conleyclan
Guru
Oh my!! Help please!! Thanks again!!
PREOPERATIVE DIAGNOSES:
1. ACUTE TYPE A AORTIC DISSECTION.
2. SEVERE AORTIC INSUFFICIENCY.
3. SEVERE VASCULAR DISEASE.
4. SEVERE CORONARY ARTERY DISEASE.
POSTOPERATIVE DIAGNOSES:
1. ACUTE TYPE A AORTIC DISSECTION.
2. SEVERE AORTIC INSUFFICIENCY.
3. SEVERE VASCULAR DISEASE.
4. SEVERE CORONARY ARTERY DISEASE.
PROCEDURE PERFORMED:
1. REOPERATIVE AORTIC ROOT REPAIR WITH NEOMEDIAL RECONSTRUCTION, ASCENDING
AORTIC AND TOTAL AORTIC ARCH REPLACEMENT (30 MM ASCENDING AORTIC GRAFT, 26
MM AORTIC ARCH GRAFT, 16 MM GRAFT FOR BRACHIOCEPHALIC RECONSTRUCTION USING
CARRELL BUTTON TECHNIQUE), DESCENDING THORACIC AORTIC STENT GRAFTING (26 MM
GORE-TAG) AORTIC VALVE REPLACEMENT (29 MM ST. JUDE TRIFECTA), REATTACHMENT
OBTUSE MARGINAL ARTERIAL VEIN GRAFT AND RIGHT CORONARY ARTERIAL VEIN GRAFT
TO THE NEOASCENDING AORTA.
2. PLACEMENT OF LEFT COMMON FEMORAL ARTERIAL LINE.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite,
placed supine, induced with general endotracheal anesthesia. A central
line and radial arterial line were placed by the anesthesia team for
intraoperative monitoring. I placed a left common femoral arterial line
for additional arterial monitoring. The arterial line was placed using a
Seldinger technique.
The patient was then prepped and draped in the usual sterile fashion from
the chin to the toes. A reoperative midline sternotomy was made in the
usual fashion using an oscillating saw for the anterior sternal table and a
straight Mayo scissors for the posterior table. There were extraordinarily
dense adhesions throughout the mediastinum. We confirmed the diagnosis
immediately of acute type A aortic dissection. The ascending aorta was
markedly aneurysmal and the adhesions throughout the mediastinum were
extraordinarily dense. We carefully dissected out the right ventricle,
right atrium, and distal ascending aorta in that order. We then drew our
attention toward identifying whether or not there was a LIMA to LAD graft.
With some difficulty, we were able to identify a graft. It remained patent
and it remained free of injury throughout the entire case. We obtained
circumferential control of it near the left pulmonary artery to facilitate
its clamping at the time of cross clamping. We then proceeded then in
dissecting out the remaining portion of the ascending aorta. The patient
was then heparinized and then cannulated for cardiopulmonary bypass. This
was done via central cannulation technique. The ascending aorta was
cannulated using a Seldinger technique, whereby we introduced a 16-gauge
needle into the true lumen and advanced the guide wire under TEE guidance
confirming that our needle and guidewire were within the true lumen. We
then serially dilated up to a #20-French Edwards Fem-Flex catheter which
was positioned in the true lumen. The right atrial appendage was
cannulated with a dual stage and the superior vena cava was cannulated with
a #26-French angled soft cannula with its tip positioned in the right
internal jugular vein for use for retrograde cerebral perfusion. A
coronary sinus catheter was placed for retrograde cardioplegia.
