conleyclan
Guru
Every time I think I have aneurysms figured out....... Any help would be appreciated!! always put too much into it and then just confuse myself.....
Thanks !!
PREOPERATIVE DIAGNOSES: Aortic arch and Kommerell's diverticular aneurysm,
right-sided aortic arch with right-sided descending thoracic aorta,
dysphagia, tracheal compression.
POSTOPERATIVE DIAGNOSES: Aortic arch and Kommerell's diverticular
aneurysm, right-sided aortic arch with right-sided descending thoracic
aorta, dysphagia, tracheal compression.
PROCEDURE PERFORMED: Ascending aortic replacement (28 mm Vascutek graft),
total aortic arch replacement (28 mm and 18 mm Vascutek grafts), descending
thoracic aortic replacement (26 mm Vascutek graft) via right fifth
interspace thoracotomy, placement of left thoracostomy tube, therapeutic
aspiration bronchoscopy, esophagogastroduodenoscopy.
BRIEF HISTORY: The patient is a 55-year-old male with a history of a
right-sided aortic arch, right-sided descending thoracic aorta and then
aortic arch and Kommerell's diverticular aneurysm causing significant
compression of both the esophagus and the trachea. The patient has
suffered from dysphagia most of his adult life and he also suffers from a
tracheal compression. The patient is a professional trumpet player and has
noted difficulty with respect to his musical instrument playing due to his
issues of a stridor and a tracheal compression. He was evaluated in our
center for thoracic aortic disease and noted to have a large aortic arch,
particularly Kommerell's diverticular aneurysm. He has right-sided arch
anatomy and he presents today for elective aortic arch replacement with
reconstructing the anatomy to eliminate all compression of the trachea and
esophagus. He has preserved right and left ventricular function with no
significant valvular disease.
DESCRIPTION OF PROCEDURE: The patient was brought to the Operating Suite,
placed supine following the placement of an epidural catheter for
postoperative pain management. A double-lumen endotracheal tube was then
placed down the left main stem bronchus after adequate central access in
both radial and femoral arterial lines for intraoperative monitoring. The
patient was then placed in the left lateral decubitus position with the
table flexed. The right chest, abdomen and groins were prepped and draped
in the usual sterile fashion. The plan was for total thoracic aortic
replacement from the level of the sinotubular junction to the distal
descending thoracic aorta via a right thoracotomy.
A 5th interspace posterolateral thoracotomy was made and we inspected the
field and confirmed the feasibility of the planned resection. We then made
a 2 cm oblique incision above the right inguinal crease and dissected out
the right common femoral artery circumferentially to facilitate arterial
inflow for cardiopulmonary bypass, with the plan of a dual arterial inflow
to facilitate the reconstruction as described below. Next, we dissected
out the descending thoracic aorta from the level just inferior to the right
inferior pulmonary vein. We opened the pericardium anterior to the right
phrenic nerve, making sure to keep the right phrenic nerve free from injury
throughout the entire case. We dissected out the ascending aorta
circumferentially and dissected out the aortic arch carefully. We ligated
and divided the azygos vein as it traversed the course from the superior
vena cava to the descending portion of the azygos vein to facilitate
exposure of the right-sided arch. After adequate exposure of the thoracic
aorta completely and the brachiocephalic vessels, we then heparinized the
patient and cannulated him for cardiopulmonary bypass via the ascending
aorta, the right femoral artery and the right atrium using a dual stage.
