Here is the OR note...
Hybrid TEVAR with one left subclavian carotid bypass graft.
2. Aortic debranching procedure done through a median sternotomy.
3. Aortic stent grafting using a Medtronic Talent 40 x 40 x 114
graft.
76-year-old male who previously
a year earlier had a stent graft placed in a penetrating ulcer in
his descending thoracic aortic aneurysm. At that time, he had a 4.5
cm descending thoracic aneurysm at the level of the subclavian. Due
to the large territory that had to be covered by a stent graft at
that time, we opted to follow him. Over the past year, his aneurysm
at the level of the left subclavian has grown to be 6.7 cm in size.
After obtaining informed consent and discussing with the patient the
various options versus open repair versus hybrid TEVAR procedure and
the patient opted for the TEVAR approach due to the fact that we had
no proximal landing zone and would have to create one.
FINDINGS: Postoperative ejection fraction was 50%.
PROCEDURE: He is taken to the operating room. The first order of
business was his chest, legs and neck were prepped and draped in the
usual sterile fashion. An incision was made 2 cm above clavicle on
the left side and dissected down along the anterior border of the
sternocleidomastoid. I identified the left internal carotid artery
and got proximal and distal control. We also attempted to find the
left subclavian through the same incision, however, his scalene
anticus and brachial plexus was lower than expected and we wanted to
avoid this area. So, we made an incision below his left clavicle on
the left side, dissected through the subcutaneous tissues. I
isolated the axillary artery and grafted it using an 8 mm Gore-Tex
graft which was tunneled below, grafting the left subclavian to
distal left subclavian artery bypass. Proximal anastomosis was sewn
first. We flushed the graft prior to reestablishing flow. Once
this was completed, we packed the incision. Median sternotomy was
then performed. A pericardial well was created. His ascending
aorta and head vessels were all identified and freed up. I
skeletonized the innominate vein so I could move it back and forth.
I then placed the partial occluding clamp. I took a 12 x 8 x 8 x 6
Hughes graft. I sewed the proximal anastomosis after I tapered it
and beveled it on the ascending aorta. I then took one of the 8 mm
limbs and grafted the anastomosis to the left internal carotid
artery. Once this was completed, we reestablished flow of the left
carotid. I then placed a side-biting clamp on the innominate artery
and grafted an additional 8 mm graft which had to be moved down onto
the graft to have a better lie. Using a side-biting clamp, I
performed my aortotomy and grafted the next head branch off the
Hughes graft using a 4-0 Surgipro. At the completion of this, we
reestablished flow. There is no bleeding and obtained hemostasis.
We then brought in our fluoroscopy equipment, cut down on the right
groin and got access to the right femoral artery. We got proximal
and distal control. I placed a Lunderquist wire up from below.
Through the sidearm graft with a Hughes graft under fluoroscopy, I
was able to snare it and capture it. Then we had a Lunderquist wire
from the femoral artery out the patient and the end of our Hughes
graft. This straightened the aorta significantly. We were then
able to bring our Talent graft up from below. Under fluoroscopy, we
deployed it initially in the graft and released it. We had good
coverage, good 3-4 cm proximal landing zone and deployed it into the
distal previously placed graft. Our followup root shot showed no
endoleak. Proximally, there was flow still coming in from the left
subclavian. Our plan at that time was to place implants once the
patient had fully recovered. We pressed the graft out with a
balloon, pulled our devices out, and closed the femoral artery in
the usual standard fashion. We placed 3 chest tubes, reclosed the
pericardium, rewired the sternum and closed the subcutaneous tissues
in 3 layers. The patient woke up neurologically intact. Followup
CT showed just an endoleak from our subclavian which was dealt with
by Dr. Clifford Lynd by placing an Amplatz plug later on.
POSTOPERATIVE DIAGNOSIS: Descending thoracic aortic aneurysm 6.7 cm
in size involving the left subclavian artery.
When i get back to work, I'll ask the guys and see what they say.