Additionally, the patient was monitored with continuous EEG and SSEPs to
help direct safe period of deep hypothermic circulatory arrest. Following
cannulation, the patient was placed on cardiopulmonary bypass and
systemically cooled to deep hypothermia. During systemic cooling, an aortic
cross-clamp was applied and bulldog clamps were placed across the LIMA to
LAD graft. We then delivered initial induction cold blood high potassium
cardioplegia retrograde to achieve a ventricular fibrillatory arrest, at
which time, the ascending aorta was transected and then we delivered direct
ostial antegrade cold blood high potassium cardioplegia to both the left
and right coronary ostia. We gave additional antegrade cardioplegia
through a vein graft to the OM and a vein graft to the right coronary
artery. These were identified during the initial dissection of the
mediastinum. Following adequate induction, we then carefully inspected the
ascending aorta and root.
We confirmed that the primary tear site was in the left coronary sinus and
adjacent and just cephalad to the left main coronary ostium. Fortunately,
the tear did not extend into the ostium, but was adjacent to it
approximately 4 mm away. The tear was several centimeters long and the
dissection extended into the left coronary, noncoronary and right coronary
sinuses all the way to the annular level throughout the entire left and
right coronary sinuses. The aortic valve was a tricuspid aortic valve, but
a few of the leaflets were mildly calcified and, therefore, I made a
decision to repair the root using a neomedial reconstruction technique,
resect the valve and replace it. We began with a repair of the root by
first debriding all clot and blood from the dissected plane within the root
proximal to the sinotubular junction.
The aorta was then transected at the supracoronary level just proximal to
the sinotubular junction. We then repaired the left non and right coronary
sinuses by tailoring a piece of Teflon felt into the shape of the sinuses.
The patch was then placed within the dissected plane and then we sewed the
native adventitia neomedial felt and then native media and intima to one
another in a sandwich technique with the felt in the inner layer using
several interrupted pledgeted 4-0 Prolene sutures. Similarly, the
commissures were resuspended with pledgeted 4-0 Prolene sutures. Following
neomedial reconstruction, we then excised the aortic valve and sounded the
LVOT and annulus to 29 mm. A 29 mm St. Jude medical Trifecta pericardial
valve was implanted using a supraannular technique with interrupted
nonpledgeted 2-0 Ti-Cron sutures. All the while, we were systemically
cooling to deep hypothermia and, following aortic valve implantation, we
achieved electrocerebral silence for greater than 4 minutes, per our
protocol, and we drew our attention toward the aortic arch.
A brief period of deep hypothermic circulatory arrest was initiated
utilizing retrograde cerebral perfusion, maintaining RCP flows of 250 mL
per minute with right internal jugular pressures of 20-22 mmHg. Upon
opening the arch, we noticed an excellent egress of dark blood through the
brachiocephalic ostia consistent with good retrograde cerebral perfusion.
We noted quite severe secondary tear within the arch, which extended from
the mid arch down into the descending thoracic aorta and this had been seen
on TEE prior to cannulation. This tear extended several centimeters into
the descending thoracic aorta. This tear mandated total arch replacement
and also mandated proximal descending thoracic aortic stent grafting
because the tear extended well beyond where we could anastomose to a level
distal to the tear site.
Therefore, we first dissected out the brachiocephalic ostia and created a
Carrell island by cutting the aorta along the edge of the 3 ostia,
innominate artery, left common carotid artery and left subclavian arteries,
removing all aorta except that associated intermittently with the ostia,
creating a single Carrell button. We then drew our attention toward the
proximal descending thoracic aorta. We transected the aorta at the
proximal descending thoracic aorta. Again, the tear noted extended beyond
this site. The dissection extended all the way to the aortic bifurcation.
We identified the true lumen and advanced a pigtail catheter into the true
lumen down the descending thoracic aorta.
Once that was in place, we then passed an Amplatz Super Stiff guide wire
into the pigtail catheter to position this guide wire in the true lumen
down the descending thoracic aorta. Over that guidewire, we then advanced
a GORE-TAG 26 mm x 10 cm stent graft for coverage of that tear in the
descending thoracic aorta to facilitate an acceptable and place to
anastomose our distal arch graft anastomosis. Following deployment of that
stent graft, we then took a 26 mm Vascutek graft and anastomosed it to the
proximal descending thoracic aorta and stent graft, taking bites of native
dissected aorta, stent graft and Vascutek graft with each bite using
running 2-0 Prolene suture, taking care to intussuscept the flares of the
tag into the Vascutek graft and ensure that all 3 layers, native aorta,
stent graft and Vascutek graft, were passed through with each needle pass.
