conleyclan
Guru
I have tried to review this and will look at it again in the morning, but... I would be more than greatful for any input.
PREOPERATIVE DIAGNOSES: Complicated acute type B aortic dissection with
mesenteric and renal malperfusion and renal insufficiency.
POSTOPERATIVE DIAGNOSES: Complicated acute type B aortic dissection with
the mesenteric and renal malperfusion and renal insufficiency.
PROCEDURES PERFORMED: Thoracic endovascular aortic repair (Cook dissection
endovascular system: 42 mm tapered to 38 x 210 mm DEG, 34 mm tapered to 30
mm x 199 mm DEG, 42 x 81 mm proximal extension TX2, 46 mm x 185 mm DES):
Stent grafting descending thoracic aorta from distal arch to celiac artery,
bare-metal stenting, abdominal aorta from the celiac to the aortic
bifurcation, superior mesenteric arterial stenting (8 mm x 30 mm SMART
control Cordis bare-metal stent), left subclavian arterial to left common
carotid arterial transposition, thoracic aortogram with radiologic
supervision and interpretation, intravascular ultrasound with radiologic
supervision and interpretation.
BRIEF HISTORY: The patient is a 48-year-old male who presented to an
outside hospital with a several-day history of severe abdominal pain,
nausea, and INTOLERANCE TO FOOD. Upon evaluation at **** , CT
angiogram was performed despite identified acute on chronic renal
insufficiency with a creatinine of 3.0. CT angiography revealed an acute
type B aortic dissection with pseudocoarctation and an acutely occluded
celiac artery with a high-grade stenosis due to thrombus of the superior
mesenteric artery. I was contacted by the surgeons at UPMC Hamot and the
patient was subsequently life-flighted to ****** for admission to
our ********* . The patient continued to complain
of abdominal pain, had severe hypertension and his creatinine was 3.2. The patient was stabilized, placed on IV nicardipine
drip, and then we had a lengthy discussion with the patient regarding the
findings of his complicated type B aortic dissection. He was then offered
entry into the Cook dissection endovascular system, STABLE II clinical
trial for testing the use of the Cook dissection endovascular system. The
patient desired entry and the patient was brought to the operating suite
today for urgent thoracic and abdominal endovascular aortic repair.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite
and first a lumbar drain was placed by the Anesthesia team. He was then
placed supine and induced with general endotracheal anesthesia. We
monitored the patient with continuous SSEPs MEP, and EEGs throughout the
entire procedure. He was then prepped and draped in usual sterile fashion
from the chin to the knees. First, we transposed the left subclavian
artery to the left common carotid artery to allow for covering the left
subclavian ostium at the time of stent graft. A 2.5 cm transverse incision
was made just above the left clavicle over top of the sternocleidomastoid.
We then divided the platysma and identified the two heads of the
sternocleidomastoid muscle, neither of which were divided, but simply split
and retracted. We then circumferentially dissected out the left common
carotid artery and carefully dissected out the left subclavian artery,
identifying the left mammary, the left vertebral, and the left
thyrocervical trunks, all of which were controlled with vessel loops.
After adequate exposure of the proximal left subclavian artery, the patient
was heparinized and then occlusive clamp placed across the proximal left
subclavian. The distal vessel was controlled and then the vessel
transected proximally. The stump was oversewn with running 5-0 Prolene
suture and reinforced with a pledgeted 5-0 Prolene suture. We then
transposed the left subclavian over to the carotid and on the posterior
aspect of the carotid, after proximal and distal clamps were placed on the
carotid, an elliptical arteriotomy was made, and then the left subclavian
anastomosis and left common carotid with running 6-0 Prolene suture in an
end-to-side fashion. Hemostasis was then confirmed, the wound was left
open, and then we proceeded down to the groin. A 2 cm oblique incision was
made above the right inguinal crease and the right common femoral artery
was circumferentially dissected out at the level of the inguinal ligament.
Proximal and distal vessel loops were secured around for control. We then
introduced an 18-gauge needle into the right common femoral artery under
direct vision and the guidewire was advanced up through the
thoracoabdominal aorta, positioning its tip in the ascending aorta. Then
using a pigtail catheter, we exchanged that for a Lunderquist Super Stiff
guidewire over, which an intravascular ultrasound probe was advanced and we
confirmed that the guidewire remained in the true lumen along its entire
course from the level of the femoral artery to the ascending aorta. We
confirmed pseudocoarctation with _____ like true lumen along the entire
abdominal segment of the aorta. Next, we placed a long 5-French
destination sheath over the guidewire to allow for placement of a buddy
wire in the true lumen of the abdominal aorta. The destination sheath was
then removed and a pigtail catheter was placed over the abdominal wire.
