conleyclan
Guru
These aneurysms are so painful to me to code. Any help would be appreciated. This particular doctor is so wordy that I am afraid I am missing something.
Thank you!!
PREOPERATIVE DIAGNOSIS: Chronic aneurysmal type B aortic dissection/Extent
II thoracoabdominal aortic aneurysm.
POSTOPERATIVE DIAGNOSIS: Chronic aneurysmal type B aortic
dissection/Extent II thoracoabdominal aortic aneurysm.
PROCEDURES PERFORMED: Re-operative Extent II thoracoabdominal aortic
replacement (24 mm 4 branched Vascutek graft - Coselli type), left renal
artery bypass graft (8 mm graft), right renal arterial bypass graft (8 mm
graft), celiac arterial bypass (10 mm graft), superior mesenteric artery
bypass graft (10-mm graft), accessory left renal arterial bypass (reverse
saphenous vein graft), inferior mesenteric arterial bypass (reverse
saphenous vein graft), 4 intercostal arterial bypass grafts (reverse
saphenous vein grafts), right endoscopic greater saphenous vein harvest,
therapeutic aspiration bronchoscopy.
BRIEF HISTORY: The patient is a 43-year-old female who sustained a type A
aortic dissection many years ago. This was initially repaired via total
root replacement using a mechanical valve conduit and aortic arch
replacement. She subsequently developed aneurysmal residual type B aortic
dissection and she underwent distal arch and descending thoracic aortic
replacement to the distal third of the descending thoracic aorta
approximately 5 years ago. These prior procedures were done by another
surgeon, and the patient was subsequently referred to our center for
thoracic aortic disease and I have been following her for several years for
her residual type B aortic dissection, which has become progressively more
aneurysmal. On her recent followup CT angiogram, we confirmed significant
interval increase in the maximal orthogonal diameter of the
thoracoabdominal aorta now over ____ 60 mm. Given the interval increase in
size and her young age, we recommended that she undergo complete Extent II
thoracoabdominal aortic replacement. She presents today electively for
that re-operation.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite,
and initially, a lumbar drain was placed by the anesthesia team for CSF
drainage. The patient has had prior spinal surgery including Harrington
rod placements and was not a candidate for an epidural placement which is
our usual protocol. The patient was subsequently placed supine and induced
with general endotracheal anesthesia. A bronchial blocker was placed in
the left main stem bronchus and the right greater saphenous vein was
subsequently harvested. The right lower extremity was prepped and draped
in the usual sterile fashion and the right greater saphenous vein was
subsequently harvested endoscopically in the usual fashion. Following
harvesting of that conduit, the incisions were closed in layers with
running absorbable sutures. The patient was then turned in the right
lateral decubitus position with the table flexed. We then prepped and
draped the patient in the usual sterile fashion from the shoulder to the
knee. A 5th interspace redo thoracoabdominal incision was then made.
There were extraordinarily dense adhesions in the left chest and it was
with great tedium that we dissected the left lung off the chest wall. It
was completely plastered to the chest wall and it took some time in
carefully freeing the lung from the chest wall and diaphragm. The
thoracoabdominal incision was carried down into the pelvis, and we
dissected out the retroperitoneal plane and exposed the thoracoabdominal
aorta. We identified the previously placed descending thoracic aortic
graft and obtained circumferential control of that graft in the mid
descending thoracic aorta range. After adequate exposure of the
thoracoabdominal aorta and lysis of all those adhesions in the left
hemithorax, the patient was subsequently heparinized and then cannulated
for cardiopulmonary bypass via the descending thoracic aortic graft and the
right atrium at the IVC RA junction. An additional left ventricular vent
was placed through the left inferior pulmonary vein at its junction with
the LA. The patient was subsequently placed on cardiopulmonary bypass and
systemically cooled to deep hypothermia. We monitored the patient with
continuous EEG and SSEPs to help direct safe period of deep hypothermic
circulatory arrest, although we never arrested the upper body circulation,
only the lower body circulation. We systemically cooled to electrocerebral
silence for greater than 4 minutes per our protocol; and once we achieved
electrocerebral silence, we placed a cross clamp in the mid descending
thoracic aorta just below the cannulation site terminating flow to the
lower body. We then filleted open the thoracoabdominal aorta. The
thoracoabdominal aorta was chronically dissected and severely diseased with
thrombus and calcium throughout the dissected walls. We extended the
incision all the way to the aortic bifurcation and then we carefully
identified the celiac arterial ostium, superior mesenteric artery, left
renal artery, accessory left renal artery, right renal artery, inferior
mesenteric artery which was a sizeable vessel. We then chose a 24-mm
Vascutek 4-branched graft Coselli type, and we first completed the distal
anastomosis. We transected the abdominal aorta at the aortic bifurcation
and then anastomosed the Coselli graft to that with running 3-0 Prolene
suture. We then cut the graft to an appropriate length and then transected
the previously placed descending thoracic aortic graft just below the cross
clamp and anastomosed the two grafts to one another using running 2-0
Prolene suture. This re-established continuity of the thoracoabdominal
aorta; and following completion of that proximal anastomosis, we began
re-perfusion of the lower body. We maintained the patient at the deep
hypothermia despite reinstituting lower body perfusion in order to complete
the mesenteric and renal arterial bypasses while the patient was
systemically hypothermic. We first drew attention toward the right renal
artery. This was circumferentially dissected out beyond its ostium. We
then took one of the 4 branches of the Coselli graft, an 8 mm limb was cut
to an appropriate length and then anastomosed to the right renal artery
using running 5-0 Prolene suture. Immediately upon completion of that
anastomosis, we reconstituted flow to the right kidney. We then identified
both primary left renal artery as well as an accessory left renal artery.
