conleyclan
Guru
I become so confused with mixed messages on how to code aortic repairs. Thank you for any help anyone can give me. Total arch...I don't think so, but 33860 is not enough.
PREOPERATIVE DIAGNOSIS: Aortic transection.
PROCEDURES PERFORMED: Arch replacement with a 26 mm Gelweave graft, bypass
of the innominate artery with a 14 mm Gelweave graft, replacement of the
ascending aorta with a 26 mm Gelweave graft.
POSTOPERATIVE DIAGNOSIS: Aortic transection.
CLINICAL NOTE: A 46-year-old male involved in a motor vehicle accident.
His history is pertinent for a coarctation repair at age 8. He had
bilateral femur fractures which were externally stabilized at the outside
hospital. He had CT scanning, which showed a transection of the aorta
between the innominate and the left carotid artery. He was brought to the
Presbyterian Hospital where he was neurologically intact and underwent
repair. He had a circulatory arrest using antegrade cerebral perfusion as
an adjunct and his body circulatory arrest time was 24 minutes. His EEG
returned to baseline close to 30 degrees and LV function was preserved. He
did have a bicuspid aortic valve with some aortic insufficiency, but
overall was felt to be mild and no intervention was undertaken during this
operation.
OPERATIVE NOTE: Once the patient was brought to operative suite, he was
prepped and draped in sterile fashion. Sternotomy was performed. We noted
significant blood in the arterial and a mediastinal hematoma. The patient
was heparinized, placed on cardiopulmonary bypass. Using a cannulation of
the distal ascending aorta with a Seldinger technique and a 2-stage venous
cannula. He was cooled and during the interval of cooling, we held digital
pressure over the arch to contain the transection. We were, however, able
to dissect out the innominate artery and divided this between a clamp and
sewed a 14 mm Gelweave graft to this. We wide off the arterial head and
perfused the innominate artery. At this point, the patient reached
electrical silence. We arrested the circulation with the exception of
perfusion through the innominate artery and kept the right radial artery
pressure around 50. This generally provided 1.5 liters of flow. We opened
the aorta beginning at the innominate and noted a transection that
encompassed 50% of the aorta between the innominate artery and the left
carotid. This injured aorta was then removed and we selected a 26 mm
Gelweave graft and sewed this to the aortic arch at the ostium of the left
carotid. We then recannulated this graft with a 6 Edwards cannula and
rewarmed the body as we continued to perfuse the head through the
innominate artery. Then, a graft to graft anastomosis for the 14 mm graft
to the 26 mm graft was performed with 2-0 Prolene suture. At this point,
we examined the bicuspid valve and felt that it was satisfactory at this
point and still had some durability thus we left the valve and sewed to the
sinotubular junction, a second piece of 26 mm Gelweave graft, then a
graft-to-graft anastomosis was completed. The root was vented and the
cross-clamp was removed. The patient was then able to be weaned from
cardiopulmonary bypass once weaning criteria had been attained. We
evacuated a large right pleural effusion and we were able to improve the
oxygenation. Then protamine was administered; and once hemostasis had been
achieved, the chest was closed in standard fashion. I was present for the
entire duration of this operation.
______________________________
PREOPERATIVE DIAGNOSIS: Aortic transection.
PROCEDURES PERFORMED: Arch replacement with a 26 mm Gelweave graft, bypass
of the innominate artery with a 14 mm Gelweave graft, replacement of the
ascending aorta with a 26 mm Gelweave graft.
POSTOPERATIVE DIAGNOSIS: Aortic transection.
CLINICAL NOTE: A 46-year-old male involved in a motor vehicle accident.
His history is pertinent for a coarctation repair at age 8. He had
bilateral femur fractures which were externally stabilized at the outside
hospital. He had CT scanning, which showed a transection of the aorta
between the innominate and the left carotid artery. He was brought to the
Presbyterian Hospital where he was neurologically intact and underwent
repair. He had a circulatory arrest using antegrade cerebral perfusion as
an adjunct and his body circulatory arrest time was 24 minutes. His EEG
returned to baseline close to 30 degrees and LV function was preserved. He
did have a bicuspid aortic valve with some aortic insufficiency, but
overall was felt to be mild and no intervention was undertaken during this
operation.
OPERATIVE NOTE: Once the patient was brought to operative suite, he was
prepped and draped in sterile fashion. Sternotomy was performed. We noted
significant blood in the arterial and a mediastinal hematoma. The patient
was heparinized, placed on cardiopulmonary bypass. Using a cannulation of
the distal ascending aorta with a Seldinger technique and a 2-stage venous
cannula. He was cooled and during the interval of cooling, we held digital
pressure over the arch to contain the transection. We were, however, able
to dissect out the innominate artery and divided this between a clamp and
sewed a 14 mm Gelweave graft to this. We wide off the arterial head and
perfused the innominate artery. At this point, the patient reached
electrical silence. We arrested the circulation with the exception of
perfusion through the innominate artery and kept the right radial artery
pressure around 50. This generally provided 1.5 liters of flow. We opened
the aorta beginning at the innominate and noted a transection that
encompassed 50% of the aorta between the innominate artery and the left
carotid. This injured aorta was then removed and we selected a 26 mm
Gelweave graft and sewed this to the aortic arch at the ostium of the left
carotid. We then recannulated this graft with a 6 Edwards cannula and
rewarmed the body as we continued to perfuse the head through the
innominate artery. Then, a graft to graft anastomosis for the 14 mm graft
to the 26 mm graft was performed with 2-0 Prolene suture. At this point,
we examined the bicuspid valve and felt that it was satisfactory at this
point and still had some durability thus we left the valve and sewed to the
sinotubular junction, a second piece of 26 mm Gelweave graft, then a
graft-to-graft anastomosis was completed. The root was vented and the
cross-clamp was removed. The patient was then able to be weaned from
cardiopulmonary bypass once weaning criteria had been attained. We
evacuated a large right pleural effusion and we were able to improve the
oxygenation. Then protamine was administered; and once hemostasis had been
achieved, the chest was closed in standard fashion. I was present for the
entire duration of this operation.
______________________________