sandy06
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PREOPERATIVE DIAGNOSIS:
Arch dissection with type 1 distal aortic aneurysm TEVAR (thoracic
endovascular aneurysm repair) endoleak at the proximal arch.
Procedure:
Sternotomy with debranching of the arch arteries with a bifurcating
graft in the ascending aorta to the innominate and left carotid
artery, ligation of innominate and left carotid artery at the arch via
sternotomy off pump.
SURGEON:
A, M.D.
CO-SURGEON:
S, M.D.
Anesthesia:
Generalized endotracheal tube general anesthesia.
incision:
Sternotomy.
DESCRIPTION OF PROCEDURE:
The patient identified in the holding area, placed on OR table in the
supine position. General endotracheal tube general anesthesia was
given to the patient. Preoperative antibiotics were given to the
patient. The patient was prepped and draped in usual sterile fashion
after appropriate monitors were placed, Foley was placed, and a right
femoral A-line was inserted.
At this point once the patient was prepped and draped, a sternotomy
was created from the jugular notch to the xiphoid process, entering
through the subcutaneous tissue with the Bovie cautery. Hemostasis was
identified. With the lung deflated we were able to transect the
sternum at the midline using a sternal saw. At this point hemostasis
was identified. Using a sternal retractor we were able to open the
sternum. The pericardium was then opened in reverse T fashion and
tacked up to the chest wall in 4 different quadrants.
At this point the aorta was palpated to be soft. There was
approximately a 3.8 cm ascending aorta, and no evidence of any
pericardial infusion or any acute areas of dissection. So at this
point we were able to mobilize the innominate vein in its entirety,
and using a vessel loop around the innominate vein to traction. At
this point we were able to mobilize the entire innominate artery from
its origin from the arch onto the innominate vein, all the way to the
bifurcation of the subclavian and carotid artery on the right side. At
this point we were also able to mobilize the left common carotid
artery coming off the arch of the aorta, and we were able to palpate
the stent distally at the takeoff of the what looked to be a partially
occluded left subclavian artery. We were able to palpate the stent in
the aorta.
At this point with all the vessels mobilized, the debranching
technique was to commence. We were able to lower the blood pressure to
80 and gave heparin to achieve an ACT of greater than 400. The
ascending aorta was partially clamped with a Satinsky clamp and a 2 cm
ascending aortic incision was created and arteriotomy was created.
Then using a 12 x 6 x 6 mm graft, the 12 mm portion of the graft was
anastomosed to the ascending aorta in a spatulated end-to-side fashion
using a 5-0 Prolene suture in a running fashion. Once the anastomosis
was completed the partial Satinsky clamp was slowly removed. The graft
was allowed to be de-aired. Both limbs of the graft were able to be
clamped with vascular clamps and hemostasis was identified at the
suture line.
At this point we mobilized the left common carotid artery. The
proximal aspect of the left common carotid artery coming off the arch
was ligated with a heavy silk suture x2. The distal aspect of the left
common carotid artery was mobilized and a vessel loop was placed
around it. An arteriotomy was created. There was excellent back-
bleeding when the vessel loop was released to identify good collateral
flow. So at this point one of the 6 mm limbs of the bifurcating graft
was passed underneath the innominate vein. This seemed to fit better
in this location. An anastomosis was created in an end-to-side fashion
using a 5-0 Prolene suture. Once the anastomosis was completed the
limb was allowed to be de-aired, as well as the common carotid artery
on the left, and the suture line was then tightened down. The vessel
loop was then removed and excellent pulsations were identified
distally in the left common carotid artery.
At this point, we turned our attention to the innominate artery. The
innominate artery was mobilized in a similar fashion, and the proximal
aspect of the innominate artery was transected with a vascular 30 mm
stapler. At this point the proximal end was stapled off, the distal
end was mobilized and a vessel loop was placed around it. Using the
2nd portion of the limb of the bifurcated limb graft was passed above
the innominate vein where it seemed to fit better, and an end-to-side
fashion anastomosis was created after arteriotomy was created into the
innominate artery. This was approximately a 1.5 cm anastomosis. The
anastomosis was created with a 5-0 Prolene suture in a running
fashion. At this point the limb and the innominate artery were allowed
to back-bleed and de-air before the anastomotic suture was tied down.
At this point the innominate artery and the left common carotid artery
were completely isolated from the arch, bypassed from the ascending
aorta in preparation for a re-stent deployment in the arch in the near
future to eliminate the type 1 endoleak the patient had a from a
previous procedure performed at another institution.
At this point all the limbs seemed to be perfusing well. The arch
vessels were completely bypassed. The left subclavian artery was
already occluded from the left common carotid subclavian bypass
performed at another institution. So at this point hemostasis was
identified. The pericardium was closed over the grafts. Two chest
tubes were inserted - one in the mediastinum as a straight chest tube
and one in the mediastinum as a right angle chest tube - emanating
through separate stab incisions. The sternum was then reapproximated
using 7 sternal wires, 2 in the manubrium and 5 in the body of the
sternum. The fascia was then closed using a 0 Vicryl suture and the
skin was closed with Monocryl. Sterile dressing was applied.
The patient tolerated procedure well. The patient will be transferred
to the intensive care unit. Chest tubes were placed to a Pleur-evac.
The patient remained hemodynamically stable and tolerated procedure
well.
The 2nd portion of the procedure will be undertaken once the patient
recovers from this at a different setting, where a stent will be
deployed isolating the rest of the arch from the leak that the patient
has from his previous aortic dissection.
Hi, I'm a little bit confused
on this report, I came up with this code 33860 but I'm not sure, since he didn't put the patient on cardiopulmonary bypass.
Can someone please give me insight on how should I code it.