The primary renal artery was circumferentially dissected out and then a
second 8 mm limb from the Coselli graft was cut to an appropriate length
and then anastomosed to the left renal artery using running 5-0 Prolene
suture. Again after completion of this anastomosis, the left kidney was
re-perfused. We then dissected out the superior mesenteric artery. One of
the 10-mm limbs of the Coselli graft was cut to an appropriate length and
anastomosed to the SMA using running 5-0 Prolene suture. Again, flow was
reconstituted to that vessel upon completion of the anastomosis. Next, the
celiac artery was circumferentially dissected out and the final 10-mm limb
of the Coselli graft was cut to an appropriate length and anastomosed to
the celiac with running 5-0 Prolene suture. Following completion of that
anastomosis, we re-constituted flow through the celiac. We then drew
attention back to the accessory left renal artery. This vessel was
dissected out and then a segment of reverse saphenous vein graft was
spatulated and anastomosed to the accessory left renal artery using running
5-0 Prolene suture. We then cut the vein graft to an appropriate length
and placed a partial occlusion clamp on the ____ graft, aortic graft and
made a circular graftotomy with the ophthalmic cautery device. The vein
graft was then spatulated and anastomosed to the thoracoabdominal aortic
graft using running 5-0 Prolene suture. After this anastomosis, we then
began systemically re-warming the patient. During re-warming, we then
proceeded to graft the inferior mesenteric artery. This vessel was
dissected out and then a second vein graft reversed, spatulated, and
anastomosed to the IMA with running 6-0 Prolene suture. We then placed a
partial occlusion clamp on the thoracoabdominal graft and then made a
circular graftotomy with the ophthalmic cautery device. We spatulated the
vein graft and anastomosed it to the thoracoabdominal graft using running
5-0 Prolene suture. We then carefully identified 4 intercostal arteries
which were critical to spinal cord blood flow, one set of 2 was identified
at the T9 level and a second set of 2 was identified at the L2 level. We
subsequently identified several other smaller left consequential pairs of
intercostal arteries which were ligated with 3-0 Prolene suture. We then
drew attention toward the T9 intercostal set. A vein graft was spatulated.
The intercostals were dissected out circumferentially and then as a pair,
the vein graft was anastomosed to the dual ostia using running 5-0 Prolene
suture. We then trimmed that vein graft to an appropriate length, placed a
partial occlusion clamp on the thoracoabdominal graft and then made a
circular graftotomy with the ophthalmic cautery device and then the vein
graft was spatulated and anastomosed to the graft using running 5-0 Prolene
suture. Similarly, we dissected out the L2 set of lumbar arteries
circumferentially. To the dual ostia, a vein graft was reversed,
spatulated, and anastomosed to both ostia using running 5-0 Prolene suture.
We cut that vein graft to an appropriate length, placed a partial
occlusion clamp on the thoracoabdominal graft, made a circular graftotomy
and then anastomosed the vein graft to the thoracoabdominal graft with
running 5-0 Prolene suture. All the while, we were systemically rewarming
the patient; and upon achieving normothermia, the patient was subsequently
weaned from cardiopulmonary bypass with preserved right and left
ventricular function. The patient's EEG and SSEP signals had returned to
baseline. After weaning from bypass, the patient was decannulated, the
heparin reversed with IV protamine, and meticulous hemostasis achieved in
the entire operative field. Blake drains and a chest tube were placed in
the left pleural space. The diaphragm, which had been taken down
circumferentially, was re-approximated using running #1 Maxon suture. The
ribs were approximated with #2 Vicryl. The latissimus dorsi and serratus
anterior, and abdominal muscular fascia were approximated with running
absorbable sutures. The subcutaneous tissues and skin were similarly
approximated with running absorbable sutures. The patient was subsequently
turned supine and then a therapeutic aspiration bronchoscopy was performed
to clear bloody tracheobronchial secretions. The patient was subsequently
transferred to the CT ICU in stable condition.
