conleyclan
Guru
Hello again,
I think I am looking too much into this report. Any input would be appreciated.
PREOPERATIVE DIAGNOSES: Aortic dissection with a descending thoracic
aortic pseudoclaudication, malperfusion to the mesenteric vessels and lower
extremities.
POSTOPERATIVE DIAGNOSES: Aortic dissection with a descending thoracic
aortic pseudoclaudication, malperfusion to the mesenteric vessels and lower
extremities.
PROCEDURES PERFORMED: Thoracic endovascular aortic repair and abdominal
endovascular aortic repair (28 mm x 150 mm Medtronic Valiant stent graft,
28 x 80 mm Cook TX2 stent graft, 49 mm Palmaz stent and 39 mm Palmaz stent,
both dilated to 28 mm), thoracic aortogram and abdominal aortogram with
radiologic supervision and interpretation, celiac arteriogram,
intravascular ultrasound with radiologic supervision and interpretation,
left common femoral arterial cutdown with primary repair.
BRIEF HISTORY: The patient presented on
December 22, 2015, with an acute type A aortic dissection. At that time,
underwent aortic root ascending and total arch replacement with
replacement of the innominate and left common carotid arteries as well.
Postoperatively, on surveillance imaging, we noted that had persistent
pseudoclaudication with compression of false lumen in the descending
thoracic aorta and took her back to the OR on December 24, 2015
for proximal descending thoracic aortic stent grafting. At that time he
placed a 26-mm x 150-mm Medtronic Valiant stent graft from the distal arch
to the mid descending thoracic aorta. Subsequent surveillance imaging
revealed persistent severe pseudoclaudication just below the distal most
aspect of the stent graft with near complete compression of the true lumen.
There was a large secondary tear near the superior mesenteric artery.
Celiac artery was also dissected and with very poor inflow. Additionally,
we noted serial dilatation of the distal descending thoracic aorta and
collectively these findings represented unstable circumstance and
demonstrated persistent malperfusion and therefore the patient was brought
back to the operating suite today for additional stent graft placement as
well as open stent placement in the abdominal aorta to correct the
pseudoclaudication.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite,
placed supine, induced with general endotracheal anesthesia. Of note, we
monitored the patient with continuous SSEPs as well as intermittent
motor-evoked potential. We elected not to place a lumbar drain, the
patient has multiple Harrington rods in her back and therefore we proceeded
with a close neurophysiologic monitoring with the patient not paralyzed.
The patient was prepped and draped in the usual sterile fashion from the
chin to the knees. A 2.5 cm oblique incision was made above the left
inguinal crease through which the previous stent graft had been placed.
The left common femoral artery was circumferentially dissected out and
vessel loops placed proximal and distally near the level of the inguinal
ligament. We then heparinized the patient and then through the prior left
common femoral arteriotomy suture line, we then inserted an 18-gauge needle
and then dilated down up, placing an 8-French sheath through which we
advanced guidewire under fluoroscopic guidance up into the ascending aorta.
Over that guidewire, we then used the intravascular ultrasound to confirm
that the guidewire and IVUS catheter were within the true lumen along its
entire course. We then exchanged the guidewire for a Lunderquist Super
Stiff guidewire over which a pigtail catheter was advanced and we then
positioned the pigtail in the distal most aspect of the previously placed
stent graft and then performed a lateral thoracoabdominal aortogram to
identify the takeoff of the celiac and SMA arteries to use as a road map We
then exchanged the pigtail for a Lunderquist Super Stiff guidewire,
positioning its tip in the ascending aorta. We then advanced a 28-mm x
150-mm Medtronic Valiant and overlapped the previously placed stent graft
by 1 Z-stent and deployed that stent graft. This still did not extend down to
the level of the celiac which was at the desired length of coverage and
therefore, a second stent graft was chosen. At this time, a 28 x 80 mm Cook
TX2 distal extension piece was chosen. This was advanced over the Super Stiff
wire after removing the Medtronic delivery system. The Cook stent graft was
then positioned to overlap 1.5 Z-stent over the previously placed Valiant. The
stent graft was then deployed and positioning its distal most aspect, right at
the proximal ostium of the celiac artery, taking care not to cover the celiac.