Thanks in advanced
Arch dissection with type 1 distal aortic aneurysm TEVAR (thoracic
endovascular aneurysm repair) endoleak at the proximal arch.
Procedure:
Sternotomy with debranching of the arch arteries with a bifurcating
graft in the ascending aorta to the innominate and left carotid
artery, ligation of innominate and left carotid artery at the arch via
sternotomy off pump.
SURGEON:
A, M.D.
CO-SURGEON:
S, M.D.
Anesthesia:
Generalized endotracheal tube general anesthesia.
incision:
Sternotomy.
DESCRIPTION OF PROCEDURE:
The patient identified in the holding area, placed on OR table in the
supine position. General endotracheal tube general anesthesia was
given to the patient. Preoperative antibiotics were given to the
patient. The patient was prepped and draped in usual sterile fashion
after appropriate monitors were placed, Foley was placed, and a right
femoral A-line was inserted.
At this point once the patient was prepped and draped, a sternotomy
was created from the jugular notch to the xiphoid process, entering
through the subcutaneous tissue with the Bovie cautery. Hemostasis was
identified. With the lung deflated we were able to transect the
sternum at the midline using a sternal saw. At this point hemostasis
was identified. Using a sternal retractor we were able to open the
sternum. The pericardium was then opened in reverse T fashion and
tacked up to the chest wall in 4 different quadrants.
At this point the aorta was palpated to be soft. There was
approximately a 3.8 cm ascending aorta, and no evidence of any
pericardial infusion or any acute areas of dissection. So at this
point we were able to mobilize the innominate vein in its entirety,
and using a vessel loop around the innominate vein to traction. At
this point we were able to mobilize the entire innominate artery from
its origin from the arch onto the innominate vein, all the way to the
bifurcation of the subclavian and carotid artery on the right side. At
this point we were also able to mobilize the left common carotid
artery coming off the arch of the aorta, and we were able to palpate
the stent distally at the takeoff of the what looked to be a partially
occluded left subclavian artery. We were able to palpate the stent in
the aorta.
At this point with all the vessels mobilized, the debranching
technique was to commence. We were able to lower the blood pressure to
80 and gave heparin to achieve an ACT of greater than 400. The
ascending aorta was partially clamped with a Satinsky clamp and a 2 cm
ascending aortic incision was created and arteriotomy was created.
Then using a 12 x 6 x 6 mm graft, the 12 mm portion of the graft was
anastomosed to the ascending aorta in a spatulated end-to-side fashion
using a 5-0 Prolene suture in a running fashion. Once the anastomosis
was completed the partial Satinsky clamp was slowly removed. The graft
was allowed to be de-aired. Both limbs of the graft were able to be
clamped with vascular clamps and hemostasis was identified at the
suture line.
At this point we mobilized the left common carotid artery. The
proximal aspect of the left common carotid artery coming off the arch
was ligated with a heavy silk suture x2. The distal aspect of the left
common carotid artery was mobilized and a vessel loop was placed
around it. An arteriotomy was created. There was excellent back-
bleeding when the vessel loop was released to identify good collateral
flow. So at this point one of the 6 mm limbs of the bifurcating graft
was passed underneath the innominate vein. This seemed to fit better
in this location. An anastomosis was created in an end-to-side fashion
using a 5-0 Prolene suture. Once the anastomosis was completed the
limb was allowed to be de-aired, as well as the common carotid artery
on the left, and the suture line was then tightened down. The vessel
loop was then removed and excellent pulsations were identified
distally in the left common carotid artery.
At this point, we turned our attention to the innominate artery. The
innominate artery was mobilized in a similar fashion, and the proximal
aspect of the innominate artery was transected with a vascular 30 mm
stapler. At this point the proximal end was stapled off, the distal
end was mobilized and a vessel loop was placed around it. Using the
2nd portion of the limb of the bifurcated limb graft was passed above
the innominate vein where it seemed to fit better, and an end-to-side
fashion anastomosis was created after arteriotomy was created into the
innominate artery. This was approximately a 1.5 cm anastomosis. The
anastomosis was created with a 5-0 Prolene suture in a running
fashion. At this point the limb and the innominate artery were allowed
to back-bleed and de-air before the anastomotic suture was tied down.
At this point the innominate artery and the left common carotid artery
were completely isolated from the arch, bypassed from the ascending
aorta in preparation for a re-stent deployment in the arch in the near
future to eliminate the type 1 endoleak the patient had a from a
previous procedure performed at another institution.
At this point all the limbs seemed to be perfusing well. The arch
vessels were completely bypassed. The left subclavian artery was
already occluded from the left common carotid subclavian bypass
performed at another institution. So at this point hemostasis was
identified. The pericardium was closed over the grafts. Two chest
tubes were inserted - one in the mediastinum as a straight chest tube
and one in the mediastinum as a right angle chest tube - emanating
through separate stab incisions. The sternum was then reapproximated
using 7 sternal wires, 2 in the manubrium and 5 in the body of the
sternum. The fascia was then closed using a 0 Vicryl suture and the
skin was closed with Monocryl. Sterile dressing was applied.
The patient tolerated procedure well. The patient will be transferred
to the intensive care unit. Chest tubes were placed to a Pleur-evac.
The patient remained hemodynamically stable and tolerated procedure
well.
The 2nd portion of the procedure will be undertaken once the patient
recovers from this at a different setting, where a stent will be
deployed isolating the rest of the arch from the leak that the patient
has from his previous aortic dissection.
Hi, I'm a little bit confused
on this report, I came up with this code 33860 but I'm not sure, since he didn't put the patient on cardiopulmonary bypass.Can someone please give me insight on how should I code it.
Thanks in advanced