The guidewire was then removed and then a mesenteric arteriogram was
performed to identify the takeoff of the celiac. The celiac artery was
occluded though we can identify its stump. We then proceeded with
advancing the first module of our multi modular descending thoracic aortic
stent graft system. First a 34 mm tapered to 30 mm x 199 mm Cook DEG stent
graft was advanced with the distalmost aspect positioned just above the
takeoff of the celiac artery approximately 2 mm above the celiac. The
stent graft was then deployed and the delivery system then removed leaving
the Cook sheath in place. Through the Cook sheath, we then advanced
pigtail catheter over the Lunderquist guidewire, positioning it in the
proximal arch. We then performed a thoracic aortogram to clearly identify
the takeoff of the patient's bovine trunk and stump of the transposed left
subclavian. This served as our road map for the arch. We then replaced
the Lunderquist Super Stiff guidewire over which a second Cook module was
advanced. At this time, a 42 mm tapered to 38 x 210 mm stent graft was
advanced with its proximal most aspect positioned over top of the ostium of
the left subclavian. There was excellent overlap with the first module and
the stent graft was deployed. For precise positioning, we gave 12 mg of
adenosine at the time of deployment to optimize the positioning of the
proximal landing site, despite this the proximal aspect did not completely
cover the left subclavian ostium and because of this, I elected to place a
third module more proximally. At this time, I chose a 42 mm x 81 mm
proximal extension Cook TX2. It was positioned approximately 6 mm more
proximally on the greater curve to cover the left subclavian ostium.
Following deployment, I then ballooned the proximal landing site multiple
times with both a Gore trilobed balloon and for the overlapping segment one
time ballooning with a 40 mL Coda balloon. This achieved an excellent
result. We then proceeded to stenting the abdominal aorta through a 22 mm
Medtronic sheath, a 46 mm x 185 mm Cook DES was deployed and throughout the
entire abdominal aorta from the level of the prior stent graft in the
descending thoracic aorta down to the aortic bifurcation. Next, we placed
the intravascular ultrasound probe over the guidewire and confirmed that
the abdominal pseudocoarctation was completely resolved with deployment of
the abdominal bare-metal stent. Next, we proceeded with stenting the SMA,
which was subtotally occluded at greater than 90%. With some difficulty,
we were able to wire the SMA, however, despite wiring the SMA, we had
difficulty advancing the 8 mm x 30 mm Cordis SMART controlled bare-metal
stent navigating both the bare-metal stent in the aorta and the nearly 880
degree turn of the SMA coming from the retrograde approach, so in order to
facilitate passing the Cordis stent into position, the combination of the
following using a SOS Omni catheter, we were able to place 2 transcend
wires serving as a double support into the SMA and then over both transcend
wires, we passed, a 7-French guide catheter, which we advanced into the
ostium of the superior mesenteric artery and then with a combination of 2
wires and the guide catheter, we were able to advance the 8 mm x 30 mm
Cordis SMART controlled bare-metal stent into the SMA. This self-expanding
stent was then deployed and then completion of the superior mesenteric
arteriogram was performed demonstrating wide patency of the SMA. I then
made multiple attempts at cannulating the celiac and getting across
occlusion, but I was unable to get a wire across the celiac occlusion. The
patient remained stable throughout the entire time and had preserved motor
and somatosensory evoked potentials throughout the procedure. I elected to
terminate at this point. Given the patient's renal insufficiency with a
creatinine of 3.2, I elected to not perform any further completion
aortogram as intravascular ultrasound exam appeared excellent and the
patient was now making over 150 mL of urine per hour with the improved
perfusion eradicating the pseudocoarctation. We then removed the sheath
from the right groin and the right common femoral artery was repaired
primarily with running 6-0 Prolene suture. The heparin was reversed with
IV protamine. Meticulous hemostasis was confirmed and then the groin
incision was closed in layers with running absorbable suture. We then drew
our attention back to the neck incision. We confirmed hemostasis and then
closed that incision in layers with running absorbable suture. The patient
was subsequently transferred to the CT ICU in stable condition.
