conleyclan
Guru
Aortic fenestration with Bare-metal Stenting/Stenting for pseudocoarctation.
Is this anywhere close to code 34842. I have not done this before.
Thanks
PREOPERATIVE DIAGNOSES: Renal insufficiency, right renal arterial inflow
obstruction, abdominal pseudocoarctation, chronic aneurysmal type B aortic
dissection.
POSTOPERATIVE DIAGNOSES: Renal insufficiency, right renal arterial inflow
obstruction, abdominal pseudocoarctation, chronic aneurysmal type B aortic
dissection.
PROCEDURES PERFORMED: Thoracic endovascular aortic repair (Cook Zenith TX2
stent grafts-- 32 mm x 200 mm, 34 mm x 77 mm, 40 mm x 81 mm), abdominal
aortic fenestration with bare-metal stenting (Palmaz 39 mm stent dilated to
33 mm caliber), infrarenal abdominal aortic stenting for pseudocoarctation
(Palmaz 49 mm length stent dilated to 24 mm in diameter), thoracic
aortogram with radiologic supervision and interpretation, intravascular
ultrasound with radiologic supervision and interpretation, right common
femoral arterial cutdown with primary repair, general endotracheal
anesthesia.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite,
placed supine, induced with general endotracheal anesthesia. The abdomen
and groins were prepped and draped in usual sterile fashion. The 2 cm
oblique incision was made above the right inguinal crease and the right
common femoral artery was circumferentially dissected out for proximal and
distal control. The patient was heparinized to an ACT over 300 seconds and
then 18-gauge needle introduced in the right common femoral artery under
direct vision. The guidewire was advanced under fluoroscopic guidance
throughout the thoracoabdominal aorta and positioned in the aortic arch.
Again, exchanged that guidewire, which was a Glidewire for a pigtail
catheter and then exchanged the pigtail catheter for a Lunderquist Super
Stiff guidewire over which an intravascular ultrasound was performed and we
confirmed that we were within the true lumen from the right common femoral
artery up through the iliac artery, abdominal aorta and in thoracic aorta.
We were able to get this guidewire all through the true lumen, despite the
very tight pseudocoarctation at the level of the infrarenal abdominal
aorta. I then exchanged the Lunderquist Super Stiff guidewire for a
pigtail catheter, positioning its tip in the aortic arch and then performed
a thoracic aortogram to create a road map of the distal arch and right
subclavian artery in particular. We then exchanged the pigtail catheter
for a Lunderquist Super Stiff guidewire over which a 32 mm x 200 mm Cook
TX2 stent graft was advanced in its proximal aspect positioned right at the
distal edge of the left subclavian ostium. At this point, using the
aortogram as a road map, we then slowly deployed the TX2 stent graft with a
very precisely ending at the distal aspect of the ostium of the left
subclavian artery. It was fully deployed and then a Gore trilobed balloon
was advanced through the Cook sheath and we ballooned the proximal landing
site with a 40 mL Tri-Lobe balloon getting excellent apposition. Next, 2
additional modules of stent grafts were placed, first a 34 mm x 77 mm
distal extension Cook TX2 was advanced and placed with a single V-stent
overlap of the first module, it was deployed and then a third module 40 mm
x 81 mm distal extension was placed again with one Z-stent overlap relative
to the second module. After all 3 modules were placed, we then used a 40
mL colored balloon to balloon the overlapping modules and a Gore trilobed
40 mL balloon for dilatation of the distal most touchdown site. Then an
intravascular ultrasound was performed and with the IVUS, we confirmed that
there was still poor inflow to the false lumen at the superior mesenteric
and right renal arterial level and therefore, I planned to perform a
controlled fenestration at this level. This was done by placing a 39 mm
length, 10 mm BRAT Palmaz stent on top of a 33 mm x 4 cm Z-Med balloon.
The Palmaz was crimped down on top of the balloon and then a 20-French
Medtronic sheath was exchanged for the Cook sheath, being a shorter length
sheath. Through the Medtronic sheath, we then advanced the Palmaz stent
loaded on the 33 mm Z-Med balloon and positioned it right at the chronic
secondary tear just at the distal aspect of the final Cook TX2 module. I
then balloon dilated the secondary care to create a larger fenestration
with the Palmaz stent dilating the stent to the 33 mm caliber. This opened
up the inflow into the false lumen very well and a mesenteric aortogram was
then performed using a half strength contrast and this demonstrated widely
patent inflow to the right renal artery and the objective of improving
arterial inflow to the right renal artery was achieved. Next, we proceeded
to address the infrarenal abdominal pseudocoarctation, a 49 mm length Palmaz
stent (size 10 mm) was loaded on to a 24 mm x 4 cm Z-Med balloon, it was
crimped down on to the balloon and then the balloon with loaded Palmaz stent
was advanced into this segment of pseudocoarctation, which had been defined by
the previous aortogram. With the stent in place, we then balloon dilated the
pseudocoarctation up to 24 mm and got excellent result. A completion
arteriogram was performed, which demonstrated wide patency of the infrarenal
abdominal aorta with this Palmaz stent in place. At this point, the Medtronic
sheath was removed. Proximal and distal clamps were placed and the right
common femoral artery was repaired with running 6-0 Prolene suture. The
heparin was reversed with IV protamine and meticulous hemostasis confirmed in
the groin incision closed in layers with running absorbable sutures. The
patient tolerated the procedure well and the patient was transferred to the
CTICU in stable condition. Of note, I monitored the patient with continuous
EEG and SSEP and MEPs throughout the case and there were no changes in his
signals.
