New to vascular surgery coding and this trauma case has my head spinning!!! Any help would be truly appreciated!!!!
PROCEDURE PERFORMED
Thoracic endovascular repair of aortic injury using Gore-TAG endograft,
left external iliac artery exposure and repair using bovine pericardial
patch, right common femoral artery puncture, diagnostic abdominal
aortogram and thoracic aortogram, right common femoral artery closure
using Angio-Seal.
CLINICAL NOTE
The patient suffered multiorgan injury. He was found to have a traumatic
aortic injury with hematoma surrounding the descending thoracic aorta.
Therefore, the patient was emergently taken to the operating room for
operative repair. Informed consent was obtained.
PROCEDURE NOTE
The patient was brought to the operating room already intubated. The
patient was then prepped and draped in usual fashion. A radial arterial
line on the left side was obtained. Based on the preoperative CT
angiogram, I knew that the left iliac artery was slightly bigger than
the right iliac artery. Therefore, I chose to deliver the endograft
through the left side. Preoperative vancomycin and Ancef were given.
Small oblique incision was then made in left groin. I then exposed the
inguinal ligament. There was some venous bleeding coming medially
through the incision likely due to the pelvic fracture. This was
packed. I then exposed the left common femoral artery. Surprisingly,
the pulse was very thready and the caliber of the left common femoral
artery was approximately 3 mm. Therefore, I exposed more proximally.
The inguinal ligament was divided and I exposed for approximately 3 cm
of distal external iliac artery. The wound was then packed.
Under direct ultrasound guidance, the right common femoral artery was then punctured using a 19-gauge needle. A 6-French sheath was then
inserted in a retrograde fashion. The C-arm was then brought in. Using
a combination of Bentson wires and marked pigtail catheter, this was
then advanced into the ascending thoracic aorta. The wire was removed.
Baseline ACT was measured and approximately 7000 units of IV heparin was
then given. After 30 minutes, the ACT was checked and it had risen to
almost twice as much as the baseline. Therefore, no further heparin was
given during the case. I did not over-anticoagulate the patient due to
the patient's liver laceration.
Diagnostic thoracic aortogram was then performed using slightly diluted
Visipaque. This demonstrated a bovine arch. The subclavian artery
could be clearly seen. However, there was no clear aortic tear on
thoracic aortogram. The injury had been likely sealed with surrounding
tissue.
We then made some measurements. The thoracic aorta just proximal to
the origin of the left subclavian artery was approximately 19 mm. The
proximal descending thoracic aorta was approximately 18 mm. Therefore,
we elected to treat this with 26 mm-26mm-10cm endograft. Even though
we did not see a distinct tear, given the mechanism of the injury as
well as the significant amount of blood surrounding the thoracic aorta,
we felt we should cover the injured aorta to prevent future bleeding,
which will be catastrophic.
I therefore exposed the left external iliac artery, which was somewhat
larger
in caliber. Prior to doing the thoracic aortogram, I in fact performed
the abdominal aortogram, which demonstrated intense spasm in the right
external iliac artery. In fact, the sheath was occlusive. The external
iliac artery measured approximately 6 mm on the left side. However, the
left common femoral artery was only about 3 mm. There was intense spasm
in the left external iliac artery. I gave 200 mcg of nitroglycerin as
well as applying nitroglycerin locally to the left common femoral
artery. However, this did not really change the caliber of the left
external iliac artery or common femoral artery. Therefore, I had to
puncture on the left external iliac artery just above the area of spasm.
The left external iliac artery was then punctured approximately 2 cm
above the inguinal ligament. A 5-French sheath was inserted. I then
advanced a curved Lunderquist wire into the most proximal portion of the
ascending thoracic aorta. Then under fluoroscopic guidance, a 20-French
hydrophilic DrySeal Sheath was then placed into the abdominal aorta.
