sslater
Networker
We are needing help with this Op Note... i have never coded for this type of procedure. I'm not sure where to even start... 
PREOPERATIVE DIAGNOSIS:
High grade probably symptomatic superior mesenteric artery stenosis.
POSTOPERATIVE DIAGNOSIS:
High grade probably symptomatic superior mesenteric artery stenosis.
NAME OF PROCEDURE:
Left brachial artery cutdown and repair, superior mesenteric artery
stent graft placement x1, left subclavian arteriogram, thoracic
aortogram, abdominal aortogram.
INDICATION FOR SURGERY: The patient is an 83-year-old male who was
evaluated for atypical type abdominal pain. The patient had a CT
angiogram done, which showed a high grade superior mesenteric artery
stenosis of 75-80%. This is an 8-9 mm very large vessel. The celiac
artery was nondiseased. The patient is not having true abdominal
angina. We reviewed as an outpatient the CT angiogram and spoke in
detail about observation versus intervention. In light of the large
diameter of the vessel our discussions revolved more towards operative
intervention. We discussed indications, technique, expected outcome,
potential complications to include but not limited to vessel injury,
need for open abdominal surgery, bowel ischemia, cerebrovascular
accident, stroke and myocardial infarction and death. The patient
fully understands and agrees to proceed with surgery without
reservations.
FINDINGS AT SURGERY: The patient had 75-80% stenosis of the superior
mesenteric artery approximately 8-9 mm from its orifice. I elected to
treat this with a covered stent to prevent or decrease the chance for
distal emboli. We did not to predilatation. We placed an 8 mm x 2.5
cm Gore Viabahn endoprosthesis. Catalog #VBJ080202, lot #9903086. An
8 mm x 20 mm balloon was used for post deployment angioplasty, catalog
#ADM080020130, lot #1E020308. This was an Invatec Admiral Xtreme
balloon. Contrast was approximately 100 mL of Visipaque. All wire
manipulation was done under continuous fluoroscopic guidance.
DESCRIPTION OF OPERATION: The patient was taken to the operating room
and placed in a supine position. General endotracheal anesthesia was
administered. The left arm was prepped and draped in usual sterile
manner and we made a 2 cm incision 2 fingerbreadths above the left
antecubital crease and exposed the brachial artery and encircled with
Vesseloops. We systemically heparinized the patient with 15,000 units
of intravenous Heparin and after adequate circulation time was
allowed, I accessed the left brachial artery with a micropuncture
needle, wire and sheath. A 4 French sheath was placed followed by an
angled Glidewire, which was advanced into the descending thoracic
aorta under fluoroscopic guidance. We parked the wire in the distal
most abdominal aorta and removed the 4 French sheath and placed a 7
French x 90 cm Raabe sheath with the sheath being placed down to
approximately lumbar vertebral body #1. We did flush aortography with
an oblique camera view and identified the superior mesenteric and the
celiac arteries positively and correlated these findings with the CT
angiogram. We went into a cross table lateral and locked the Zeego
sheath and also locked the table and did flush aortography and road
mapping techniques were used. Using a Berenstein catheter we directed
an angled tip Glidewire into the superior mesenteric artery and
advanced the Raabe sheath down and engaged the proximal superior
mesenteric artery. We did detailed angiography and roadmapping. I
exchanged the wire for a 0.018 wire and placed the 8 mm x 2.5 cm Gore
Viabahn endoprosthesis across the lesion. We did balloon angioplasty
with the 8 mm balloon and completion angiography in the PA and lateral
cross table position showed approximately 10% residual and excellent
flow and no dissection noted. We did pullback angiography of the
abdominal aorta, the thoracic aorta and the left subclavian. We
removed the sheath and repaired the artery with interrupted 7-0
monofilament sutures and partially reversed the protamine. Doppler
interrogation and palpation of the radial pulse was excellent pulses
detected. Hemostasis was obtained. The incision was closed with
interrupted 3-0 Vicryl sutures and a running 4-0 subcuticular stitch.
Sterile dressing was applied and the patient was awakened and
transported to the intensive care unit for postoperative monitoring.
All needles and wires, sharps and sponge count were correct x2.
Angiography interpretation showed no high grade lesions in the left
subclavian artery. The thoracic aorta and the abdominal aorta were
unremarkable. There was calcification in the walls but no aneurysmal
dilatations or atherosclerotic stenoses noted.