Excellent positioning was obtained and we then released the Cook device and
then removed the delivery system. We then placed the 18-French Medtronic sheath
in the left common femoral artery through which we then balloon dilated the
overlapping segments of both the proximal Valiant and the Cook to Valiant at
the overlapping portions of the modules. Using a Gore trilobed balloon, we
ballooned to a profiling at both overlapping site. Next, we mounted the 10 mm
x 49 mm Palmaz bare-metal stent on a 28-mm x 4 cm Z-Med balloon. It was
crimped on the balloon and then that Palmaz stent mounted on the balloon was
advanced and positioned just at the distal aspect of the Cook stent. We then
deployed that Palmaz, dilating to 28 mm, extending from across the inflow
to the celiac and SMA arteries where we had noted a large secondary tear at
the SMA ostium. We then removed that balloon-tipped catheter and mounted a
second 10 x 39 mm Palmaz stent, again on a 28 mm x 4 cm Z-Med balloon. The
Palmaz was mounted on the balloon, crimped in place and then the Palmaz
advanced and placed overlapping the previously placed stent by
approximately one diamond of the Palmaz and then the balloon expanded that
Palmaz again to 28 mm. This extended the stent coverage down below the
level of the renal arteries. We then removed the balloon tip catheter and
advanced the IVUS. The IVUS confirmed the patency of the celiac, SMA, and
renal arteries. We then performed a completion aortogram, confirmed wide
patency of the SMA and both renals. We noted that there was continued
dissection of the celiac and I then made multiple attempts at cannulating
the celiac through the Palmaz using a combination of soft catheter, V1
catheter, multiple different guidewires including Whisper wire and a
Glidewires, multiple angled catheters. We were unable to secure a stiff
wire into the celiac to allow for celiac stent placement. I was able to
pass a Glidewire multiple times into the celiac demonstrating its patency;
however, I could not get a guide catheter over that Glidewire without
reflex of the wire back into the aorta. After multiple attempts, I
eventually terminated attempts at stenting the celiac due to the very steep
angle of the celiac and difficulty with adequately cannulating the
acceptable guidewire to facilitate stent placement. A final aortogram was
performed and we confirmed that the celiac was indeed patent with adequate
inflow. Given the desire to halt any further fluoroscopy time, I felt the
patient could be managed expectantly at this point and we reserved the
right to return at a later date for celiac stenting if the patient
developed any abdominal symptoms. The Medtronic sheath was removed from
the left common femoral artery. Proximal and distal clamps were placed and
the vessel was repaired primarily with running 6-0 Prolene suture. The
heparin was then reversed with IV protamine. Meticulous hemostasis was
confirmed. The groin incision was then closed in layers with running
absorbable sutures. The patient was awoken in the operating room with a
normal neurologic exam with normal motor strength to both lower
extremities.
I think I am looking too much into this report. Any input would be appreciated.
PREOPERATIVE DIAGNOSES: Aortic dissection with a descending thoracic
aortic pseudoclaudication, malperfusion to the mesenteric vessels and lower
extremities.
POSTOPERATIVE DIAGNOSES: Aortic dissection with a descending thoracic
aortic pseudoclaudication, malperfusion to the mesenteric vessels and lower
extremities.
PROCEDURES PERFORMED: Thoracic endovascular aortic repair and abdominal
endovascular aortic repair (28 mm x 150 mm Medtronic Valiant stent graft,
28 x 80 mm Cook TX2 stent graft, 49 mm Palmaz stent and 39 mm Palmaz stent,
both dilated to 28 mm), thoracic aortogram and abdominal aortogram with
radiologic supervision and interpretation, celiac arteriogram,
intravascular ultrasound with radiologic supervision and interpretation,
left common femoral arterial cutdown with primary repair.
BRIEF HISTORY: The patient presented on
December 22, 2015, with an acute type A aortic dissection. At that time,
underwent aortic root ascending and total arch replacement with
replacement of the innominate and left common carotid arteries as well.