Following completion of the entire anastomosis, we then reinforced this
anastomosis with multiple pledgeted 3-0 Prolene sutures on the exterior
side of the anastomosis. We paid particular attention to the area of the
aorta where the tear site was.
Next, we took a 16 mm Vascutek graft and cut it in a steep beveled fashion
and then anastomosed it to the Carrell button for the brachiocephalics
using running 4-0 Prolene suture, taking care to intussuscept graft to the
intimal surface of the button for hemostatic suture line. Following
completion of this anastomosis, we connected a #18-French Fem-Flex Edwards
catheter to the 16-mm graft and began antegrade cerebral perfusion through
this graft after adequately deairing the graft retrograde. We then
cannulated the distal arch graft with the 7 mm Sarns soft-tip cannula and
began perfusion of the lower body. Following adequate perfusion of both
the head and lower body, we then began systemically rewarming. We then
made an elliptical graftotomy on the arch graft along its greater curve and
then cut the 16 mm graft in a beveled fashion. We maintained perfusion
through the distal end and then anastomosed the 16 mm brachiocephalic graft
to the arch graft in an end-to-side fashion using running 2-0 Prolene
suture.
Following completion of the anastomosis just prior to the last suture being
placed, we removed the Edwards Fem-Flex catheter from the 16 mm graft,
de-aired the system appropriately, and then began central perfusion of the
brachiocephalic arch and descending thoracic aorta via the Sarns soft-tip
inflow catheter. Next, we drew attention back to the root. We then took a
30 mm Vascutek graft and anastomosed it to the repaired root at the
supracoronary level using running 4-0 Prolene suture, taking care to
intussuscept grafting to the native root for hemostatic suture line.
Following completion of that anastomosis, we then trimmed the distal aspect
of the root graft in a beveled fashion posteriorly and trimmed the proximal
aspect of the 26 mm arch graft proximal to the anastomosis of the 16 mm
brachiocephalic graft and cut it in a beveled fashion posteriorly and then
anastomosed the 26 mm graft to the 30 mm graft using running 2-0 Prolene
suture.
This completed the aortic reconstruction. We then debrided the vein graft
to the OM and vein graft to right coronary arteries, which had been
previously placed. We then made two circular graftotomies with the
ophthalmic cautery device and transferred the obtuse marginal graft and the
right coronary graft to the neoascending aorta using running 5-0 Prolene
suture for each anastomosis. Of note, these anastomoses were completed
with the cross clamp off and partial occlusion clamp was used to complete
each of the 2 anastomoses.
Following their completion, we continued with systemic rewarming until we
achieved normothermia. Upon achieving normothermia, the patient was
carefully weaned from cardiopulmonary bypass with preserved right and left
ventricular function with a well-seated bioprosthesis in the aortic
position with no perivalvular leak and no gradient across it. Following
weaning from bypass, the patient was decannulated and the heparin reversed
with IV protamine. Meticulous hemostasis was achieved in the entire
operative field with the administration of Factor VII cryoprecipitate and
platelet transfusions. Blake drains were placed in the right pleural space
in the mediastinum, as well a #36-French chest tube placed in the
mediastinum. Temporary atrial and ventricular pacing leads were secured,
although the patient returned to normal sinus rhythm. We covered as much
graft material as we could with surrounding soft tissues and then
reapproximated the sternum with interrupted heavy gauge wire. The
pectoralis fascia, subcutaneous tissues, and skin were all approximated
with running absorbable sutures. The patient tolerated the procedure well
and was sent to the CT ICU in stable condition. Of note, both EEG and SSEP
signals returned to their baseline prior to closure.