This was then followed by the endograft, which was 26-26-10 cm. Another
thoracic aortogram was then performed through the catheter on the right
side, clearly did not delineate the anatomy. With this in view, I then
deployed the endograft, with the proximal portion of the endograft
approximately 2 mm distal to the origin of the left subclavian artery. Therefore, the left subclavian artery was not covered in this
case. I then lightly tamponaded the endograft using Tri-Lobe balloons.
Completion of thoracic aortogram was then performed, demonstrated
satisfactory results.
At this point, we then exposed the left external iliac artery. A
vascular clamp was then placed after removing the 20-French sheath.
There was no change in pressure after the sheath was removed, indicating
no significant iliac artery injury. The artery caliber was somewhat
small and then there was a fairly large hole. I therefore closed the
arteriotomy on the left external iliac artery primarily in the
transverse fashion. The wound was then closed. Then I checked the left
leg. Unfortunately, I could not get any Doppler signals. Therefore,
the left leg was reprepped and draped including the left groin. The
left groin wound was then opened again. I reexamined the repair area.
It appeared there was an area of stenosis just distal to the area of
repair. Therefore, a vascular clamp was then reapplied and I made a
longitudinal arteriotomy approximately 2 cm in length from the proximal
common femoral artery extending across the area of repair that was done
previously. There appeared to be a significant narrowing there. I also
passed on #3 Foley catheter down to the popliteal artery to make sure
there were no clots there. One pass was made and there were no clots.
There was excellent backbleeding from SFA. I then patched the
longitudinal arteriotomy using a bovine pericardial patch using running
6-0 Prolene sutures. This was completed without difficulty. The system
was then flushed and irrigated. I clamped and then released. Now there
was excellent biphasic Doppler signal over the left dorsalis pedis and
posterior tibial artery. Hemostasis was achieved and the wound was then
closed in 3 layers using 2-0 Vicryl,
3-0 Vicryl, and 4-0 Monocryl sutures. Steri-Strips were then applied.
Right sheath angiogram confirms the placement in the right common femoral
artery. Therefore a 6 French Angioseal closure device was deployed in the
usual manner to achieve hemostasis in the right groin.
PROCEDURE PERFORMED
Thoracic endovascular repair of aortic injury using Gore-TAG endograft,
left external iliac artery exposure and repair using bovine pericardial
patch, right common femoral artery puncture, diagnostic abdominal
aortogram and thoracic aortogram, right common femoral artery closure
using Angio-Seal.
CLINICAL NOTE
The patient suffered multiorgan injury. He was found to have a traumatic
aortic injury with hematoma surrounding the descending thoracic aorta.
Therefore, the patient was emergently taken to the operating room for
operative repair. Informed consent was obtained.
PROCEDURE NOTE
The patient was brought to the operating room already intubated. The
patient was then prepped and draped in usual fashion. A radial arterial
line on the left side was obtained. Based on the preoperative CT
angiogram, I knew that the left iliac artery was slightly bigger than
the right iliac artery. Therefore, I chose to deliver the endograft
through the left side. Preoperative vancomycin and Ancef were given.
Small oblique incision was then made in left groin. I then exposed the
inguinal ligament. There was some venous bleeding coming medially
through the incision likely due to the pelvic fracture. This was
packed. I then exposed the left common femoral artery. Surprisingly,
the pulse was very thready and the caliber of the left common femoral
artery was approximately 3 mm. Therefore, I exposed more proximally.
The inguinal ligament was divided and I exposed for approximately 3 cm
of distal external iliac artery. The wound was then packed.
Under direct ultrasound guidance, the right common femoral artery was then punctured using a 19-gauge needle. A 6-French sheath was then
inserted in a retrograde fashion. The C-arm was then brought in. Using
a combination of Bentson wires and marked pigtail catheter, this was
then advanced into the ascending thoracic aorta. The wire was removed.
Baseline ACT was measured and approximately 7000 units of IV heparin was
then given. After 30 minutes, the ACT was checked and it had risen to
almost twice as much as the baseline. Therefore, no further heparin was
given during the case. I did not over-anticoagulate the patient due to
the patient's liver laceration.