PREOPERATIVE DIAGNOSES: Complicated acute type B aortic dissection with
mesenteric and renal malperfusion and renal insufficiency.
POSTOPERATIVE DIAGNOSES: Complicated acute type B aortic dissection with
the mesenteric and renal malperfusion and renal insufficiency.
PROCEDURES PERFORMED: Thoracic endovascular aortic repair (Cook dissection
endovascular system: 42 mm tapered to 38 x 210 mm DEG, 34 mm tapered to 30
mm x 199 mm DEG, 42 x 81 mm proximal extension TX2, 46 mm x 185 mm DES):
Stent grafting descending thoracic aorta from distal arch to celiac artery,
bare-metal stenting, abdominal aorta from the celiac to the aortic
bifurcation, superior mesenteric arterial stenting (8 mm x 30 mm SMART
control Cordis bare-metal stent), left subclavian arterial to left common
carotid arterial transposition, thoracic aortogram with radiologic
supervision and interpretation, intravascular ultrasound with radiologic
supervision and interpretation.
BRIEF HISTORY: The patient is a 48-year-old male who presented to an
outside hospital with a several-day history of severe abdominal pain,
nausea, and INTOLERANCE TO FOOD. Upon evaluation at **** , CT
angiogram was performed despite identified acute on chronic renal
insufficiency with a creatinine of 3.0. CT angiography revealed an acute
type B aortic dissection with pseudocoarctation and an acutely occluded
celiac artery with a high-grade stenosis due to thrombus of the superior
mesenteric artery. I was contacted by the surgeons at UPMC Hamot and the
patient was subsequently life-flighted to ****** for admission to
our ********* . The patient continued to complain
of abdominal pain, had severe hypertension and his creatinine was 3.2. The patient was stabilized, placed on IV nicardipine
drip, and then we had a lengthy discussion with the patient regarding the
findings of his complicated type B aortic dissection. He was then offered
entry into the Cook dissection endovascular system, STABLE II clinical
trial for testing the use of the Cook dissection endovascular system. The
patient desired entry and the patient was brought to the operating suite
today for urgent thoracic and abdominal endovascular aortic repair.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite
and first a lumbar drain was placed by the Anesthesia team. He was then
placed supine and induced with general endotracheal anesthesia. We
monitored the patient with continuous SSEPs MEP, and EEGs throughout the
entire procedure. He was then prepped and draped in usual sterile fashion
from the chin to the knees. First, we transposed the left subclavian
artery to the left common carotid artery to allow for covering the left
subclavian ostium at the time of stent graft. A 2.5 cm transverse incision
was made just above the left clavicle over top of the sternocleidomastoid.
We then divided the platysma and identified the two heads of the
sternocleidomastoid muscle, neither of which were divided, but simply split
and retracted. We then circumferentially dissected out the left common
carotid artery and carefully dissected out the left subclavian artery,
identifying the left mammary, the left vertebral, and the left
thyrocervical trunks, all of which were controlled with vessel loops.
After adequate exposure of the proximal left subclavian artery, the patient
was heparinized and then occlusive clamp placed across the proximal left
subclavian. The distal vessel was controlled and then the vessel
transected proximally. The stump was oversewn with running 5-0 Prolene
suture and reinforced with a pledgeted 5-0 Prolene suture. We then
transposed the left subclavian over to the carotid and on the posterior
aspect of the carotid, after proximal and distal clamps were placed on the
carotid, an elliptical arteriotomy was made, and then the left subclavian
anastomosis and left common carotid with running 6-0 Prolene suture in an
end-to-side fashion. Hemostasis was then confirmed, the wound was left
open, and then we proceeded down to the groin. A 2 cm oblique incision was
made above the right inguinal crease and the right common femoral artery
was circumferentially dissected out at the level of the inguinal ligament.
Proximal and distal vessel loops were secured around for control. We then
introduced an 18-gauge needle into the right common femoral artery under
direct vision and the guidewire was advanced up through the
thoracoabdominal aorta, positioning its tip in the ascending aorta. Then
using a pigtail catheter, we exchanged that for a Lunderquist Super Stiff
guidewire over, which an intravascular ultrasound probe was advanced and we
confirmed that the guidewire remained in the true lumen along its entire
course from the level of the femoral artery to the ascending aorta. We
confirmed pseudocoarctation with _____ like true lumen along the entire
abdominal segment of the aorta. Next, we placed a long 5-French
destination sheath over the guidewire to allow for placement of a buddy
wire in the true lumen of the abdominal aorta. The destination sheath was
then removed and a pigtail catheter was placed over the abdominal wire.
