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I am not sure if this in the right section, and I am new to this field. Any help would be appreciated!!
Operative Report Procedures performed: 1. Left transfem aortogram 2. RLE r/o 3. Right fem exploration 4. Open thrombectomy 5. Fem-BK popl bp insitu GSV 6. Side branch ligation 7. Completion angio Primary Surgeon: Hue Thai, MD Assistant(s): none Pre-procedure diagnosis: ALI Post-procedure diagnosis: ALI Start date: 11/23/15 Start time: 2130 Anesthesia: general anesthesia Estimated blood loss in ml's: 600 Blood products: 2 units pRBC Technique/Procedure:
This is a 51 year male with severe peripheral arterial disease status bilateral femoropopliteal bypasses and stenting. He continues to use tobacco. He presented with 3 days history of right lower extremity pain and coldness. He had preserved motor but with paresthesia. His preoperative duplex demonstrated complete thrombosis of the fem-popl bypass and only monophasic waveforms in the right lower leg. Operative management was discussed including risks, benefits, and alternatives and patient consented to proceed.
Patient was seen in preoperative area with consent and site confirmed. He was taken to the operating room, properly identified and placed supine. General anesthesia was induced and the abdomen and bilateral groins were prepped and draped in the usual sterile fashion. perioperative was started and time out was called.
Page 1 of 3
We began with a left femoral access with a micropuncture kit under ultrasound guidance. This was up sized to a 5F sheath and an Omni catheter was brought up the infrarenal aorta for an aortogram. The catheter was pulled down to the aortic bifurcation for additional pelvic views. The right iliac artery was cannulated and the catheter was parked in the distal external iliac artery for right lower extremity run-off. It was difficult to determine patient's lower leg run off due to poor collaterals. A decision was made to explore the right groin. The is was extremity scared down from prior surgery requiring much more than expected time. The femoral artery and its bifurcation was dissected and controlled. Patient came to the OR on heparin drip and was continued with every hour boluses.
The femoral bypass graftotomy was performed and sequential balloon embolectomy was done with a #3, #4, and #5 Folgarty catheters. This retrieved a large amount of old and new thrombus. We were able to pass our #3 catheter to the tibioperoneal vessels with continuous return of old and new thrombus despite patient being on adequate heparin. Thus heparin products were discontinued and Argatroban was utilized. At this point, very little new thrombi were seen. Given little outflow seen, a decision was made to explore the distal fem-pop bypass. An incision was made through previous above knee operative site and the graft was exposed and controlled. The graftotomy was made and more thrombus with multiple stents were removed. Given how poorly the graft appeared a decision was made to abandon this plan and the graft was thus ligated.
The infrapopliteal artery was explored as a last resort via an infrapopliteal incision. No bleeding in the soft tissue was seen but muscles were viable. We encountered the GSV with adequate calliber. The infrapopliteal artery was freely dissected and controlled. Following this a return to the femoral groin was made to explore the saphenofemoral junction. This was carefully dissected and transected flushed. The GSV stump was suture ligated and divided. The vein was spatulated to fit and anastomosed to the femoral artery in an end-to-side fashion with 6-0 Prolene running suture. The distal GSV was dissected, divided, and a LeMaitre valvulotome was passed retrograde multiple times until pulsatile bleed was obtained. Following this the vein was prepped and the distal end to side anastomosis was created in a standard running fashion with a 6-0 Prolene. Pulsatile flow was established and a completion angiogram demonstrated 1 vessel run-off into the foot. Major side branches were ligated and divided. Once hemostasis was satisfactory the wounds were irrigated and inicions closed in multiple layers and dressings placed. Patient tolerated the procedure well, was kept intubated and taken to the ICU in satisfactory condition. All counts were correct.