Thank you!!
PREOPERATIVE DIAGNOSIS: Chronic aneurysmal type B aortic dissection/Extent
II thoracoabdominal aortic aneurysm.
POSTOPERATIVE DIAGNOSIS: Chronic aneurysmal type B aortic
dissection/Extent II thoracoabdominal aortic aneurysm.
PROCEDURES PERFORMED: Re-operative Extent II thoracoabdominal aortic
replacement (24 mm 4 branched Vascutek graft - Coselli type), left renal
artery bypass graft (8 mm graft), right renal arterial bypass graft (8 mm
graft), celiac arterial bypass (10 mm graft), superior mesenteric artery
bypass graft (10-mm graft), accessory left renal arterial bypass (reverse
saphenous vein graft), inferior mesenteric arterial bypass (reverse
saphenous vein graft), 4 intercostal arterial bypass grafts (reverse
saphenous vein grafts), right endoscopic greater saphenous vein harvest,
therapeutic aspiration bronchoscopy.
BRIEF HISTORY: The patient is a 43-year-old female who sustained a type A
aortic dissection many years ago. This was initially repaired via total
root replacement using a mechanical valve conduit and aortic arch
replacement. She subsequently developed aneurysmal residual type B aortic
dissection and she underwent distal arch and descending thoracic aortic
replacement to the distal third of the descending thoracic aorta
approximately 5 years ago. These prior procedures were done by another
surgeon, and the patient was subsequently referred to our center for
thoracic aortic disease and I have been following her for several years for
her residual type B aortic dissection, which has become progressively more
aneurysmal. On her recent followup CT angiogram, we confirmed significant
interval increase in the maximal orthogonal diameter of the
thoracoabdominal aorta now over ____ 60 mm. Given the interval increase in
size and her young age, we recommended that she undergo complete Extent II
thoracoabdominal aortic replacement. She presents today electively for
that re-operation.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite,
and initially, a lumbar drain was placed by the anesthesia team for CSF
drainage. The patient has had prior spinal surgery including Harrington
rod placements and was not a candidate for an epidural placement which is
our usual protocol. The patient was subsequently placed supine and induced
with general endotracheal anesthesia. A bronchial blocker was placed in
the left main stem bronchus and the right greater saphenous vein was
subsequently harvested. The right lower extremity was prepped and draped
in the usual sterile fashion and the right greater saphenous vein was
subsequently harvested endoscopically in the usual fashion. Following
harvesting of that conduit, the incisions were closed in layers with
running absorbable sutures. The patient was then turned in the right
lateral decubitus position with the table flexed. We then prepped and
draped the patient in the usual sterile fashion from the shoulder to the
knee. A 5th interspace redo thoracoabdominal incision was then made.
There were extraordinarily dense adhesions in the left chest and it was
with great tedium that we dissected the left lung off the chest wall. It
was completely plastered to the chest wall and it took some time in
carefully freeing the lung from the chest wall and diaphragm. The
thoracoabdominal incision was carried down into the pelvis, and we
dissected out the retroperitoneal plane and exposed the thoracoabdominal
aorta. We identified the previously placed descending thoracic aortic
graft and obtained circumferential control of that graft in the mid
descending thoracic aorta range. After adequate exposure of the
thoracoabdominal aorta and lysis of all those adhesions in the left
hemithorax, the patient was subsequently heparinized and then cannulated
for cardiopulmonary bypass via the descending thoracic aortic graft and the
right atrium at the IVC RA junction. An additional left ventricular vent
was placed through the left inferior pulmonary vein at its junction with
the LA. The patient was subsequently placed on cardiopulmonary bypass and
systemically cooled to deep hypothermia. We monitored the patient with
continuous EEG and SSEPs to help direct safe period of deep hypothermic
circulatory arrest, although we never arrested the upper body circulation,
only the lower body circulation. We systemically cooled to electrocerebral
silence for greater than 4 minutes per our protocol; and once we achieved
electrocerebral silence, we placed a cross clamp in the mid descending
thoracic aorta just below the cannulation site terminating flow to the
lower body. We then filleted open the thoracoabdominal aorta. The
thoracoabdominal aorta was chronically dissected and severely diseased with
thrombus and calcium throughout the dissected walls. We extended the
incision all the way to the aortic bifurcation and then we carefully
identified the celiac arterial ostium, superior mesenteric artery, left
renal artery, accessory left renal artery, right renal artery, inferior
mesenteric artery which was a sizeable vessel. We then chose a 24-mm
Vascutek 4-branched graft Coselli type, and we first completed the distal
anastomosis. We transected the abdominal aorta at the aortic bifurcation
and then anastomosed the Coselli graft to that with running 3-0 Prolene
suture. We then cut the graft to an appropriate length and then transected
the previously placed descending thoracic aortic graft just below the cross
clamp and anastomosed the two grafts to one another using running 2-0
Prolene suture. This re-established continuity of the thoracoabdominal
aorta; and following completion of that proximal anastomosis, we began
re-perfusion of the lower body. We maintained the patient at the deep
hypothermia despite reinstituting lower body perfusion in order to complete
the mesenteric and renal arterial bypasses while the patient was
systemically hypothermic. We first drew attention toward the right renal
artery. This was circumferentially dissected out beyond its ostium. We
then took one of the 4 branches of the Coselli graft, an 8 mm limb was cut
to an appropriate length and then anastomosed to the right renal artery
using running 5-0 Prolene suture. Immediately upon completion of that
anastomosis, we reconstituted flow to the right kidney. We then identified
both primary left renal artery as well as an accessory left renal artery.