I was present and participating for the entire procedure.
______________________________
PREOPERATIVE DIAGNOSES:
1. ACUTE TYPE A AORTIC DISSECTION.
2. SEVERE AORTIC INSUFFICIENCY.
3. SEVERE VASCULAR DISEASE.
4. SEVERE CORONARY ARTERY DISEASE.
POSTOPERATIVE DIAGNOSES:
1. ACUTE TYPE A AORTIC DISSECTION.
2. SEVERE AORTIC INSUFFICIENCY.
3. SEVERE VASCULAR DISEASE.
4. SEVERE CORONARY ARTERY DISEASE.
PROCEDURE PERFORMED:
1. REOPERATIVE AORTIC ROOT REPAIR WITH NEOMEDIAL RECONSTRUCTION, ASCENDING
AORTIC AND TOTAL AORTIC ARCH REPLACEMENT (30 MM ASCENDING AORTIC GRAFT, 26
MM AORTIC ARCH GRAFT, 16 MM GRAFT FOR BRACHIOCEPHALIC RECONSTRUCTION USING
CARRELL BUTTON TECHNIQUE), DESCENDING THORACIC AORTIC STENT GRAFTING (26 MM
GORE-TAG) AORTIC VALVE REPLACEMENT (29 MM ST. JUDE TRIFECTA), REATTACHMENT
OBTUSE MARGINAL ARTERIAL VEIN GRAFT AND RIGHT CORONARY ARTERIAL VEIN GRAFT
TO THE NEOASCENDING AORTA.
2. PLACEMENT OF LEFT COMMON FEMORAL ARTERIAL LINE.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite,
placed supine, induced with general endotracheal anesthesia. A central
line and radial arterial line were placed by the anesthesia team for
intraoperative monitoring. I placed a left common femoral arterial line
for additional arterial monitoring. The arterial line was placed using a
Seldinger technique.
The patient was then prepped and draped in the usual sterile fashion from
the chin to the toes. A reoperative midline sternotomy was made in the
usual fashion using an oscillating saw for the anterior sternal table and a
straight Mayo scissors for the posterior table. There were extraordinarily
dense adhesions throughout the mediastinum. We confirmed the diagnosis
immediately of acute type A aortic dissection. The ascending aorta was
markedly aneurysmal and the adhesions throughout the mediastinum were
extraordinarily dense. We carefully dissected out the right ventricle,
right atrium, and distal ascending aorta in that order. We then drew our
attention toward identifying whether or not there was a LIMA to LAD graft.
With some difficulty, we were able to identify a graft. It remained patent
and it remained free of injury throughout the entire case. We obtained
circumferential control of it near the left pulmonary artery to facilitate
its clamping at the time of cross clamping. We then proceeded then in
dissecting out the remaining portion of the ascending aorta. The patient
was then heparinized and then cannulated for cardiopulmonary bypass. This
was done via central cannulation technique. The ascending aorta was
cannulated using a Seldinger technique, whereby we introduced a 16-gauge
needle into the true lumen and advanced the guide wire under TEE guidance
confirming that our needle and guidewire were within the true lumen. We
then serially dilated up to a #20-French Edwards Fem-Flex catheter which
was positioned in the true lumen. The right atrial appendage was
cannulated with a dual stage and the superior vena cava was cannulated with
a #26-French angled soft cannula with its tip positioned in the right
internal jugular vein for use for retrograde cerebral perfusion. A
coronary sinus catheter was placed for retrograde cardioplegia.
Additionally, the patient was monitored with continuous EEG and SSEPs to
help direct safe period of deep hypothermic circulatory arrest. Following
cannulation, the patient was placed on cardiopulmonary bypass and
systemically cooled to deep hypothermia. During systemic cooling, an aortic
cross-clamp was applied and bulldog clamps were placed across the LIMA to
LAD graft. We then delivered initial induction cold blood high potassium
cardioplegia retrograde to achieve a ventricular fibrillatory arrest, at
which time, the ascending aorta was transected and then we delivered direct
ostial antegrade cold blood high potassium cardioplegia to both the left
and right coronary ostia. We gave additional antegrade cardioplegia
through a vein graft to the OM and a vein graft to the right coronary
artery. These were identified during the initial dissection of the
mediastinum. Following adequate induction, we then carefully inspected the
ascending aorta and root.