An additional ascending aortic catheter was placed for use for antegrade
cardioplegia, and the patient was placed on cardiopulmonary bypass
initially with inflow only via the ascending aorta. The patient was
subsequently cooled to deep hypothermia and during systemic cooling, an
aortic cross-clamp was placed in the mid descending thoracic aorta and the
distal descending thoracic aorta. Upon placement of these clamps, we began
perfusion of the lower body via the right common femoral artery. An
18-French Fem-Flex Edwards catheter was placed in the right common femoral
artery under direct vision using a Seldinger technique. With maintenance
of a total body perfusion using dual inflow, we then transected the
descending thoracic aorta in its distal third and took a 26 mm Vascutek
graft and anastomosed it end-to-end to the distal descending thoracic aorta
using running 4-0 Prolene suture, taking care to intussuscept graft into
the native aorta for hemostatic suture line. All the while, he was
continued with systemic cooling. Next, we drew our attention toward the
ascending aorta and an aortic cross-clamp was applied proximal to the
ascending aortic inflow cannula. We then administered antegrade cold blood
high potassium cardioplegia to the aortic root to achieve an asystolic
arrest. We then transected the ascending aorta into a precurved 28 mm
Vascutek graft with an 8 mm side limb trimmed to an appropriate length and
anastomosed it to the ascending aorta near the sinotubular junction using
running 4-0 Prolene suture, again taking care to intussuscept graft into
the native aorta for hemostatic suture line. Following completion of this
anastomosis, we gave additional antegrade cardioplegia via that graft with
simply cold blood, maintaining perfusion to the heart. All the while, we
were systemically cooling to deep hypothermia and on achieving
electrocerebral silence for greater than 4 minutes per our deep hypothermic
protocol, a brief period of deep hypothermic circulatory arrest was
initiated utilizing retrograde cerebral perfusion with a 26 French angled
catheter placed into the superior vena cava. We delivered retrograde
cerebral perfusion using our cardioplegia circuit maintaining flows 200-250
mL per minute with a right internal jugular venous pressure of 20 mmHg.
All the while, we maintained the perfusion to the lower body while arterial
circulation was terminated in the upper body. We began by separating the
brachiocephalic vessels from the aortic arch creating an island of aorta,
which housed only the innominate, left common carotid and left subclavian
arteries at their ostia with no excess aorta creating a small island of the
brachiocephalic vessels. We then took an 18 mm Vascutek graft, cut it in a
steep beveled fashion and anastomosed it to this brachiocephalic island
using running 4-0 Prolene suture, taking care to intussuscept graft
material to the intimal surface of the ____ button housing the
brachiocephalic ostia. Following completion of this anastomosis, we
cannulated the proximal end of the 18 mm graft feeding the brachiocephalics
using a second 18 French Edwards Fem-Flex catheter and began antegrade
cerebral perfusion to all the brachiocephalics. This terminated the period
of retrograde cerebral reperfusion and now, we were maintaining a total
body perfusion using the right common femoral arterial inflow cannula, the
18 French cannula in the brachiocephalic graft and delivered antegrade
cardioplegia while we completed the arch reconstruction. At this point, we
ligated all of the intercostal arteries and bronchial arteries emanating
from the descending thoracic aorta by filleting open the descending
thoracic aorta and ligating these either externally with a double metal
clips or internal using pledgeted 3-0 Prolene sutures. Following adequate
hemostasis of all the intercostal branches, we then drew our attention
toward completion of the arch reconstruction. We passed the 18 mm graft
feeding the big cephalics in the retrocaval fashion while the arch graft
itself, which was the precurved 28 mm Vascutek graft, which had been sewn
to the proximal ascending aorta that was passed anterior to the superior
vena cava heading down into the paraspinous gutter of the right hemithorax
adjacent to the now replaced native descending thoracic aorta and adjacent
to the azygos vein course. We then cut the proximal end of the 26 mm
Vascutek graft sewn to the descending thoracic aorta in beveled fashion and
trimmed the distal end of the 28 mm precurved graft in a beveled fashion
and anastomosed to one another creating a new right-sided aortic arch,
which was positioned anterior to the superior vena cava rather than
posterior, which was the patient's native anatomy. This anastomosis was
completed with running 2-0 Prolene suture. We then took the 18 mm Vascutek
graft to the brachiocephalics and cut it in a bevelled fashion proximally.
