conleyclan
Guru
Are the intercostal arterial bypass grafts included. How would this be coded?Thanks.
He presents today for elective descending thoracic aortic
replacement with the defenestration of the abdominal aorta.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite,
at which time Anesthesia placed a thoracic epidural for postoperative pain
management and a lumbar spinal drain for postoperative CSF drainage. He
was then placed supine, induced with general endotracheal anesthesia. The
right lower extremity was then prepped and draped in the usual sterile
fashion, and the right greater saphenous vein in the thigh was
endoscopically harvested. That incision was then closed in layers with
running absorbable sutures, and then, the patient was turned in the right
lateral decubitus position with the table flexed. A bronchial blocker was
placed down the left main stem bronchus for left lung isolation. A
transesophageal echocardiogram was performed and it demonstrated no
significant aortic insufficiency with mildly reduced left ventricular
function. The left chest, the abdomen, and groin were prepped and draped
in the usual sterile fashion. We monitored arterial pressure via the right
radial arterial line and via a right femoral arterial line. A fifth
interspace posterolateral thoracotomy was made and extended anteriorly to
expose the descending thoracic aorta. It was exposed from the level of the
arch to the diaphragmatic hiatus. Two retraction sutures were tunneled
from the level of the 12th rib transcutaneously and the diaphragm tented
laterally to expose the aortic hiatus at the level of diaphragm. We then
made a transverse pericardiotomy posterior to the left phrenic nerve and
exposed the inferior vena cava at the RA caval junction. We then opened
the pericardium just anterior to the takeoff of the left inferior pulmonary
vein. The patient was then heparinized, and then, we cannulated the true
lumen of the mid descending thoracic aorta using a Seldinger technique, and
both epiaortic and TEE guidance confirmed placement of a 20-French Fem-Flex
catheter in the true lumen of the descending thoracic aorta. The right
atrium was cannulated at the IVC-RA junction with a 31-French right angle
metal cannula and the patient was placed on cardiopulmonary bypass. Prior
to systemic cooling, we placed a left ventricular vent through the junction
of the left atrium and left inferior pulmonary vein. Multiple attempts
were made getting the vent into the LV itself. Initially, we placed it in
the LA and then ultimately got it into the LV for good decompression. We
began systemically cooling the patient to deep hypothermia and monitored
the patient with continuous EEG and SSEPs to help direct a safe period of
deep hypothermic circulatory arrest to facilitate hemiarch reconstruction
from the distal aspect and an open anastomosis of the arch.
During systemic cooling, we dissected out the distal descending thoracic
aorta just above the diaphragm, and upon achieving core body temperature of
22 degrees centigrade, we placed a crossclamp just beyond the descending
thoracic aortic cannulation site, which was again in the mid descending
thoracic aorta. We maintained perfusion of the upper body and then
transected the distal thoracic aorta just above the diaphragm and then took
a 26 mm Vascutek graft and anastomosed it in an end-to-end fashion to the
distal thoracic aorta. Prior to completing that anastomosis, we resected
the chronic septum of the dissection as deeply as possible to widely
fenestrate the abdominal aorta. The anastomosis was completed with running
4-0 Prolene suture, and upon completion, we then cannulated the distal
graft using a separate arterial inflow cannula and then maintained dual
perfusion to the upper and lower body until systemically cooling to
electrocerebral silence, which was at a core temperature of approximately
19 degrees centigrade. At this point, we maintained the lower body
perfusion, but terminated upper body perfusion. We then transected the
aortic arch distally just at the level of the left subclavian artery.