We confirmed that the primary tear site was in the left coronary sinus and
adjacent and just cephalad to the left main coronary ostium. Fortunately,
the tear did not extend into the ostium, but was adjacent to it
approximately 4 mm away. The tear was several centimeters long and the
dissection extended into the left coronary, noncoronary and right coronary
sinuses all the way to the annular level throughout the entire left and
right coronary sinuses. The aortic valve was a tricuspid aortic valve, but
a few of the leaflets were mildly calcified and, therefore, I made a
decision to repair the root using a neomedial reconstruction technique,
resect the valve and replace it. We began with a repair of the root by
first debriding all clot and blood from the dissected plane within the root
proximal to the sinotubular junction.
The aorta was then transected at the supracoronary level just proximal to
the sinotubular junction. We then repaired the left non and right coronary
sinuses by tailoring a piece of Teflon felt into the shape of the sinuses.
The patch was then placed within the dissected plane and then we sewed the
native adventitia neomedial felt and then native media and intima to one
another in a sandwich technique with the felt in the inner layer using
several interrupted pledgeted 4-0 Prolene sutures. Similarly, the
commissures were resuspended with pledgeted 4-0 Prolene sutures. Following
neomedial reconstruction, we then excised the aortic valve and sounded the
LVOT and annulus to 29 mm. A 29 mm St. Jude medical Trifecta pericardial
valve was implanted using a supraannular technique with interrupted
nonpledgeted 2-0 Ti-Cron sutures. All the while, we were systemically
cooling to deep hypothermia and, following aortic valve implantation, we
achieved electrocerebral silence for greater than 4 minutes, per our
protocol, and we drew our attention toward the aortic arch.
A brief period of deep hypothermic circulatory arrest was initiated
utilizing retrograde cerebral perfusion, maintaining RCP flows of 250 mL
per minute with right internal jugular pressures of 20-22 mmHg. Upon
opening the arch, we noticed an excellent egress of dark blood through the
brachiocephalic ostia consistent with good retrograde cerebral perfusion.
We noted quite severe secondary tear within the arch, which extended from
the mid arch down into the descending thoracic aorta and this had been seen
on TEE prior to cannulation. This tear extended several centimeters into
the descending thoracic aorta. This tear mandated total arch replacement
and also mandated proximal descending thoracic aortic stent grafting
because the tear extended well beyond where we could anastomose to a level
distal to the tear site.
Therefore, we first dissected out the brachiocephalic ostia and created a
Carrell island by cutting the aorta along the edge of the 3 ostia,
innominate artery, left common carotid artery and left subclavian arteries,
removing all aorta except that associated intermittently with the ostia,
creating a single Carrell button. We then drew our attention toward the
proximal descending thoracic aorta. We transected the aorta at the
proximal descending thoracic aorta. Again, the tear noted extended beyond
this site. The dissection extended all the way to the aortic bifurcation.
We identified the true lumen and advanced a pigtail catheter into the true
lumen down the descending thoracic aorta.
Once that was in place, we then passed an Amplatz Super Stiff guide wire
into the pigtail catheter to position this guide wire in the true lumen
down the descending thoracic aorta. Over that guidewire, we then advanced
a GORE-TAG 26 mm x 10 cm stent graft for coverage of that tear in the
descending thoracic aorta to facilitate an acceptable and place to
anastomose our distal arch graft anastomosis. Following deployment of that
stent graft, we then took a 26 mm Vascutek graft and anastomosed it to the
proximal descending thoracic aorta and stent graft, taking bites of native
dissected aorta, stent graft and Vascutek graft with each bite using
running 2-0 Prolene suture, taking care to intussuscept the flares of the
tag into the Vascutek graft and ensure that all 3 layers, native aorta,
stent graft and Vascutek graft, were passed through with each needle pass.