We then placed partial occlusion clamps on the neoaortic arch graft and
created a elliptical graftotomy with the ophthalmic cautery device. Prior
to completion of that anastomosis, we setup a third arterial inflow cannula
placed within the 8 mm side arm of the 28 mm arch graft . The arch graft
and ascending aortic graft were deaired via this side arm inflow graft. We
then completed the 18 mm graft anastomosis to the neoarch graft using
running 2-0 Prolene suture and just prior to completion of that final
anastomotic stitch, an 18 mm inflow cannula that was in the 18 mm
brachiocephalic graft was removed. All the arch graft and brachiocephalic
grafts were deaired via the new central cannulation within the arch graft
and then we completed the anastomosis and began total body perfusion via
the central inflow cannula and terminated inflow via the right common
femoral artery. We began systemically rewarming at this point and during
systemic rewarming, we repaired the right common femoral artery. The 18
French catheter was removed from the femoral artery and the vessel repaired
primarily using 5-0 Prolene sutures, with proximal and distal clamps placed
to facilitate that repair.
During systemic rewarming, we confirmed hemostasis of all the anastomotic
suture line as well as carefully inspected the descending thoracic aortic
bed to ensure that all intercostals had been ligated. Upon achieving
normothermia, the patient was subsequently weaned from cardiopulmonary
bypass with preserved right and left ventricular function. He was
subsequently decannulated, the heparin reversed with IV protamine,
meticulous hemostasis confirmed in entire operative field. We then placed
Blake drains in the mediastinum and the right pleural space. The
pericardium was reapproximated with several interrupted 2-0 Vicryl sutures.
The thoracotomy was then closed in layers. The ribs were approximated
with #2 Vicryl and then the latissimus dorsi and serratus anterior muscle
fascia were reapproximated along with subcutaneous tissue and skin with
running absorbable sutures. A left thoracostomy tube, 28 French, was then
placed in the 10th interspace to drain a left-sided pericardial effusion,
which had accumulated during the case. This was done by making an 8 mm
transverse incision in the 10th interspace and then entering the pleural
space and securing that with sutures. We then turned the patient supine.
We then performed an esophagogastroduodenoscopy to carefully inspect the
esophagus and ensure that there had been no injury throughout the case and
that all esophagus appeared ____. The esophagus was normal in appearance
with no evidence of any traumatic injury. After removal of the
double-lumen endotracheal tube and replacement of a single-lumen, we then
performed a therapeutic aspiration bronchoscopy and confirmed that both the
right and left bronchial trees were free of any bloody secretions. By this
point, the patient had returned to normal EEG and SSEP signals and the
patient was subsequently transferred to the CTICU in stable condition.
Thanks !!
PREOPERATIVE DIAGNOSES: Aortic arch and Kommerell's diverticular aneurysm,
right-sided aortic arch with right-sided descending thoracic aorta,
dysphagia, tracheal compression.
POSTOPERATIVE DIAGNOSES: Aortic arch and Kommerell's diverticular
aneurysm, right-sided aortic arch with right-sided descending thoracic
aorta, dysphagia, tracheal compression.
PROCEDURE PERFORMED: Ascending aortic replacement (28 mm Vascutek graft),
total aortic arch replacement (28 mm and 18 mm Vascutek grafts), descending
thoracic aortic replacement (26 mm Vascutek graft) via right fifth
interspace thoracotomy, placement of left thoracostomy tube, therapeutic
aspiration bronchoscopy, esophagogastroduodenoscopy.
BRIEF HISTORY: The patient is a 55-year-old male with a history of a
right-sided aortic arch, right-sided descending thoracic aorta and then
aortic arch and Kommerell's diverticular aneurysm causing significant
compression of both the esophagus and the trachea. The patient has
suffered from dysphagia most of his adult life and he also suffers from a
tracheal compression. The patient is a professional trumpet player and has
noted difficulty with respect to his musical instrument playing due to his
issues of a stridor and a tracheal compression. He was evaluated in our
center for thoracic aortic disease and noted to have a large aortic arch,
particularly Kommerell's diverticular aneurysm. He has right-sided arch
anatomy and he presents today for elective aortic arch replacement with
reconstructing the anatomy to eliminate all compression of the trachea and
esophagus. He has preserved right and left ventricular function with no
significant valvular disease.
DESCRIPTION OF PROCEDURE: The patient was brought to the Operating Suite,
placed supine following the placement of an epidural catheter for
postoperative pain management. A double-lumen endotracheal tube was then
placed down the left main stem bronchus after adequate central access in
both radial and femoral arterial lines for intraoperative monitoring. The
patient was then placed in the left lateral decubitus position with the
table flexed. The right chest, abdomen and groins were prepped and draped
in the usual sterile fashion. The plan was for total thoracic aortic
replacement from the level of the sinotubular junction to the distal
descending thoracic aorta via a right thoracotomy.
