conleyclan
Guru
Hello, Some day I will be able to look at all the aneuryms, and not even think about how to code them......I hope 
PREOPERATIVE DIAGNOSIS: ACUTE RUPTURED TYPE B AORTIC DISSECTION, SPINAL
CORD ISCHEMIA, RIGHT LOWER EXTREMITY ISCHEMIA, RENAL INSUFFICIENCY.
POSTOPERATIVE DIAGNOSIS: ACUTE RUPTURED TYPE B AORTIC DISSECTION, SPINAL
CORD ISCHEMIA, RIGHT LOWER EXTREMITY ISCHEMIA, RENAL INSUFFICIENCY.
PROCEDURES PERFORMED: LEFT SUBCLAVIAN ARTERY TO LEFT COMMON CAROTID ARTERY
TRANSPOSITION, THORACIC ENDOVASCULAR AORTIC REPAIR (COOK ZDEG 34 MM X 204
MM STENT GRAFT, COOK ZDES 46 MM X 185 MM, 36 MM X 120 MM, 36 MM X 80 MM
COOK NITINOL STENTS), THORACIC AORTOGRAM WITH RADIOLOGIC SNI, INTRAVASCULAR
ULTRASOUND.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite,
placed supine and induced with general endotracheal anesthesia. A central
line and radial arterial line were placed by the Anesthesia Team for
intraoperative monitoring. The patient was prepped and draped in the usual
sterile fashion from the mandible to the knees. The head was turned to the
right to expose the base of the left neck. We first drew our attention
towards completing the transposition. A 3-cm transverse incision was made
1 fingerbreadth above the clavicle over the sternocleidomastoid muscle. We
then identified the sternal and clavicular heads of the sternocleidomastoid
and we split the muscle in between the 2 bellies and retracted them
medially and laterally, respectively. We then carefully dissected out the
left common carotid artery within the base of the neck. We then mobilized
the left internal jugular vein, retracted it medially, and then dissected
out the left subclavian artery, including its primary branches including
the left internal mammary artery, the thoracoacromial artery, and the left
vertebral arteries. The left internal mammary artery was ligated and
divided near its takeoff to facilitate greater mobilization of the
subclavian. We then administered argatroban as an anticoagulant because
the patient had a remote history 3 years ago of heparin-induced
thrombocytopenia. Therefore, we utilized no heparin throughout the case.
We maintained an ACT of over 200 seconds with intermittent argatroban
doses. Once we achieved an ACT of approximately 210 seconds, we then
placed a cross-clamp across the proximal left subclavian artery proximal to
the takeoff of the left vertebral artery. Distally, all the branches that
were named above and the left subclavian were controlled with Vesseloops,
preventing any back bleeding. We then oversewed the proximal stump of the
left subclavian artery with running 5-0 Prolene suture and reinforced the
closure with a single pledgeted 4-0 Prolene suture which served as a stay
suture until completion of the reconstruction. We then transposed the left
subclavian with an intact left vertebral artery and left thoracoacromial
artery, transposed it posterior to the left internal jugular vein in a
retrojugular fashion and swept it up towards the left common carotid
artery. On the posterolateral aspect of the left common carotid artery, we
made an elliptical arteriotomy and then anastomosed the left subclavian in
an end-to-side fashion to the left common carotid using running 6-0 Prolene
suture. Following completion, we left the wound open until completion of
the _____ at which time, the argatroban was worn off. Next, we drew our
attention toward the left groin. The right common femoral artery was fed
entirely by the false lumen and had a diminished pulse; therefore, we
provided access to the true lumen via the left common femoral artery. An
oblique incision 2.5 cm in length was made just above the left inguinal
crease and then the left common femoral artery at the level of the inguinal
ligament was circumferentially dissected out and controlled proximally and
distally. With adequate anticoagulation using argatroban again to an ACT
over 210 seconds, we then introduced an 18-gauge needle into the left
common femoral artery and then advanced the guidewire under fluoroscopic
guidance up into the ascending aorta. That guidewire, which was a floppy
starter wire, was then exchanged for a pigtail catheter which was then
exchanged for a Lunderquist super stiff guidewire. Over that Lunderquist
super stiff guidewire, we then performed an intravascular ultrasound and
confirmed that we were within the true lumen along the entire course of the
wire. Once true lumen confirmation was made, we then exchanged the
Lunderquist super stiff guidewire again for a marked pigtail catheter and
performed a Dyna-CT using 1/5 strength contrast. We performed an
additional 2-dimensional aortic arch aortogram and carefully mapped out the
takeoff of the left common carotid artery and the stump of the left
subclavian artery. Using this as an overlay roadmap, we then exchanged the
pigtail catheter for a Lunderquist super stiff guidewire over which we then
advanced a Cook ZDEG 34 mm x 204 mm stent graft advancing it into position
with the proximal most landing site being at the ostium of the left
subclavian just beyond the takeoff the left common carotid artery. We then
slowly deployed the stent graft with the proximal most aspect covering the
left subclavian ostium. Once we confirmed excellent positioning, we then
released the stent graft. We then exchanged the 20-French Cook sheath for
a 20-French Gore DrySeal sheath. Through the 20-French Gore DrySeal
sheath, we then balloon profiled the proximal landing site using a 40 mL
Coda balloon. We positioned the balloon at the proximal landing site, did
1 ballooning to achieve profiling of the stent graft. We then removed the
Coda balloon and advanced a Cook ZDES stent 46 mm x 185 mm nitinol stent.