Following completion of the entire anastomosis, we then reinforced this
anastomosis with multiple pledgeted 3-0 Prolene sutures on the exterior
side of the anastomosis. We paid particular attention to the area of the
aorta where the tear site was.
Next, we took a 16 mm Vascutek graft and cut it in a steep beveled fashion
and then anastomosed it to the Carrell button for the brachiocephalics
using running 4-0 Prolene suture, taking care to intussuscept graft to the
intimal surface of the button for hemostatic suture line. Following
completion of this anastomosis, we connected a #18-French Fem-Flex Edwards
catheter to the 16-mm graft and began antegrade cerebral perfusion through
this graft after adequately deairing the graft retrograde. We then
cannulated the distal arch graft with the 7 mm Sarns soft-tip cannula and
began perfusion of the lower body. Following adequate perfusion of both
the head and lower body, we then began systemically rewarming. We then
made an elliptical graftotomy on the arch graft along its greater curve and
then cut the 16 mm graft in a beveled fashion. We maintained perfusion
through the distal end and then anastomosed the 16 mm brachiocephalic graft
to the arch graft in an end-to-side fashion using running 2-0 Prolene
suture.
Following completion of the anastomosis just prior to the last suture being
placed, we removed the Edwards Fem-Flex catheter from the 16 mm graft,
de-aired the system appropriately, and then began central perfusion of the
brachiocephalic arch and descending thoracic aorta via the Sarns soft-tip
inflow catheter. Next, we drew attention back to the root. We then took a
30 mm Vascutek graft and anastomosed it to the repaired root at the
supracoronary level using running 4-0 Prolene suture, taking care to
intussuscept grafting to the native root for hemostatic suture line.
Following completion of that anastomosis, we then trimmed the distal aspect
of the root graft in a beveled fashion posteriorly and trimmed the proximal
aspect of the 26 mm arch graft proximal to the anastomosis of the 16 mm
brachiocephalic graft and cut it in a beveled fashion posteriorly and then
anastomosed the 26 mm graft to the 30 mm graft using running 2-0 Prolene
suture.
This completed the aortic reconstruction. We then debrided the vein graft
to the OM and vein graft to right coronary arteries, which had been
previously placed. We then made two circular graftotomies with the
ophthalmic cautery device and transferred the obtuse marginal graft and the
right coronary graft to the neoascending aorta using running 5-0 Prolene
suture for each anastomosis. Of note, these anastomoses were completed
with the cross clamp off and partial occlusion clamp was used to complete
each of the 2 anastomoses.
Following their completion, we continued with systemic rewarming until we
achieved normothermia. Upon achieving normothermia, the patient was
carefully weaned from cardiopulmonary bypass with preserved right and left
ventricular function with a well-seated bioprosthesis in the aortic
position with no perivalvular leak and no gradient across it. Following
weaning from bypass, the patient was decannulated and the heparin reversed
with IV protamine. Meticulous hemostasis was achieved in the entire
operative field with the administration of Factor VII cryoprecipitate and
platelet transfusions. Blake drains were placed in the right pleural space
in the mediastinum, as well a #36-French chest tube placed in the
mediastinum. Temporary atrial and ventricular pacing leads were secured,
although the patient returned to normal sinus rhythm. We covered as much
graft material as we could with surrounding soft tissues and then
reapproximated the sternum with interrupted heavy gauge wire. The
pectoralis fascia, subcutaneous tissues, and skin were all approximated
with running absorbable sutures. The patient tolerated the procedure well
and was sent to the CT ICU in stable condition. Of note, both EEG and SSEP
signals returned to their baseline prior to closure.
I was present and participating for the entire procedure.
______________________________