A 5th interspace posterolateral thoracotomy was made and we inspected the
field and confirmed the feasibility of the planned resection. We then made
a 2 cm oblique incision above the right inguinal crease and dissected out
the right common femoral artery circumferentially to facilitate arterial
inflow for cardiopulmonary bypass, with the plan of a dual arterial inflow
to facilitate the reconstruction as described below. Next, we dissected
out the descending thoracic aorta from the level just inferior to the right
inferior pulmonary vein. We opened the pericardium anterior to the right
phrenic nerve, making sure to keep the right phrenic nerve free from injury
throughout the entire case. We dissected out the ascending aorta
circumferentially and dissected out the aortic arch carefully. We ligated
and divided the azygos vein as it traversed the course from the superior
vena cava to the descending portion of the azygos vein to facilitate
exposure of the right-sided arch. After adequate exposure of the thoracic
aorta completely and the brachiocephalic vessels, we then heparinized the
patient and cannulated him for cardiopulmonary bypass via the ascending
aorta, the right femoral artery and the right atrium using a dual stage.
An additional ascending aortic catheter was placed for use for antegrade
cardioplegia, and the patient was placed on cardiopulmonary bypass
initially with inflow only via the ascending aorta. The patient was
subsequently cooled to deep hypothermia and during systemic cooling, an
aortic cross-clamp was placed in the mid descending thoracic aorta and the
distal descending thoracic aorta. Upon placement of these clamps, we began
perfusion of the lower body via the right common femoral artery. An
18-French Fem-Flex Edwards catheter was placed in the right common femoral
artery under direct vision using a Seldinger technique. With maintenance
of a total body perfusion using dual inflow, we then transected the
descending thoracic aorta in its distal third and took a 26 mm Vascutek
graft and anastomosed it end-to-end to the distal descending thoracic aorta
using running 4-0 Prolene suture, taking care to intussuscept graft into
the native aorta for hemostatic suture line. All the while, he was
continued with systemic cooling. Next, we drew our attention toward the
ascending aorta and an aortic cross-clamp was applied proximal to the
ascending aortic inflow cannula. We then administered antegrade cold blood
high potassium cardioplegia to the aortic root to achieve an asystolic
arrest. We then transected the ascending aorta into a precurved 28 mm
Vascutek graft with an 8 mm side limb trimmed to an appropriate length and
anastomosed it to the ascending aorta near the sinotubular junction using
running 4-0 Prolene suture, again taking care to intussuscept graft into
the native aorta for hemostatic suture line. Following completion of this
anastomosis, we gave additional antegrade cardioplegia via that graft with
simply cold blood, maintaining perfusion to the heart. All the while, we
were systemically cooling to deep hypothermia and on achieving
electrocerebral silence for greater than 4 minutes per our deep hypothermic
protocol, a brief period of deep hypothermic circulatory arrest was
initiated utilizing retrograde cerebral perfusion with a 26 French angled
catheter placed into the superior vena cava. We delivered retrograde
cerebral perfusion using our cardioplegia circuit maintaining flows 200-250
mL per minute with a right internal jugular venous pressure of 20 mmHg.
