conleyclan
Guru
Hello, I have read this report, and am not 100% sure I am capturing all of the work. I am trying to capture the intercostal artery reimplantation). CPT 33870 does capture this, but this is a descending thoracic aneurysm, and I am leaning toward 33875.
PREOPERATIVE DIAGNOSIS: Acute on chronic expanding and aneurysmal
dilatation of chronic type B aortic dissection.
POSTOPERATIVE DIAGNOSIS: Acute on chronic expanding and aneurysmal
dilatation of chronic type B aortic dissection.
PROCEDURES:
1. Repair of acute on chronic type B aortic dissection with replacement of
the descending aorta from the level of the subclavian with 34 mm Gelweave
graft to the level of the distal descending thoracic aorta.
2. Reimplantation of the intercostal artery with reverse saphenous vein
graft.
3. Cutdown and repair of the left common femoral artery.
4. Bronchoscopy.
.
CLINICAL NOTE AND NEUROPHYSIOLOGIC DATA:
been following for approximately 2 years. Recently, he has had ongoing
expansion of his type B aortic dissection; however, most recently, he
appears to have had bleeding into the proximal descending thoracic aorta
with expansion and given this, we felt that there was strong indication to
proceed with repair. We confirmed acute blood in the false lumen. We were
able to identify his recurrent laryngeal nerve and felt that we had
protected it. We replaced from the level of the subclavian artery down to
the distal descending thoracic aorta. We implanted 1 large intercostal
with the saphenous vein bypass. His EEG and SSEPs were returned to
baseline, although he had lagging of the left leg, but this was most likely
attributable to the perfusion cannula. His body circulatory arrest time
was 35 minutes. We used a total body retrograde perfusion for that same
period of time. He was isoelectric at a bladder temperature of 19.7
degrees, and he was, as stated above, returned to baseline at the
conclusion of the operation.
OPERATIVE NOTE: Once the patient was brought to operative suite, he was
prepped and draped in a sterile fashion. After perivertebral block and
lumbar drain had been placed and the patient in the supine position, had
endoscopic vein harvesting performed and cutdown in the left common femoral
artery. At this point, we stapled the groin incision closed, prepared the
vein, and then turned the patient with left side up. We made an incision 2
cm below the scapula and entered between the 4th and 5th ribs and notched
the ribs distal at their origin. We used a suture to retract the diaphragm
and deflated along. The lung was adhered to the proximal portion of
descending thoracic aorta. This was dissected free. We opened the
pericardium and identified the proximal portion of the atrial caval
junction inferiorly and then heparinized the patient. We placed a 28
angled cannula in the site for venous drainage and then used the 18
Fem-Flex for the left common femoral artery, which was used for
percutaneous technique. After this was done, cardiopulmonary bypass was
instituted. During this period, we were able to remove the lung adhesions
on the aneurysm and identified the ductus arteriosus, dissect the vein off
the recurrent laryngeal nerve off of the aorta with sharp dissection and
then from the outside of the aorta divided small intercostal and bronchial
branches with clips. Once the patient was isoelectric, we used retrograde
total body perfusion by opening the Y in the circuit and then opening the
aneurysm. There was fresh blood in the false lumen that was clotted and
then we identified the primary tear and the subclavian artery. We sewed a
34 mm Gelweave graft to this area using long 3-0 Prolene suture. Then, we
cannulated this graft and resume perfusion and we had dual perfusion from
above and below. Then, we removed the bottom clamp and cut a large V in
the septum and then proceeded to place the graft distally with the same
suture technique. We also used a saphenous vein to graft the largest
intercostal and then brought this out laterally and use Ophthalmology
cautery and 5-0 Prolene to place the vein to the graft. At this point, the
patient was rewarmed fully. Both lungs were ventilated and he was weaned
from cardiopulmonary bypass without difficulty. Cannulas were removed. It
was also noted that the left common femoral artery was repaired earlier and
then once hemostasis had been achieved, the wounds were closed in several
layers. Drains were placed. The patient was turned supine and
bronchoscopy was performed. The double-lumen tube was removed and he was
transported to Cardiothoracic ICU.
