This was a procedure done by a cardiothoracic surgeon but wondering if this group may be of some assistance to me as I don't really know how to code this. Seems to have a vascular component to it which is why I'm trying this group as well.
The chest was entered through a primary median sternotomy and after identification of the innominate vein, the pericardium was opened and a pericardial well was created.
The SVC was then mobilized all the way up towards the innominate vein. Vessel loops were then placed around the proximal SVC near the right atrium, then around the left side of the innominate vein. The extremely large azygous vein was also identified and mobilized with vessel loops also placed around it.
Systemic heparin was administered and then with all the vessel loops ensnared the SVC was entered in plans to possibly do a patch repair of the innominate SVC junction. But when entered there was substantial flow from distal end coming likely from the jugular veins or the left subclavian, so we then decided not to patch the vein. We then allowed vascular surgery to gain access and expose the right cephalic / right axillary vein
Once this was accomplished then a tunnel via the medial portion of the 2nd intercostal space was created by also taking a segment of the medial anterior portion of the 2nd rib. This allowed passage of the 12 mm Dacron graft from the axillary fossa thru the chest to the SVC. The right pleural pericardium was divided with removal of the majority of the thymic tissue to allow ideal angle of the graft towards the SVC.
A suitable site on the mid to proximal SVC was identified and a longitudinal venotomy was then created. The larger end of the 12mm graft was then anastomosed to with a #5-0 Prolene running in an end-to-side fashion. Anastomosis to confirm patency and hemostasis.
This graft was then tunneled up into the axillary space to allow vascular surgery to then anastomose this to the right cephalic vein in a similar fashion.
Protamine was administered without complication, surgical sites were examined and hemostasis was secured. Graft was in good position without kinking or tension. Drainage tubes were placed in the mediastinum and right pleural space. A drain also was placed in the axillary fossa access site by vascular surgery.
The chest was entered through a primary median sternotomy and after identification of the innominate vein, the pericardium was opened and a pericardial well was created.
The SVC was then mobilized all the way up towards the innominate vein. Vessel loops were then placed around the proximal SVC near the right atrium, then around the left side of the innominate vein. The extremely large azygous vein was also identified and mobilized with vessel loops also placed around it.
Systemic heparin was administered and then with all the vessel loops ensnared the SVC was entered in plans to possibly do a patch repair of the innominate SVC junction. But when entered there was substantial flow from distal end coming likely from the jugular veins or the left subclavian, so we then decided not to patch the vein. We then allowed vascular surgery to gain access and expose the right cephalic / right axillary vein
Once this was accomplished then a tunnel via the medial portion of the 2nd intercostal space was created by also taking a segment of the medial anterior portion of the 2nd rib. This allowed passage of the 12 mm Dacron graft from the axillary fossa thru the chest to the SVC. The right pleural pericardium was divided with removal of the majority of the thymic tissue to allow ideal angle of the graft towards the SVC.
A suitable site on the mid to proximal SVC was identified and a longitudinal venotomy was then created. The larger end of the 12mm graft was then anastomosed to with a #5-0 Prolene running in an end-to-side fashion. Anastomosis to confirm patency and hemostasis.
This graft was then tunneled up into the axillary space to allow vascular surgery to then anastomose this to the right cephalic vein in a similar fashion.
Protamine was administered without complication, surgical sites were examined and hemostasis was secured. Graft was in good position without kinking or tension. Drainage tubes were placed in the mediastinum and right pleural space. A drain also was placed in the axillary fossa access site by vascular surgery.