PREOPERATIVE DIAGNOSIS:
High grade probably symptomatic superior mesenteric artery stenosis.
POSTOPERATIVE DIAGNOSIS:
High grade probably symptomatic superior mesenteric artery stenosis.
NAME OF PROCEDURE:
Left brachial artery cutdown and repair, superior mesenteric artery
stent graft placement x1, left subclavian arteriogram, thoracic
aortogram, abdominal aortogram.
INDICATION FOR SURGERY: The patient is an 83-year-old male who was
evaluated for atypical type abdominal pain. The patient had a CT
angiogram done, which showed a high grade superior mesenteric artery
stenosis of 75-80%. This is an 8-9 mm very large vessel. The celiac
artery was nondiseased. The patient is not having true abdominal
angina. We reviewed as an outpatient the CT angiogram and spoke in
detail about observation versus intervention. In light of the large
diameter of the vessel our discussions revolved more towards operative
intervention. We discussed indications, technique, expected outcome,
potential complications to include but not limited to vessel injury,
need for open abdominal surgery, bowel ischemia, cerebrovascular
accident, stroke and myocardial infarction and death. The patient
fully understands and agrees to proceed with surgery without
reservations.
FINDINGS AT SURGERY: The patient had 75-80% stenosis of the superior
mesenteric artery approximately 8-9 mm from its orifice. I elected to
treat this with a covered stent to prevent or decrease the chance for
distal emboli. We did not to predilatation. We placed an 8 mm x 2.5
cm Gore Viabahn endoprosthesis. Catalog #VBJ080202, lot #9903086. An
8 mm x 20 mm balloon was used for post deployment angioplasty, catalog
#ADM080020130, lot #1E020308. This was an Invatec Admiral Xtreme
balloon. Contrast was approximately 100 mL of Visipaque. All wire
manipulation was done under continuous fluoroscopic guidance.
DESCRIPTION OF OPERATION: The patient was taken to the operating room
and placed in a supine position. General endotracheal anesthesia was
administered. The left arm was prepped and draped in usual sterile
manner and we made a 2 cm incision 2 fingerbreadths above the left
antecubital crease and exposed the brachial artery and encircled with
Vesseloops. We systemically heparinized the patient with 15,000 units
of intravenous Heparin and after adequate circulation time was
allowed, I accessed the left brachial artery with a micropuncture
needle, wire and sheath. A 4 French sheath was placed followed by an
angled Glidewire, which was advanced into the descending thoracic
aorta under fluoroscopic guidance. We parked the wire in the distal
most abdominal aorta and removed the 4 French sheath and placed a 7
French x 90 cm Raabe sheath with the sheath being placed down to
approximately lumbar vertebral body #1. We did flush aortography with
an oblique camera view and identified the superior mesenteric and the
celiac arteries positively and correlated these findings with the CT
angiogram. We went into a cross table lateral and locked the Zeego
sheath and also locked the table and did flush aortography and road
mapping techniques were used. Using a Berenstein catheter we directed
an angled tip Glidewire into the superior mesenteric artery and
advanced the Raabe sheath down and engaged the proximal superior
mesenteric artery. We did detailed angiography and roadmapping. I
exchanged the wire for a 0.018 wire and placed the 8 mm x 2.5 cm Gore
Viabahn endoprosthesis across the lesion. We did balloon angioplasty
with the 8 mm balloon and completion angiography in the PA and lateral
cross table position showed approximately 10% residual and excellent
flow and no dissection noted. We did pullback angiography of the
abdominal aorta, the thoracic aorta and the left subclavian. We
removed the sheath and repaired the artery with interrupted 7-0
monofilament sutures and partially reversed the protamine. Doppler
interrogation and palpation of the radial pulse was excellent pulses
detected. Hemostasis was obtained. The incision was closed with
interrupted 3-0 Vicryl sutures and a running 4-0 subcuticular stitch.
Sterile dressing was applied and the patient was awakened and
transported to the intensive care unit for postoperative monitoring.
All needles and wires, sharps and sponge count were correct x2.
Angiography interpretation showed no high grade lesions in the left
subclavian artery. The thoracic aorta and the abdominal aorta were
unremarkable. There was calcification in the walls but no aneurysmal
dilatations or atherosclerotic stenoses noted.