It was positioned with overlap of 1-1/2 Z-stents with the stent graft.
Once we confirmed positioning, this nitinol stent was deployed. We then
deployed a second 36 mm x 120 mm ZDES stent. It was overlapped with the
prior 46 mm stent by 1 Z-stent. This extended stent down below the renal
arteries. There was still some residual unstented aorta approximately 5 cm
in length between the terminal point of the 36 x 120 stent from the aortic
bifurcation and yet the dissection extended down both iliac arteries and
was markedly compromising true lumen inflow to the right. Therefore, we
wanted to stent all the way to the aortic bifurcation; therefore, a third
ZDES stent 36 mm x 80 mm was positioned such that its terminal aspect was
right at the aortic bifurcation. Once we confirmed its positioning with an
aortogram, we then deployed it and then performed a completion aortogram
confirming excellent positioning of all the stent grafts. We then
performed a completion aortogram of the aortic arch confirmed no type 1 or
type 2 endoleaks. We then advanced the intravascular ultrasound probe
again over the Lunderquist guidewire and confirmed patency of both renal
arteries, the celiac and SMA arteries. We then removed the Gore DrySeal
sheath and repaired the left common femoral artery primarily using running
5-0 Prolene suture after placing proximal and distal clamps. Following
completion, we then waited until the ACT had fallen to near normal. We
then closed both the left groin and the left base of the neck incisions in
layers with running absorbable sutures. We left a 15-French Jackson-Pratt
drain in the bed of the base of the left neck incision bringing it out
through a separate stab incision. Following closure of both wounds, we
then turned the case over to ------- who wanted to perform an EGD
to examine the esophagus given concerns about its disruption on the chest
CT done earlier. Please refer to the details for that operative procedure.
Of note, throughout the entire procedure, we monitored the patient with
continuous EEG and intermittent MEPs as well as continuous SSEPs. His
lower extremity and upper extremity signals for both MEP and SSEPs remained
at baseline for the entire reconstruction with 1 exception. During the
left subclavian to left common carotid transposition, we lost left upper
extremity SSEPs signals due to cross-clamping the left subclavian artery as
soon as that vessel was revascularized, there was return to normal baseline
evoked potentials in the left upper extremity as well.
PREOPERATIVE DIAGNOSIS: ACUTE RUPTURED TYPE B AORTIC DISSECTION, SPINAL
CORD ISCHEMIA, RIGHT LOWER EXTREMITY ISCHEMIA, RENAL INSUFFICIENCY.
POSTOPERATIVE DIAGNOSIS: ACUTE RUPTURED TYPE B AORTIC DISSECTION, SPINAL
CORD ISCHEMIA, RIGHT LOWER EXTREMITY ISCHEMIA, RENAL INSUFFICIENCY.
PROCEDURES PERFORMED: LEFT SUBCLAVIAN ARTERY TO LEFT COMMON CAROTID ARTERY
TRANSPOSITION, THORACIC ENDOVASCULAR AORTIC REPAIR (COOK ZDEG 34 MM X 204
MM STENT GRAFT, COOK ZDES 46 MM X 185 MM, 36 MM X 120 MM, 36 MM X 80 MM
COOK NITINOL STENTS), THORACIC AORTOGRAM WITH RADIOLOGIC SNI, INTRAVASCULAR
ULTRASOUND.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite,
placed supine and induced with general endotracheal anesthesia. A central
line and radial arterial line were placed by the Anesthesia Team for
intraoperative monitoring. The patient was prepped and draped in the usual
sterile fashion from the mandible to the knees. The head was turned to the
right to expose the base of the left neck. We first drew our attention
towards completing the transposition. A 3-cm transverse incision was made
1 fingerbreadth above the clavicle over the sternocleidomastoid muscle. We
then identified the sternal and clavicular heads of the sternocleidomastoid
and we split the muscle in between the 2 bellies and retracted them
medially and laterally, respectively. We then carefully dissected out the
left common carotid artery within the base of the neck. We then mobilized
the left internal jugular vein, retracted it medially, and then dissected
out the left subclavian artery, including its primary branches including
the left internal mammary artery, the thoracoacromial artery, and the left
vertebral arteries. The left internal mammary artery was ligated and
divided near its takeoff to facilitate greater mobilization of the
subclavian. We then administered argatroban as an anticoagulant because
the patient had a remote history 3 years ago of heparin-induced
thrombocytopenia. Therefore, we utilized no heparin throughout the case.