Great care was taken to avoid injury to the left vagus nerve or recurrent
laryngeal nerves. We then trimmed the 26 mm graft to an appropriate length
in a beveled fashion for distal hemiarch replacement. The anastomosis was
then completed with running 4-0 Prolene suture. Upon its completion, we
spent some time de-airing the graft and de-airing the arch slowly. Upon
adequate de-airing, we then reconstituted flow through the graft and began
systemically rewarming. During systemic rewarming, we then filleted open
the entire descending thoracic aorta, we resected the entire septum and
identified multiple intercostal arteries, which were ligated with 4-0
Prolene suture endoluminally as well as several bronchial arteries. We
identified 2 intercostal arteries, which were of large caliber at the T9
level, and these were revascularized. We created a small ____ button
associated with the 2 intercostal arterial ostia. We then took a reverse
saphenous vein graft, cut it in a beveled fashion, and anastomosed it to
the intercostal arterial button using running 5-0 Prolene suture. It was
then wrapped around the anterior aspect of the descending thoracic aortic
graft. Partial occlusion clamp was placed on the graft and a circular
graftotomy made with the ophthalmic cautery device. The proximal aspect of
the vein graft was then cut to an appropriate length, spatulated, and
anastomosed to the descending thoracic aortic graft with running 5-0
Prolene suture. We continued perfusion until the patient had achieved a
core temperature of 35 degrees centigrade, at which time he was weaned from
cardiopulmonary bypass using dual lung ventilation without difficulty.
Following weaning from bypass, he was decannulated, the heparin was
reversed with IV protamine, meticulous hemostasis confirmed. We then
interrogated the intercostal arterial graft, which fed 2 intercostal
arteries, and using a Medistim flow probe, we confirmed flows of
approximately 75 mL per minute with a pulse index of 1.0 indicative of
excellent intercostal arterial graft. Hemostasis was confirmed, and then,
Blake drains were placed in the left pleural space, all cannulation sites
were oversewn, and the chest was then closed in layers. The ribs were
approximated with #2 Vicryl, the latissimus dorsi and serratus anterior
muscle fascia was approximated with running #1 Maxon, subcutaneous tissue
and skin were also approximated with running absorbable sutures. The
patient was then turned supine and a therapeutic aspiration bronchoscopy
was performed, some mild bloody secretions were aspirated from the
tracheobronchial tree. The patient was subsequently was transferred to the
CT ICU in stable condition. All EEG and SSEP signals have returned to
their baseline prior to completion of the case.
______________________________
He presents today for elective descending thoracic aortic
replacement with the defenestration of the abdominal aorta.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite,
at which time Anesthesia placed a thoracic epidural for postoperative pain
management and a lumbar spinal drain for postoperative CSF drainage. He
was then placed supine, induced with general endotracheal anesthesia. The
right lower extremity was then prepped and draped in the usual sterile
fashion, and the right greater saphenous vein in the thigh was
endoscopically harvested. That incision was then closed in layers with
running absorbable sutures, and then, the patient was turned in the right
lateral decubitus position with the table flexed. A bronchial blocker was
placed down the left main stem bronchus for left lung isolation. A
transesophageal echocardiogram was performed and it demonstrated no
significant aortic insufficiency with mildly reduced left ventricular
function. The left chest, the abdomen, and groin were prepped and draped
in the usual sterile fashion. We monitored arterial pressure via the right
radial arterial line and via a right femoral arterial line. A fifth
interspace posterolateral thoracotomy was made and extended anteriorly to
expose the descending thoracic aorta. It was exposed from the level of the
arch to the diaphragmatic hiatus. Two retraction sutures were tunneled
from the level of the 12th rib transcutaneously and the diaphragm tented
laterally to expose the aortic hiatus at the level of diaphragm. We then
made a transverse pericardiotomy posterior to the left phrenic nerve and
exposed the inferior vena cava at the RA caval junction. We then opened
the pericardium just anterior to the takeoff of the left inferior pulmonary
vein. The patient was then heparinized, and then, we cannulated the true
lumen of the mid descending thoracic aorta using a Seldinger technique, and
both epiaortic and TEE guidance confirmed placement of a 20-French Fem-Flex
catheter in the true lumen of the descending thoracic aorta. The right
atrium was cannulated at the IVC-RA junction with a 31-French right angle
metal cannula and the patient was placed on cardiopulmonary bypass. Prior
to systemic cooling, we placed a left ventricular vent through the junction
of the left atrium and left inferior pulmonary vein. Multiple attempts
were made getting the vent into the LV itself. Initially, we placed it in
the LA and then ultimately got it into the LV for good decompression. We
began systemically cooling the patient to deep hypothermia and monitored
the patient with continuous EEG and SSEPs to help direct a safe period of
deep hypothermic circulatory arrest to facilitate hemiarch reconstruction
from the distal aspect and an open anastomosis of the arch.
