate it more
proximally and distally with vessel loops. At this point, a modified
Seldinger technique was utilized with the guidewire without any
resistance; and with a subcutaneous tissue dilator over the
guidewire, we were able to place in an 18-French arterial cannula
into the subclavian artery without any difficulty and without any
resistance. This was connected to arterial line and cardiopulmonary
bypass circuit. This was done with 10,000 units of heparin on board.
At this point, sternotomy was created from the jugular notch to the
xiphoid process, and entering through the subcutaneous tissue with
the Bovie cautery, and the midline of the sternum was transected with
a sternal saw. Once the sternum was transected, the sternum was made
hemostatic with Bovie cautery in both the anterior and posterior
aspect of the sternum, and a sternal retractor was inserted. At this
point, the pericardium was opened in a reverse-T fashion and tacked
up to the sternal wall in four different quadrants. A dilated
ascending and arch of the aorta were identified with evidence of
acute dissection and ecchymosis of the arch. At this point, the
pursestring suture was placed in the right atrial appendage, and a
dual-stage venous cannula was inserted into the IVC from the right
atrial pursestring suture, and a retrograde cardioplegia line was
inserted into the coronary sinus via pursestring suture in the body
of the right atrium. At this point, the patient was commenced on
cardiopulmonary bypass. Once commenced on cardiopulmonary bypass, the
patient was allowed to cool and we able to cool the patient down to
18 degrees Celsius, which took about 40 minutes. As the patient was
being cooled, we were able to mobilize the aorta and the innominate
vein, identifying the arch vessels. Once the arch vessels were
identified coming off the aneurysm, we were able to isolate the
innominate and the left carotid artery, which were very close to each
other, which was almost like a bovine arch; and we were able to
isolate the left subclavian which was very distal right after the
evidence of the ecchymosis and tear. So, we believe that this was a
type B dissection with retrograde dissection toward the ascending
aorta. As the patient was being cooled, we identified that the
axillary flow was not great and we felt that maybe the dissection was
involved in the flow resistance from the cardiopulmonary bypass
circuit, as the patient being cooled. So, then we stopped the flow
from the right axillary and cannulated the left femoral artery. This
was done in the routine fashion, isolating the femoral artery through
a groin incision. We were able to cannulate this with an 18-French
arterial cannula, and then the flows were identified to be excellent,
and we were definitely in the true lumen and there was good flow. We
were able to arrest the heart with cold perfusion of the
cardiopulmonary bypass circuit. As the heart block began to
fibrillate, a Sarns vent was inserted into the right ventricle via
the right superior pulmonary vein, and we will continue to cool
further for the duration of 40 minutes. At this point, the (____) was
isolated with a vessel loop, and a right angle Pacifico 24-French was
inserted and a pursestring suture, and this was to be utilized for
retrograde cerebral perfusion.

At this point, once the patient was completely cool down and the
heart was arrested, we were able to stop the cardiopulmonary bypass
circuit and begin the circulatory arrest with ice packing on the head
and steroids given to the patient. We were able to remove the
arterial line from the femoral cannula and place it in the SVC
cannula for retrograde cerebral perfusion. At this point, we were
able to transect the ascending aorta just above the sinotubular
junction. I mobilized the entire ascending aorta all the way up to
the arch. Once we obtained access to the arch, we were able to
identify an acute dissection at the arch, and a tear just proximal to
the left subclavian artery. At this point, the entire arch was able
to be transected; and once we were able to transect the entire arch,
we were able to isolate the left common and the innominate artery.
The subclavian artery on the left was very close to the endpoint
where we were to reach our distal anastomosis, so we decided to
maintain continuity of the left subclavian artery to the distal aorta
as one anastomosis so as not to anastomose separately. At this point,
with the entire arch resected, we decided to perform a bifurcating
branch graft with one branch encompassing the innominate and the left
common carotid together, reinforced with felt, such as almost like a
bovine arch, and we were able to utilize a 14 x 10 x 10 mm graft. One
of the 10 mm side ports was transected and clamped, and the other
side port was utilized later for cannulation for antegrade selective
cerebral perfusion. At this point, the anastomosis was created with
4-0 Prolene suture. Once the anastomosis was completed, the distal
end of the graft was cannulated with an 18-French arterial cannula,
and we were able to wire off the arterial line of the cardiopulmonary
bypass circuit, and we are able to perfuse selectively both the
innominate on the right and the left common carotid a  1 L/minute and
remain cool. Once this was performed, the retrograde cerebral
perfusion was closed down, and we were able to connect our arterial
line to the cannula of the Hemashield graft which was anastomosed to
the innominate and left carotid.

At this point, with the patient being selectively perfused, and the
distal anastomosis of the subclavian and the proximal distal
descending aorta were anastomosis, we were able to use felt with 4
Prolene suture in a circumferential fashion to reinforce the intima
to the adventitia. Once this was able to be performed, we were able
to utilize a 22 mm Hemashield graft in a two-layer anastomosis using
4-0 Prolene suture once the anastomosis was completed. At this point,
the Y of the arterial line was then connected to the femoral
cannulation once again, and we were able to retrograde perfuse the
remainder of the body, as we were still perfusing the brain
selectively via the graft. At this point, we remained cool because we
were going to go on circ arrest for a second short period. Once the
perfusion had began to the lower extremity and to the remainder of
the body, we were able to fill the graft; and once the distal aortic
graft was de-aired, a cross-clamp was placed on the graft and the
patient was now being perfused at 2 L/minute both in antegrade
selective cerebral perfusion graft and via retrograde via the femoral
artery. At this point, with the patient remaining cool and not
perfusing, the distal anastomosis was performed from the subclavian
and the distal arch using a 22 mm Hemashield graft.