Specimens removed/altered: stents Complications: none Drain(s)/tube(s): none Implant(s): Vac dressings x 2 Cultures sent: No Fluids:
Page 2 of 3
4500 Urine output: 800 Operative findings: Hypercoagulable Acute and subacute graft thrombosis Completion angio with 2 vessels r/o to foot
Operative Report Procedures performed: 1. Left transfem aortogram 2. RLE r/o 3. Right fem exploration 4. Open thrombectomy 5. Fem-BK popl bp insitu GSV 6. Side branch ligation 7. Completion angio Primary Surgeon: Hue Thai, MD Assistant(s): none Pre-procedure diagnosis: ALI Post-procedure diagnosis: ALI Start date: 11/23/15 Start time: 2130 Anesthesia: general anesthesia Estimated blood loss in ml's: 600 Blood products: 2 units pRBC Technique/Procedure:
This is a 51 year male with severe peripheral arterial disease status bilateral femoropopliteal bypasses and stenting. He continues to use tobacco. He presented with 3 days history of right lower extremity pain and coldness. He had preserved motor but with paresthesia. His preoperative duplex demonstrated complete thrombosis of the fem-popl bypass and only monophasic waveforms in the right lower leg. Operative management was discussed including risks, benefits, and alternatives and patient consented to proceed.
Patient was seen in preoperative area with consent and site confirmed. He was taken to the operating room, properly identified and placed supine. General anesthesia was induced and the abdomen and bilateral groins were prepped and draped in the usual sterile fashion. perioperative was started and time out was called.
Page 1 of 3
We began with a left femoral access with a micropuncture kit under ultrasound guidance. This was up sized to a 5F sheath and an Omni catheter was brought up the infrarenal aorta for an aortogram. The catheter was pulled down to the aortic bifurcation for additional pelvic views. The right iliac artery was cannulated and the catheter was parked in the distal external iliac artery for right lower extremity run-off. It was difficult to determine patient's lower leg run off due to poor collaterals. A decision was made to explore the right groin. The is was extremity scared down from prior surgery requiring much more than expected time. The femoral artery and its bifurcation was dissected and controlled. Patient came to the OR on heparin drip and was continued with every hour boluses.
The femoral bypass graftotomy was performed and sequential balloon embolectomy was done with a #3, #4, and #5 Folgarty catheters. This retrieved a large amount of old and new thrombus. We were able to pass our #3 catheter to the tibioperoneal vessels with continuous return of old and new thrombus despite patient being on adequate heparin. Thus heparin products were discontinued and Argatroban was utilized. At this point, very little new thrombi were seen. Given little outflow seen, a decision was made to explore the distal fem-pop bypass. An incision was made through previous above knee operative site and the graft was exposed and controlled. The graftotomy was made and more thrombus with multiple stents were removed. Given how poorly the graft appeared a decision was made to abandon this plan and the graft was thus ligated.
The infrapopliteal artery was explored as a last resort via an infrapopliteal incision. No bleeding in the soft tissue was seen but muscles were viable. We encountered the GSV with adequate calliber. The infrapopliteal artery was freely dissected and controlled. Following this a return to the femoral groin was made to explore the saphenofemoral junction. This was carefully dissected and transected flushed. The GSV stump was suture ligated and divided. The vein was spatulated to fit and anastomosed to the femoral artery in an end-to-side fashion with 6-0 Prolene running suture. The distal GSV was dissected, divided, and a LeMaitre valvulotome was passed retrograde multiple times until pulsatile bleed was obtained. Following this the vein was prepped and the distal end to side anastomosis was created in a standard running fashion with a 6-0 Prolene. Pulsatile flow was established and a completion angiogram demonstrated 1 vessel run-off into the foot. Major side branches were ligated and divided. Once hemostasis was satisfactory the wounds were irrigated and inicions closed in multiple layers and dressings placed. Patient tolerated the procedure well, was kept intubated and taken to the ICU in satisfactory condition. All counts were correct.
Specimens removed/altered: stents Complications: none Drain(s)/tube(s): none Implant(s): Vac dressings x 2 Cultures sent: No Fluids:
Page 2 of 3
4500 Urine output: 800 Operative findings: Hypercoagulable Acute and subacute graft thrombosis Completion angio with 2 vessels r/o to foot