Is this anywhere close to code 34842. I have not done this before.
Thanks
PREOPERATIVE DIAGNOSES: Renal insufficiency, right renal arterial inflow
obstruction, abdominal pseudocoarctation, chronic aneurysmal type B aortic
dissection.
POSTOPERATIVE DIAGNOSES: Renal insufficiency, right renal arterial inflow
obstruction, abdominal pseudocoarctation, chronic aneurysmal type B aortic
dissection.
PROCEDURES PERFORMED: Thoracic endovascular aortic repair (Cook Zenith TX2
stent grafts-- 32 mm x 200 mm, 34 mm x 77 mm, 40 mm x 81 mm), abdominal
aortic fenestration with bare-metal stenting (Palmaz 39 mm stent dilated to
33 mm caliber), infrarenal abdominal aortic stenting for pseudocoarctation
(Palmaz 49 mm length stent dilated to 24 mm in diameter), thoracic
aortogram with radiologic supervision and interpretation, intravascular
ultrasound with radiologic supervision and interpretation, right common
femoral arterial cutdown with primary repair, general endotracheal
anesthesia.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite,
placed supine, induced with general endotracheal anesthesia. The abdomen
and groins were prepped and draped in usual sterile fashion. The 2 cm
oblique incision was made above the right inguinal crease and the right
common femoral artery was circumferentially dissected out for proximal and
distal control. The patient was heparinized to an ACT over 300 seconds and
then 18-gauge needle introduced in the right common femoral artery under
direct vision. The guidewire was advanced under fluoroscopic guidance
throughout the thoracoabdominal aorta and positioned in the aortic arch.
Again, exchanged that guidewire, which was a Glidewire for a pigtail
catheter and then exchanged the pigtail catheter for a Lunderquist Super
Stiff guidewire over which an intravascular ultrasound was performed and we
confirmed that we were within the true lumen from the right common femoral
artery up through the iliac artery, abdominal aorta and in thoracic aorta.
We were able to get this guidewire all through the true lumen, despite the
very tight pseudocoarctation at the level of the infrarenal abdominal
aorta. I then exchanged the Lunderquist Super Stiff guidewire for a
pigtail catheter, positioning its tip in the aortic arch and then performed
a thoracic aortogram to create a road map of the distal arch and right
subclavian artery in particular. We then exchanged the pigtail catheter
for a Lunderquist Super Stiff guidewire over which a 32 mm x 200 mm Cook
TX2 stent graft was advanced in its proximal aspect positioned right at the
distal edge of the left subclavian ostium. At this point, using the
aortogram as a road map, we then slowly deployed the TX2 stent graft with a
very precisely ending at the distal aspect of the ostium of the left
subclavian artery. It was fully deployed and then a Gore trilobed balloon
was advanced through the Cook sheath and we ballooned the proximal landing
site with a 40 mL Tri-Lobe balloon getting excellent apposition. Next, 2
additional modules of stent grafts were placed, first a 34 mm x 77 mm
distal extension Cook TX2 was advanced and placed with a single V-stent
overlap of the first module, it was deployed and then a third module 40 mm
x 81 mm distal extension was placed again with one Z-stent overlap relative
to the second module. After all 3 modules were placed, we then used a 40
mL colored balloon to balloon the overlapping modules and a Gore trilobed
40 mL balloon for dilatation of the distal most touchdown site. Then an
intravascular ultrasound was performed and with the IVUS, we confirmed that
there was still poor inflow to the false lumen at the superior mesenteric
and right renal arterial level and therefore, I planned to perform a
controlled fenestration at this level. This was done by placing a 39 mm
length, 10 mm BRAT Palmaz stent on top of a 33 mm x 4 cm Z-Med balloon.
The Palmaz was crimped down on top of the balloon and then a 20-French
Medtronic sheath was exchanged for the Cook sheath, being a shorter length
sheath. Through the Medtronic sheath, we then advanced the Palmaz stent
loaded on the 33 mm Z-Med balloon and positioned it right at the chronic
secondary tear just at the distal aspect of the final Cook TX2 module. I
then balloon dilated the secondary care to create a larger fenestration
with the Palmaz stent dilating the stent to the 33 mm caliber. This opened
up the inflow into the false lumen very well and a mesenteric aortogram was
then performed using a half strength contrast and this demonstrated widely
patent inflow to the right renal artery and the objective of improving
arterial inflow to the right renal artery was achieved. Next, we proceeded
to address the infrarenal abdominal pseudocoarctation, a 49 mm length Palmaz
stent (size 10 mm) was loaded on to a 24 mm x 4 cm Z-Med balloon, it was
crimped down on to the balloon and then the balloon with loaded Palmaz stent
was advanced into this segment of pseudocoarctation, which had been defined by
the previous aortogram. With the stent in place, we then balloon dilated the
pseudocoarctation up to 24 mm and got excellent result. A completion
arteriogram was performed, which demonstrated wide patency of the infrarenal
abdominal aorta with this Palmaz stent in place. At this point, the Medtronic
sheath was removed. Proximal and distal clamps were placed and the right
common femoral artery was repaired with running 6-0 Prolene suture. The
heparin was reversed with IV protamine and meticulous hemostasis confirmed in
the groin incision closed in layers with running absorbable sutures. The
patient tolerated the procedure well and the patient was transferred to the
CTICU in stable condition. Of note, I monitored the patient with continuous
EEG and SSEP and MEPs throughout the case and there were no changes in his
signals.
