TWilliam2019
Guru
Procedure:
#1 right axillary cutdown with insertion of percutaneous left ventricular assist device ( Impella CP)
#2 Placement of in to side 6 mm Dacron graft to the right axillary artery
#3 TEE with visualization and interpretation
#4 Fluoroscopy with intraoperative visualization and interpretation
Intraoperative findings:
TEE showed severe left ventricular dysfunction with global hypokinesis. Aortic valve was a trileaflet valve with no insufficiency or stenosis. Limited TEE was performed for the purposes of placement of the ventricular assist device. After placement of the device, the device was positioned appropriately across the aortic valve.
*
On fluoroscopy, the final resting position of the percutaneous left ventricular assist device had the elbow of the device positioned at the level of the aortic valve. Device was functioning appropriately.
*
Procedure in detail:
The patient had his history and physical updated prior to the procedure. He was transferred to the operating suite and placed on the operating table where he underwent general anesthesia. The patient was already endotracheally intubated.the right shoulder and chest were prepped and draped in usual sterile fashion using DuraPrep solution after TEE probe was inserted by anesthesia. Timeout was used confirm patient identity as well as the surgery to be performed. Antibiotics given prior the incision. Next
The right axillary artery cutdown was performed by Dr. X. Once this was completed, the right actually artery was exposed and proximal distal vessel loops were placed. I then took over the operation. The patient was anticoagulated with ACT greater than 250 seconds after giving heparin. Proximal distal control of the axillary artery was performed. A longitudinal arteriotomy was then made and extended with angled scissors. A 6 mm Dacron graft was then beveled and anastomosed using 6-0 Prolene. Once this was completed, the graft was de-aired.
*
The introducer sheath was then placed within the 6 mm graft and secured. The dilator was removed. The graft was de-aired and then carefully flushed with hep saline. J-wire was then introduced and advanced into the Aortic arch under fluoroscopic guidance. The pigtail catheter was inserted over the wire and positioned within the aortic arch, then used to manipulate the wire into the aortic root. The pigtail catheter was then positioned within the aortic root and the wire was carefully advanced across the aortic valve under fluoroscopic and TEE guidance. Pigtail catheter was advanced into the left ventricle. The J-wire was removed and the 018 guidewire was then placed within the left ventricle. Next
*
The ventricular assist device then placed over wire and advanced in position within the left ventricle using fluoroscopic and TEE guidance. The wire was removed. The device was started, with excellent flows, improvement in the mean arterial pressure,as well as good motor current. The 6 mm graft was then trimmed to just above the level of the skin. The peel-away sheath was removed. The positioning sheath was then inserted and secured with 0 Ethibond and 0 silk. The Impala device was then secured with final fluoroscopic Evaluation used to pull the Impala back slightly as it had advanced during these maneuvers. Once this was completed, the soft tissues reapproximated with 0 Vicryl. The skin was closed with 4-0 Monocryl in running subcuticular manner. Dermabond was placed over the wound. The patient tolerated procedure well was transferred to CVRU in critical condition.
IMPELLA 33990
axillary cutdown by DR X?
axillary graft?
*
#1 right axillary cutdown with insertion of percutaneous left ventricular assist device ( Impella CP)
#2 Placement of in to side 6 mm Dacron graft to the right axillary artery
#3 TEE with visualization and interpretation
#4 Fluoroscopy with intraoperative visualization and interpretation
Intraoperative findings:
TEE showed severe left ventricular dysfunction with global hypokinesis. Aortic valve was a trileaflet valve with no insufficiency or stenosis. Limited TEE was performed for the purposes of placement of the ventricular assist device. After placement of the device, the device was positioned appropriately across the aortic valve.
*
On fluoroscopy, the final resting position of the percutaneous left ventricular assist device had the elbow of the device positioned at the level of the aortic valve. Device was functioning appropriately.
*
Procedure in detail:
The patient had his history and physical updated prior to the procedure. He was transferred to the operating suite and placed on the operating table where he underwent general anesthesia. The patient was already endotracheally intubated.the right shoulder and chest were prepped and draped in usual sterile fashion using DuraPrep solution after TEE probe was inserted by anesthesia. Timeout was used confirm patient identity as well as the surgery to be performed. Antibiotics given prior the incision. Next
The right axillary artery cutdown was performed by Dr. X. Once this was completed, the right actually artery was exposed and proximal distal vessel loops were placed. I then took over the operation. The patient was anticoagulated with ACT greater than 250 seconds after giving heparin. Proximal distal control of the axillary artery was performed. A longitudinal arteriotomy was then made and extended with angled scissors. A 6 mm Dacron graft was then beveled and anastomosed using 6-0 Prolene. Once this was completed, the graft was de-aired.
*
The introducer sheath was then placed within the 6 mm graft and secured. The dilator was removed. The graft was de-aired and then carefully flushed with hep saline. J-wire was then introduced and advanced into the Aortic arch under fluoroscopic guidance. The pigtail catheter was inserted over the wire and positioned within the aortic arch, then used to manipulate the wire into the aortic root. The pigtail catheter was then positioned within the aortic root and the wire was carefully advanced across the aortic valve under fluoroscopic and TEE guidance. Pigtail catheter was advanced into the left ventricle. The J-wire was removed and the 018 guidewire was then placed within the left ventricle. Next
*
The ventricular assist device then placed over wire and advanced in position within the left ventricle using fluoroscopic and TEE guidance. The wire was removed. The device was started, with excellent flows, improvement in the mean arterial pressure,as well as good motor current. The 6 mm graft was then trimmed to just above the level of the skin. The peel-away sheath was removed. The positioning sheath was then inserted and secured with 0 Ethibond and 0 silk. The Impala device was then secured with final fluoroscopic Evaluation used to pull the Impala back slightly as it had advanced during these maneuvers. Once this was completed, the soft tissues reapproximated with 0 Vicryl. The skin was closed with 4-0 Monocryl in running subcuticular manner. Dermabond was placed over the wound. The patient tolerated procedure well was transferred to CVRU in critical condition.
IMPELLA 33990
axillary cutdown by DR X?
axillary graft?
*