We maintained an ACT of over 200 seconds with intermittent argatroban
doses. Once we achieved an ACT of approximately 210 seconds, we then
placed a cross-clamp across the proximal left subclavian artery proximal to
the takeoff of the left vertebral artery. Distally, all the branches that
were named above and the left subclavian were controlled with Vesseloops,
preventing any back bleeding. We then oversewed the proximal stump of the
left subclavian artery with running 5-0 Prolene suture and reinforced the
closure with a single pledgeted 4-0 Prolene suture which served as a stay
suture until completion of the reconstruction. We then transposed the left
subclavian with an intact left vertebral artery and left thoracoacromial
artery, transposed it posterior to the left internal jugular vein in a
retrojugular fashion and swept it up towards the left common carotid
artery. On the posterolateral aspect of the left common carotid artery, we
made an elliptical arteriotomy and then anastomosed the left subclavian in
an end-to-side fashion to the left common carotid using running 6-0 Prolene
suture. Following completion, we left the wound open until completion of
the _____ at which time, the argatroban was worn off. Next, we drew our
attention toward the left groin. The right common femoral artery was fed
entirely by the false lumen and had a diminished pulse; therefore, we
provided access to the true lumen via the left common femoral artery. An
oblique incision 2.5 cm in length was made just above the left inguinal
crease and then the left common femoral artery at the level of the inguinal
ligament was circumferentially dissected out and controlled proximally and
distally. With adequate anticoagulation using argatroban again to an ACT
over 210 seconds, we then introduced an 18-gauge needle into the left
common femoral artery and then advanced the guidewire under fluoroscopic
guidance up into the ascending aorta. That guidewire, which was a floppy
starter wire, was then exchanged for a pigtail catheter which was then
exchanged for a Lunderquist super stiff guidewire. Over that Lunderquist
super stiff guidewire, we then performed an intravascular ultrasound and
confirmed that we were within the true lumen along the entire course of the
wire. Once true lumen confirmation was made, we then exchanged the
Lunderquist super stiff guidewire again for a marked pigtail catheter and
performed a Dyna-CT using 1/5 strength contrast. We performed an
additional 2-dimensional aortic arch aortogram and carefully mapped out the
takeoff of the left common carotid artery and the stump of the left
subclavian artery. Using this as an overlay roadmap, we then exchanged the
pigtail catheter for a Lunderquist super stiff guidewire over which we then
advanced a Cook ZDEG 34 mm x 204 mm stent graft advancing it into position
with the proximal most landing site being at the ostium of the left
subclavian just beyond the takeoff the left common carotid artery. We then
slowly deployed the stent graft with the proximal most aspect covering the
left subclavian ostium. Once we confirmed excellent positioning, we then
released the stent graft. We then exchanged the 20-French Cook sheath for
a 20-French Gore DrySeal sheath. Through the 20-French Gore DrySeal
sheath, we then balloon profiled the proximal landing site using a 40 mL
Coda balloon. We positioned the balloon at the proximal landing site, did
1 ballooning to achieve profiling of the stent graft. We then removed the
Coda balloon and advanced a Cook ZDES stent 46 mm x 185 mm nitinol stent.
It was positioned with overlap of 1-1/2 Z-stents with the stent graft.
Once we confirmed positioning, this nitinol stent was deployed. We then
deployed a second 36 mm x 120 mm ZDES stent. It was overlapped with the
prior 46 mm stent by 1 Z-stent. This extended stent down below the renal
arteries. There was still some residual unstented aorta approximately 5 cm
in length between the terminal point of the 36 x 120 stent from the aortic
bifurcation and yet the dissection extended down both iliac arteries and
was markedly compromising true lumen inflow to the right. Therefore, we
wanted to stent all the way to the aortic bifurcation; therefore, a third
ZDES stent 36 mm x 80 mm was positioned such that its terminal aspect was
right at the aortic bifurcation. Once we confirmed its positioning with an
aortogram, we then deployed it and then performed a completion aortogram
confirming excellent positioning of all the stent grafts. We then
performed a completion aortogram of the aortic arch confirmed no type 1 or
type 2 endoleaks. We then advanced the intravascular ultrasound probe
again over the Lunderquist guidewire and confirmed patency of both renal
arteries, the celiac and SMA arteries. We then removed the Gore DrySeal
sheath and repaired the left common femoral artery primarily using running
5-0 Prolene suture after placing proximal and distal clamps. Following
completion, we then waited until the ACT had fallen to near normal. We
then closed both the left groin and the left base of the neck incisions in
layers with running absorbable sutures. We left a 15-French Jackson-Pratt
drain in the bed of the base of the left neck incision bringing it out
through a separate stab incision. Following closure of both wounds, we
then turned the case over to ------- who wanted to perform an EGD
to examine the esophagus given concerns about its disruption on the chest
CT done earlier. Please refer to the details for that operative procedure.
Of note, throughout the entire procedure, we monitored the patient with
continuous EEG and intermittent MEPs as well as continuous SSEPs. His
lower extremity and upper extremity signals for both MEP and SSEPs remained
at baseline for the entire reconstruction with 1 exception. During the
left subclavian to left common carotid transposition, we lost left upper
extremity SSEPs signals due to cross-clamping the left subclavian artery as
soon as that vessel was revascularized, there was return to normal baseline
evoked potentials in the left upper extremity as well.