Diagnostic thoracic aortogram was then performed using slightly diluted
Visipaque. This demonstrated a bovine arch. The subclavian artery
could be clearly seen. However, there was no clear aortic tear on
thoracic aortogram. The injury had been likely sealed with surrounding
tissue.
We then made some measurements. The thoracic aorta just proximal to
the origin of the left subclavian artery was approximately 19 mm. The
proximal descending thoracic aorta was approximately 18 mm. Therefore,
we elected to treat this with 26 mm-26mm-10cm endograft. Even though
we did not see a distinct tear, given the mechanism of the injury as
well as the significant amount of blood surrounding the thoracic aorta,
we felt we should cover the injured aorta to prevent future bleeding,
which will be catastrophic.
I therefore exposed the left external iliac artery, which was somewhat
larger
in caliber. Prior to doing the thoracic aortogram, I in fact performed
the abdominal aortogram, which demonstrated intense spasm in the right
external iliac artery. In fact, the sheath was occlusive. The external
iliac artery measured approximately 6 mm on the left side. However, the
left common femoral artery was only about 3 mm. There was intense spasm
in the left external iliac artery. I gave 200 mcg of nitroglycerin as
well as applying nitroglycerin locally to the left common femoral
artery. However, this did not really change the caliber of the left
external iliac artery or common femoral artery. Therefore, I had to
puncture on the left external iliac artery just above the area of spasm.
The left external iliac artery was then punctured approximately 2 cm
above the inguinal ligament. A 5-French sheath was inserted. I then
advanced a curved Lunderquist wire into the most proximal portion of the
ascending thoracic aorta. Then under fluoroscopic guidance, a 20-French
hydrophilic DrySeal Sheath was then placed into the abdominal aorta.
This was then followed by the endograft, which was 26-26-10 cm. Another
thoracic aortogram was then performed through the catheter on the right
side, clearly did not delineate the anatomy. With this in view, I then
deployed the endograft, with the proximal portion of the endograft
approximately 2 mm distal to the origin of the left subclavian artery. Therefore, the left subclavian artery was not covered in this
case. I then lightly tamponaded the endograft using Tri-Lobe balloons.
Completion of thoracic aortogram was then performed, demonstrated
satisfactory results.
At this point, we then exposed the left external iliac artery. A
vascular clamp was then placed after removing the 20-French sheath.
There was no change in pressure after the sheath was removed, indicating
no significant iliac artery injury. The artery caliber was somewhat
small and then there was a fairly large hole. I therefore closed the
arteriotomy on the left external iliac artery primarily in the
transverse fashion. The wound was then closed. Then I checked the left
leg. Unfortunately, I could not get any Doppler signals. Therefore,
the left leg was reprepped and draped including the left groin. The
left groin wound was then opened again. I reexamined the repair area.
It appeared there was an area of stenosis just distal to the area of
repair. Therefore, a vascular clamp was then reapplied and I made a
longitudinal arteriotomy approximately 2 cm in length from the proximal
common femoral artery extending across the area of repair that was done
previously. There appeared to be a significant narrowing there. I also
passed on #3 Foley catheter down to the popliteal artery to make sure
there were no clots there. One pass was made and there were no clots.
There was excellent backbleeding from SFA. I then patched the
longitudinal arteriotomy using a bovine pericardial patch using running
6-0 Prolene sutures. This was completed without difficulty. The system
was then flushed and irrigated. I clamped and then released. Now there
was excellent biphasic Doppler signal over the left dorsalis pedis and
posterior tibial artery. Hemostasis was achieved and the wound was then
closed in 3 layers using 2-0 Vicryl,
3-0 Vicryl, and 4-0 Monocryl sutures. Steri-Strips were then applied.
Right sheath angiogram confirms the placement in the right common femoral
artery. Therefore a 6 French Angioseal closure device was deployed in the
usual manner to achieve hemostasis in the right groin.