The primary renal artery was circumferentially dissected out and then a
second 8 mm limb from the Coselli graft was cut to an appropriate length
and then anastomosed to the left renal artery using running 5-0 Prolene
suture. Again after completion of this anastomosis, the left kidney was
re-perfused. We then dissected out the superior mesenteric artery. One of
the 10-mm limbs of the Coselli graft was cut to an appropriate length and
anastomosed to the SMA using running 5-0 Prolene suture. Again, flow was
reconstituted to that vessel upon completion of the anastomosis. Next, the
celiac artery was circumferentially dissected out and the final 10-mm limb
of the Coselli graft was cut to an appropriate length and anastomosed to
the celiac with running 5-0 Prolene suture. Following completion of that
anastomosis, we re-constituted flow through the celiac. We then drew
attention back to the accessory left renal artery. This vessel was
dissected out and then a segment of reverse saphenous vein graft was
spatulated and anastomosed to the accessory left renal artery using running
5-0 Prolene suture. We then cut the vein graft to an appropriate length
and placed a partial occlusion clamp on the ____ graft, aortic graft and
made a circular graftotomy with the ophthalmic cautery device. The vein
graft was then spatulated and anastomosed to the thoracoabdominal aortic
graft using running 5-0 Prolene suture. After this anastomosis, we then
began systemically re-warming the patient. During re-warming, we then
proceeded to graft the inferior mesenteric artery. This vessel was
dissected out and then a second vein graft reversed, spatulated, and
anastomosed to the IMA with running 6-0 Prolene suture. We then placed a
partial occlusion clamp on the thoracoabdominal graft and then made a
circular graftotomy with the ophthalmic cautery device. We spatulated the
vein graft and anastomosed it to the thoracoabdominal graft using running
5-0 Prolene suture. We then carefully identified 4 intercostal arteries
which were critical to spinal cord blood flow, one set of 2 was identified
at the T9 level and a second set of 2 was identified at the L2 level. We
subsequently identified several other smaller left consequential pairs of
intercostal arteries which were ligated with 3-0 Prolene suture. We then
drew attention toward the T9 intercostal set. A vein graft was spatulated.
The intercostals were dissected out circumferentially and then as a pair,
the vein graft was anastomosed to the dual ostia using running 5-0 Prolene
suture. We then trimmed that vein graft to an appropriate length, placed a
partial occlusion clamp on the thoracoabdominal graft and then made a
circular graftotomy with the ophthalmic cautery device and then the vein
graft was spatulated and anastomosed to the graft using running 5-0 Prolene
suture. Similarly, we dissected out the L2 set of lumbar arteries
circumferentially. To the dual ostia, a vein graft was reversed,
spatulated, and anastomosed to both ostia using running 5-0 Prolene suture.
We cut that vein graft to an appropriate length, placed a partial
occlusion clamp on the thoracoabdominal graft, made a circular graftotomy
and then anastomosed the vein graft to the thoracoabdominal graft with
running 5-0 Prolene suture. All the while, we were systemically rewarming
the patient; and upon achieving normothermia, the patient was subsequently
weaned from cardiopulmonary bypass with preserved right and left
ventricular function. The patient's EEG and SSEP signals had returned to
baseline. After weaning from bypass, the patient was decannulated, the
heparin reversed with IV protamine, and meticulous hemostasis achieved in
the entire operative field. Blake drains and a chest tube were placed in
the left pleural space. The diaphragm, which had been taken down
circumferentially, was re-approximated using running #1 Maxon suture. The
ribs were approximated with #2 Vicryl. The latissimus dorsi and serratus
anterior, and abdominal muscular fascia were approximated with running
absorbable sutures. The subcutaneous tissues and skin were similarly
approximated with running absorbable sutures. The patient was subsequently
turned supine and then a therapeutic aspiration bronchoscopy was performed
to clear bloody tracheobronchial secretions. The patient was subsequently
transferred to the CT ICU in stable condition.
