hthr.santos
Contributor
Based on the op note I think it's 33853 but the note doesn't mention interruption or hypoplasia of the aortic arch. Can someone help me with this cpt?
At this time, I switched gears and focused on the aortic arch reconstruction. The patient had a
known aberrant right subclavian artery, and each of the head vessels was dissected and
encircled with silk ligatures and snares. The patient had a common trunk that led to the origins
of the right and left common carotid arteries. The aberrant subclavian was also identified
coursing posteriorly, and this was also snared. The descending thoracic aorta was mobilized
fully, and the left recurrent laryngeal nerve was identified and spared throughout the entire
operation. At this time, the ligamentum arteriosum was dissected off the main pulmonary
artery, and two 5-0 Prolene transfixion sutures were placed and tied, and the ligamentum
arteriosum was divided in between ligatures. This allowed to give me a good handle of the
distal thoracic aorta for exposure. The 1st and 2nd order intercostal arteries were identified,
and the descending thoracic aorta clamp was placed as low as possible. At this time, I
instructed the perfusionist to drop our flows to 50 mL/kg/minute. The aortic cannula was then
withdrawn back to the base of the common carotid artery and advanced into the right carotid
artery and re-secured. The vessel was snared and tightened. In addition, a side arm of the
arterial line was connected, and a pursestring suture was placed in the aortic root. An 11 blade
was utilized to make an arteriotomy, and a 3 mm olive-tip cannula was then connected to the
side arm to provide antegrade coronary perfusion. The suture was snared and tightened, and
the aortic crossclamp was placed just distal to this. This isolated the arch quite well, allowing
perfusion to the brain and to the heart while we worked on the arch.
All of the head vessels were snared, and then the aortic arch was opened. Metzenbaum
scissors were utilized to resect all the remnant ductal tissue. The cut back on the transverse
arch was brought all the way back to the distal ascending aorta, and the stay sutures were
placed for exposure. There was clear redundancy of the aortic arch with a decreased caliber of
the distal transverse aortic arch as well as isthmus. The thoracic aorta had a good caliber.
Then, a piece of pulmonary artery homograft was brought to the field and cut to shape, and this
was utilized to reconstruct the aortic arch with a running 7-0 Prolene suture. First, a lesser
curvature suture line was performed, and then the greater curvature. As I brought back the
patch toward the ascending aorta, it was trimmed to the desired length and width, and the
suture line was continued anteriorly. Before tying the suture, the descending thoracic aorta
clamp was removed, allowing the arch to fill and de-air completely. It plumped quite well, and I
was satisfied with the lay. Each of the head vessels was unsnared, and the ligatures were cut
and removed. The suture was tied. The proximal aortic crossclamp was removed, allowing
antegrade flow to the newly reconstructed arch. The common carotid artery snare was
released and cut, and the aortic cannula was withdrawn from the common carotid artery and
advanced into the newly reconstructed arch. I instructed the perfusionist to come up on our
flows to full flow and to fully rewarm.
At this time, I switched gears and focused on the aortic arch reconstruction. The patient had a
known aberrant right subclavian artery, and each of the head vessels was dissected and
encircled with silk ligatures and snares. The patient had a common trunk that led to the origins
of the right and left common carotid arteries. The aberrant subclavian was also identified
coursing posteriorly, and this was also snared. The descending thoracic aorta was mobilized
fully, and the left recurrent laryngeal nerve was identified and spared throughout the entire
operation. At this time, the ligamentum arteriosum was dissected off the main pulmonary
artery, and two 5-0 Prolene transfixion sutures were placed and tied, and the ligamentum
arteriosum was divided in between ligatures. This allowed to give me a good handle of the
distal thoracic aorta for exposure. The 1st and 2nd order intercostal arteries were identified,
and the descending thoracic aorta clamp was placed as low as possible. At this time, I
instructed the perfusionist to drop our flows to 50 mL/kg/minute. The aortic cannula was then
withdrawn back to the base of the common carotid artery and advanced into the right carotid
artery and re-secured. The vessel was snared and tightened. In addition, a side arm of the
arterial line was connected, and a pursestring suture was placed in the aortic root. An 11 blade
was utilized to make an arteriotomy, and a 3 mm olive-tip cannula was then connected to the
side arm to provide antegrade coronary perfusion. The suture was snared and tightened, and
the aortic crossclamp was placed just distal to this. This isolated the arch quite well, allowing
perfusion to the brain and to the heart while we worked on the arch.
All of the head vessels were snared, and then the aortic arch was opened. Metzenbaum
scissors were utilized to resect all the remnant ductal tissue. The cut back on the transverse
arch was brought all the way back to the distal ascending aorta, and the stay sutures were
placed for exposure. There was clear redundancy of the aortic arch with a decreased caliber of
the distal transverse aortic arch as well as isthmus. The thoracic aorta had a good caliber.
Then, a piece of pulmonary artery homograft was brought to the field and cut to shape, and this
was utilized to reconstruct the aortic arch with a running 7-0 Prolene suture. First, a lesser
curvature suture line was performed, and then the greater curvature. As I brought back the
patch toward the ascending aorta, it was trimmed to the desired length and width, and the
suture line was continued anteriorly. Before tying the suture, the descending thoracic aorta
clamp was removed, allowing the arch to fill and de-air completely. It plumped quite well, and I
was satisfied with the lay. Each of the head vessels was unsnared, and the ligatures were cut
and removed. The suture was tied. The proximal aortic crossclamp was removed, allowing
antegrade flow to the newly reconstructed arch. The common carotid artery snare was
released and cut, and the aortic cannula was withdrawn from the common carotid artery and
advanced into the newly reconstructed arch. I instructed the perfusionist to come up on our
flows to full flow and to fully rewarm.