______________________________
PREOPERATIVE DIAGNOSIS: Acute on chronic expanding and aneurysmal
dilatation of chronic type B aortic dissection.
POSTOPERATIVE DIAGNOSIS: Acute on chronic expanding and aneurysmal
dilatation of chronic type B aortic dissection.
PROCEDURES:
1. Repair of acute on chronic type B aortic dissection with replacement of
the descending aorta from the level of the subclavian with 34 mm Gelweave
graft to the level of the distal descending thoracic aorta.
2. Reimplantation of the intercostal artery with reverse saphenous vein
graft.
3. Cutdown and repair of the left common femoral artery.
4. Bronchoscopy.
.
CLINICAL NOTE AND NEUROPHYSIOLOGIC DATA:
been following for approximately 2 years. Recently, he has had ongoing
expansion of his type B aortic dissection; however, most recently, he
appears to have had bleeding into the proximal descending thoracic aorta
with expansion and given this, we felt that there was strong indication to
proceed with repair. We confirmed acute blood in the false lumen. We were
able to identify his recurrent laryngeal nerve and felt that we had
protected it. We replaced from the level of the subclavian artery down to
the distal descending thoracic aorta. We implanted 1 large intercostal
with the saphenous vein bypass. His EEG and SSEPs were returned to
baseline, although he had lagging of the left leg, but this was most likely
attributable to the perfusion cannula. His body circulatory arrest time
was 35 minutes. We used a total body retrograde perfusion for that same
period of time. He was isoelectric at a bladder temperature of 19.7
degrees, and he was, as stated above, returned to baseline at the
conclusion of the operation.
OPERATIVE NOTE: Once the patient was brought to operative suite, he was
prepped and draped in a sterile fashion. After perivertebral block and
lumbar drain had been placed and the patient in the supine position, had
endoscopic vein harvesting performed and cutdown in the left common femoral
artery. At this point, we stapled the groin incision closed, prepared the
vein, and then turned the patient with left side up. We made an incision 2
cm below the scapula and entered between the 4th and 5th ribs and notched
the ribs distal at their origin. We used a suture to retract the diaphragm
and deflated along. The lung was adhered to the proximal portion of
descending thoracic aorta. This was dissected free. We opened the
pericardium and identified the proximal portion of the atrial caval
junction inferiorly and then heparinized the patient. We placed a 28
angled cannula in the site for venous drainage and then used the 18
Fem-Flex for the left common femoral artery, which was used for
percutaneous technique. After this was done, cardiopulmonary bypass was
instituted. During this period, we were able to remove the lung adhesions
on the aneurysm and identified the ductus arteriosus, dissect the vein off
the recurrent laryngeal nerve off of the aorta with sharp dissection and
then from the outside of the aorta divided small intercostal and bronchial
branches with clips. Once the patient was isoelectric, we used retrograde
total body perfusion by opening the Y in the circuit and then opening the
aneurysm. There was fresh blood in the false lumen that was clotted and
then we identified the primary tear and the subclavian artery. We sewed a
34 mm Gelweave graft to this area using long 3-0 Prolene suture. Then, we
cannulated this graft and resume perfusion and we had dual perfusion from
above and below. Then, we removed the bottom clamp and cut a large V in
the septum and then proceeded to place the graft distally with the same
suture technique. We also used a saphenous vein to graft the largest
intercostal and then brought this out laterally and use Ophthalmology
cautery and 5-0 Prolene to place the vein to the graft. At this point, the
patient was rewarmed fully. Both lungs were ventilated and he was weaned
from cardiopulmonary bypass without difficulty. Cannulas were removed. It
was also noted that the left common femoral artery was repaired earlier and
then once hemostasis had been achieved, the wounds were closed in several
layers. Drains were placed. The patient was turned supine and
bronchoscopy was performed. The double-lumen tube was removed and he was
transported to Cardiothoracic ICU.
______________________________