All the while, we maintained the perfusion to the lower body while arterial
circulation was terminated in the upper body. We began by separating the
brachiocephalic vessels from the aortic arch creating an island of aorta,
which housed only the innominate, left common carotid and left subclavian
arteries at their ostia with no excess aorta creating a small island of the
brachiocephalic vessels. We then took an 18 mm Vascutek graft, cut it in a
steep beveled fashion and anastomosed it to this brachiocephalic island
using running 4-0 Prolene suture, taking care to intussuscept graft
material to the intimal surface of the ____ button housing the
brachiocephalic ostia. Following completion of this anastomosis, we
cannulated the proximal end of the 18 mm graft feeding the brachiocephalics
using a second 18 French Edwards Fem-Flex catheter and began antegrade
cerebral perfusion to all the brachiocephalics. This terminated the period
of retrograde cerebral reperfusion and now, we were maintaining a total
body perfusion using the right common femoral arterial inflow cannula, the
18 French cannula in the brachiocephalic graft and delivered antegrade
cardioplegia while we completed the arch reconstruction. At this point, we
ligated all of the intercostal arteries and bronchial arteries emanating
from the descending thoracic aorta by filleting open the descending
thoracic aorta and ligating these either externally with a double metal
clips or internal using pledgeted 3-0 Prolene sutures. Following adequate
hemostasis of all the intercostal branches, we then drew our attention
toward completion of the arch reconstruction. We passed the 18 mm graft
feeding the big cephalics in the retrocaval fashion while the arch graft
itself, which was the precurved 28 mm Vascutek graft, which had been sewn
to the proximal ascending aorta that was passed anterior to the superior
vena cava heading down into the paraspinous gutter of the right hemithorax
adjacent to the now replaced native descending thoracic aorta and adjacent
to the azygos vein course. We then cut the proximal end of the 26 mm
Vascutek graft sewn to the descending thoracic aorta in beveled fashion and
trimmed the distal end of the 28 mm precurved graft in a beveled fashion
and anastomosed to one another creating a new right-sided aortic arch,
which was positioned anterior to the superior vena cava rather than
posterior, which was the patient's native anatomy. This anastomosis was
completed with running 2-0 Prolene suture. We then took the 18 mm Vascutek
graft to the brachiocephalics and cut it in a bevelled fashion proximally.
We then placed partial occlusion clamps on the neoaortic arch graft and
created a elliptical graftotomy with the ophthalmic cautery device. Prior
to completion of that anastomosis, we setup a third arterial inflow cannula
placed within the 8 mm side arm of the 28 mm arch graft . The arch graft
and ascending aortic graft were deaired via this side arm inflow graft. We
then completed the 18 mm graft anastomosis to the neoarch graft using
running 2-0 Prolene suture and just prior to completion of that final
anastomotic stitch, an 18 mm inflow cannula that was in the 18 mm
brachiocephalic graft was removed. All the arch graft and brachiocephalic
grafts were deaired via the new central cannulation within the arch graft
and then we completed the anastomosis and began total body perfusion via
the central inflow cannula and terminated inflow via the right common
femoral artery. We began systemically rewarming at this point and during
systemic rewarming, we repaired the right common femoral artery. The 18
French catheter was removed from the femoral artery and the vessel repaired
primarily using 5-0 Prolene sutures, with proximal and distal clamps placed
to facilitate that repair.
During systemic rewarming, we confirmed hemostasis of all the anastomotic
suture line as well as carefully inspected the descending thoracic aortic
bed to ensure that all intercostals had been ligated. Upon achieving
normothermia, the patient was subsequently weaned from cardiopulmonary
bypass with preserved right and left ventricular function. He was
subsequently decannulated, the heparin reversed with IV protamine,
meticulous hemostasis confirmed in entire operative field. We then placed
Blake drains in the mediastinum and the right pleural space. The
pericardium was reapproximated with several interrupted 2-0 Vicryl sutures.
The thoracotomy was then closed in layers. The ribs were approximated
with #2 Vicryl and then the latissimus dorsi and serratus anterior muscle
fascia were reapproximated along with subcutaneous tissue and skin with
running absorbable sutures. A left thoracostomy tube, 28 French, was then
placed in the 10th interspace to drain a left-sided pericardial effusion,
which had accumulated during the case. This was done by making an 8 mm
transverse incision in the 10th interspace and then entering the pleural
space and securing that with sutures. We then turned the patient supine.
We then performed an esophagogastroduodenoscopy to carefully inspect the
esophagus and ensure that there had been no injury throughout the case and
that all esophagus appeared ____. The esophagus was normal in appearance
with no evidence of any traumatic injury. After removal of the
double-lumen endotracheal tube and replacement of a single-lumen, we then
performed a therapeutic aspiration bronchoscopy and confirmed that both the
right and left bronchial trees were free of any bloody secretions. By this
point, the patient had returned to normal EEG and SSEP signals and the
patient was subsequently transferred to the CTICU in stable condition.