The guidewire was then removed and then a mesenteric arteriogram was
performed to identify the takeoff of the celiac. The celiac artery was
occluded though we can identify its stump. We then proceeded with
advancing the first module of our multi modular descending thoracic aortic
stent graft system. First a 34 mm tapered to 30 mm x 199 mm Cook DEG stent
graft was advanced with the distalmost aspect positioned just above the
takeoff of the celiac artery approximately 2 mm above the celiac. The
stent graft was then deployed and the delivery system then removed leaving
the Cook sheath in place. Through the Cook sheath, we then advanced
pigtail catheter over the Lunderquist guidewire, positioning it in the
proximal arch. We then performed a thoracic aortogram to clearly identify
the takeoff of the patient's bovine trunk and stump of the transposed left
subclavian. This served as our road map for the arch. We then replaced
the Lunderquist Super Stiff guidewire over which a second Cook module was
advanced. At this time, a 42 mm tapered to 38 x 210 mm stent graft was
advanced with its proximal most aspect positioned over top of the ostium of
the left subclavian. There was excellent overlap with the first module and
the stent graft was deployed. For precise positioning, we gave 12 mg of
adenosine at the time of deployment to optimize the positioning of the
proximal landing site, despite this the proximal aspect did not completely
cover the left subclavian ostium and because of this, I elected to place a
third module more proximally. At this time, I chose a 42 mm x 81 mm
proximal extension Cook TX2. It was positioned approximately 6 mm more
proximally on the greater curve to cover the left subclavian ostium.
Following deployment, I then ballooned the proximal landing site multiple
times with both a Gore trilobed balloon and for the overlapping segment one
time ballooning with a 40 mL Coda balloon. This achieved an excellent
result. We then proceeded to stenting the abdominal aorta through a 22 mm
Medtronic sheath, a 46 mm x 185 mm Cook DES was deployed and throughout the
entire abdominal aorta from the level of the prior stent graft in the
descending thoracic aorta down to the aortic bifurcation. Next, we placed
the intravascular ultrasound probe over the guidewire and confirmed that
the abdominal pseudocoarctation was completely resolved with deployment of
the abdominal bare-metal stent. Next, we proceeded with stenting the SMA,
which was subtotally occluded at greater than 90%. With some difficulty,
we were able to wire the SMA, however, despite wiring the SMA, we had
difficulty advancing the 8 mm x 30 mm Cordis SMART controlled bare-metal
stent navigating both the bare-metal stent in the aorta and the nearly 880
degree turn of the SMA coming from the retrograde approach, so in order to
facilitate passing the Cordis stent into position, the combination of the
following using a SOS Omni catheter, we were able to place 2 transcend
wires serving as a double support into the SMA and then over both transcend
wires, we passed, a 7-French guide catheter, which we advanced into the
ostium of the superior mesenteric artery and then with a combination of 2
wires and the guide catheter, we were able to advance the 8 mm x 30 mm
Cordis SMART controlled bare-metal stent into the SMA. This self-expanding
stent was then deployed and then completion of the superior mesenteric
arteriogram was performed demonstrating wide patency of the SMA. I then
made multiple attempts at cannulating the celiac and getting across
occlusion, but I was unable to get a wire across the celiac occlusion. The
patient remained stable throughout the entire time and had preserved motor
and somatosensory evoked potentials throughout the procedure. I elected to
terminate at this point. Given the patient's renal insufficiency with a
creatinine of 3.2, I elected to not perform any further completion
aortogram as intravascular ultrasound exam appeared excellent and the
patient was now making over 150 mL of urine per hour with the improved
perfusion eradicating the pseudocoarctation. We then removed the sheath
from the right groin and the right common femoral artery was repaired
primarily with running 6-0 Prolene suture. The heparin was reversed with
IV protamine. Meticulous hemostasis was confirmed and then the groin
incision was closed in layers with running absorbable suture. We then drew
our attention back to the neck incision. We confirmed hemostasis and then
closed that incision in layers with running absorbable suture. The patient
was subsequently transferred to the CT ICU in stable condition.