We then turned our attention to the root of the aorta. The root was
intact. The coronary ostia were intact. Cardioplegia was given both
in the coronary sinus and down the coronary ostium every 20 minutes
to maintain a myocardial arrest. The Sarns vent was activated and the
heart was completely decompressed, and the aortic valve was intact.
The sinotubular junction was transected and the old calcified type A
dissection was identified. We were to remove this part of the
pathology of the aorta, sent off to the lab. At this point, using
(____) as reinforcement, the intima and adventitia at the sinotubular
junction were reinforced. At this time, once the reinforcement was
performed, we were able to place our 22 mm Hemashield graft and then
anastomose this to the sinotubular junction using 4-0 Prolene suture
in a two-layer closure. Once this anastomosis was completed, we were
able to continue perfusion of the remainder of the body. However, at
this point, the graft was measured at the bifurcating graft, where
the cannula was selectively antegrade perfusing the brain via the
innominate and left carotid. It was measured and, at this point,
another period of circ arrest was performed. Once the cardioplegia
circuit was shut down, the cannula in the bifurcating graft to the
innominate was removed, and the graft was then measured to meet the
ascending aortic graft coming off the root, and this anastomosis was
then created after (____) coronary was utilized to achieve an opening
in the graft. Using a 5-0 Prolene suture in a running fashion, the 14
mm graft was then anastomosed to the ascending aortic graft. Once the
anastomosis was completed, the de-airing needle was inserted into the
ascending aorta. Once the de-airing needle was placed into the
ascending aorta, the arterial circuit was connected back to the
femoral cannulation, and the patient was able to be de-aired. Once
the graft was de-aired, a clamp was placed on the 14 mm graft
perfusing the left common carotid and the innominate, and the femoral
artery cannula was then able to flow fully. Once on full
cardiopulmonary bypass, the IC was removed off the head, and the
patient was now rewarmed. As the patient was rewarmed, we were able
to vent our graft using a vent connected to the cardiopulmonary
bypass circuit via a pursestring suture in the body of the 22 mm
Hemashield graft.

At this point, the retrograde cerebral cannula had been removed and
the pursestring suture was tied down, and the retrograde cardioplegia
line was removed and the pursestring suture was tied down.  Two chest
tubes were inserted in the mediastinum, one in each pleural cavity,
and a pacing wire was placed on the epicardium of the right ventricle
and brought out through a separate stab incision. At this point, the
heart began to beat in a normal sinus rhythm. The clamps were removed
and the heart was being deaired. On transesophageal echo, there was
no evidence of any arch insufficiency; and once the air was
completely removed, the deairing needle was removed, and the
pursestring suture was tied down and reinforced with a 5-0 Prolene
suture. At this point, the patient was able to be weaned off the
cardiopulmonary bypass. Once weaned off cardiopulmonary bypass,
hemostasis was identified of the entire mediastinum. About two hours
of hemostasis was able to be performed. At this point, the patient
was hemodynamically stable with no evidence of any active bleeding.
We were able to reapproximate his sternum using seven sternal wires,
two in the manubrium and five in the body of the sternum, and the
fascia was closed in multiple layers of #0 Vicryl suture in running
subcuticular closure in two-layer fashion, and 3-0 Monocryl to skin,
sterile bandages to the skin, and a pressure dressing was applied.
The patient was hemodynamically stable and tolerated this massive
operation well, and was brought to the intensive care unit in a
stable but guarded condition.

The concerns I have at this point are bleeding, end-organ damage,
kidney failure, dialysis, and the possibility of brain death or
stroke. All this has been discussed in great detail with the
patient's family and full disclosure was given to the patient's
family. The patient was brought to intensive care unit and remained
cautiously optimistic that, typically, the operation went well and I
hope the patient recovers just as well.

Addendum: The entire circ arrest time added 43 minutes to the first
circ arrest period and 19 minutes to the second.

Can someone please help me with this Report I'm reading it and confuse with it. I'll really appreciate any help.
Thanks in advance........


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## lisigirl (Aug 1, 2012)

Hi,

Let me know if you have specific questions but I would bill with the following codes:

33860
33870-59
dx: 441.01

I wouldn't code the repair of the arteries unless the repairs were complex (which I don't think these were but I need to add, by the end of this note I was just scanning it so if you think the repairs were complex, go ahead and bill for them). Otherwise, closing them is just a necessary thing the surgeon needs to do after cannulating them. The cannulation was done in order to place the patient on bypass so you would not charge separately for this.

As for the -59 on the arch repair, for some insane reason, CCI now bundles a transverse arch repair with the ascending aorta graft.  My surgeon found this to be completely unreasonable (because replacing the arch is much more work and risk to the patient) and so I asked about this at the Society of Thoracic Surgeons coding workshop. They agreed that if the head vessels are re-implanted you should bill with 33870 but you will need to add modifier -59 to unbundle it. (This is not true for a hemi-arch graft - that's when the bottom of the arch is replaced but the surgeon leaves all the head vessels - innominate, carotid & subclavian- alone. You cannot bill separately in that situation).

Let me know if you have more questions. Feel free to email me directly.

Lisi, CPC
eharkler@nmh.org


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## sandy06 (Aug 14, 2012)

Thanks, for your help.........


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