During systemic cooling, we dissected out the distal descending thoracic
aorta just above the diaphragm, and upon achieving core body temperature of
22 degrees centigrade, we placed a crossclamp just beyond the descending
thoracic aortic cannulation site, which was again in the mid descending
thoracic aorta. We maintained perfusion of the upper body and then
transected the distal thoracic aorta just above the diaphragm and then took
a 26 mm Vascutek graft and anastomosed it in an end-to-end fashion to the
distal thoracic aorta. Prior to completing that anastomosis, we resected
the chronic septum of the dissection as deeply as possible to widely
fenestrate the abdominal aorta. The anastomosis was completed with running
4-0 Prolene suture, and upon completion, we then cannulated the distal
graft using a separate arterial inflow cannula and then maintained dual
perfusion to the upper and lower body until systemically cooling to
electrocerebral silence, which was at a core temperature of approximately
19 degrees centigrade. At this point, we maintained the lower body
perfusion, but terminated upper body perfusion. We then transected the
aortic arch distally just at the level of the left subclavian artery.
Great care was taken to avoid injury to the left vagus nerve or recurrent
laryngeal nerves. We then trimmed the 26 mm graft to an appropriate length
in a beveled fashion for distal hemiarch replacement. The anastomosis was
then completed with running 4-0 Prolene suture. Upon its completion, we
spent some time de-airing the graft and de-airing the arch slowly. Upon
adequate de-airing, we then reconstituted flow through the graft and began
systemically rewarming. During systemic rewarming, we then filleted open
the entire descending thoracic aorta, we resected the entire septum and
identified multiple intercostal arteries, which were ligated with 4-0
Prolene suture endoluminally as well as several bronchial arteries. We
identified 2 intercostal arteries, which were of large caliber at the T9
level, and these were revascularized. We created a small ____ button
associated with the 2 intercostal arterial ostia. We then took a reverse
saphenous vein graft, cut it in a beveled fashion, and anastomosed it to
the intercostal arterial button using running 5-0 Prolene suture. It was
then wrapped around the anterior aspect of the descending thoracic aortic
graft. Partial occlusion clamp was placed on the graft and a circular
graftotomy made with the ophthalmic cautery device. The proximal aspect of
the vein graft was then cut to an appropriate length, spatulated, and
anastomosed to the descending thoracic aortic graft with running 5-0
Prolene suture. We continued perfusion until the patient had achieved a
core temperature of 35 degrees centigrade, at which time he was weaned from
cardiopulmonary bypass using dual lung ventilation without difficulty.
Following weaning from bypass, he was decannulated, the heparin was
reversed with IV protamine, meticulous hemostasis confirmed. We then
interrogated the intercostal arterial graft, which fed 2 intercostal
arteries, and using a Medistim flow probe, we confirmed flows of
approximately 75 mL per minute with a pulse index of 1.0 indicative of
excellent intercostal arterial graft. Hemostasis was confirmed, and then,
Blake drains were placed in the left pleural space, all cannulation sites
were oversewn, and the chest was then closed in layers. The ribs were
approximated with #2 Vicryl, the latissimus dorsi and serratus anterior
muscle fascia was approximated with running #1 Maxon, subcutaneous tissue
and skin were also approximated with running absorbable sutures. The
patient was then turned supine and a therapeutic aspiration bronchoscopy
was performed, some mild bloody secretions were aspirated from the
tracheobronchial tree. The patient was subsequently was transferred to the
CT ICU in stable condition. All EEG and SSEP signals have returned to
their baseline prior to completion of the case.
______________________________