Postoperatively, on surveillance imaging, we noted that had persistent
pseudoclaudication with compression of false lumen in the descending
thoracic aorta and took her back to the OR on December 24, 2015
for proximal descending thoracic aortic stent grafting. At that time he
placed a 26-mm x 150-mm Medtronic Valiant stent graft from the distal arch
to the mid descending thoracic aorta. Subsequent surveillance imaging
revealed persistent severe pseudoclaudication just below the distal most
aspect of the stent graft with near complete compression of the true lumen.
There was a large secondary tear near the superior mesenteric artery.
Celiac artery was also dissected and with very poor inflow. Additionally,
we noted serial dilatation of the distal descending thoracic aorta and
collectively these findings represented unstable circumstance and
demonstrated persistent malperfusion and therefore the patient was brought
back to the operating suite today for additional stent graft placement as
well as open stent placement in the abdominal aorta to correct the
pseudoclaudication.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite,
placed supine, induced with general endotracheal anesthesia. Of note, we
monitored the patient with continuous SSEPs as well as intermittent
motor-evoked potential. We elected not to place a lumbar drain, the
patient has multiple Harrington rods in her back and therefore we proceeded
with a close neurophysiologic monitoring with the patient not paralyzed.
The patient was prepped and draped in the usual sterile fashion from the
chin to the knees. A 2.5 cm oblique incision was made above the left
inguinal crease through which the previous stent graft had been placed.
The left common femoral artery was circumferentially dissected out and
vessel loops placed proximal and distally near the level of the inguinal
ligament. We then heparinized the patient and then through the prior left
common femoral arteriotomy suture line, we then inserted an 18-gauge needle
and then dilated down up, placing an 8-French sheath through which we
advanced guidewire under fluoroscopic guidance up into the ascending aorta.
Over that guidewire, we then used the intravascular ultrasound to confirm
that the guidewire and IVUS catheter were within the true lumen along its
entire course. We then exchanged the guidewire for a Lunderquist Super
Stiff guidewire over which a pigtail catheter was advanced and we then
positioned the pigtail in the distal most aspect of the previously placed
stent graft and then performed a lateral thoracoabdominal aortogram to
identify the takeoff of the celiac and SMA arteries to use as a road map We
then exchanged the pigtail for a Lunderquist Super Stiff guidewire,
positioning its tip in the ascending aorta. We then advanced a 28-mm x
150-mm Medtronic Valiant and overlapped the previously placed stent graft
by 1 Z-stent and deployed that stent graft. This still did not extend down to
the level of the celiac which was at the desired length of coverage and
therefore, a second stent graft was chosen. At this time, a 28 x 80 mm Cook
TX2 distal extension piece was chosen. This was advanced over the Super Stiff
wire after removing the Medtronic delivery system. The Cook stent graft was
then positioned to overlap 1.5 Z-stent over the previously placed Valiant. The
stent graft was then deployed and positioning its distal most aspect, right at
the proximal ostium of the celiac artery, taking care not to cover the celiac.
Excellent positioning was obtained and we then released the Cook device and
then removed the delivery system. We then placed the 18-French Medtronic sheath
in the left common femoral artery through which we then balloon dilated the
overlapping segments of both the proximal Valiant and the Cook to Valiant at
the overlapping portions of the modules. Using a Gore trilobed balloon, we
ballooned to a profiling at both overlapping site. Next, we mounted the 10 mm
x 49 mm Palmaz bare-metal stent on a 28-mm x 4 cm Z-Med balloon. It was
crimped on the balloon and then that Palmaz stent mounted on the balloon was
advanced and positioned just at the distal aspect of the Cook stent. We then
deployed that Palmaz, dilating to 28 mm, extending from across the inflow
to the celiac and SMA arteries where we had noted a large secondary tear at
the SMA ostium. We then removed that balloon-tipped catheter and mounted a
second 10 x 39 mm Palmaz stent, again on a 28 mm x 4 cm Z-Med balloon. The
Palmaz was mounted on the balloon, crimped in place and then the Palmaz
advanced and placed overlapping the previously placed stent by
approximately one diamond of the Palmaz and then the balloon expanded that
Palmaz again to 28 mm. This extended the stent coverage down below the
level of the renal arteries. We then removed the balloon tip catheter and
advanced the IVUS. The IVUS confirmed the patency of the celiac, SMA, and
renal arteries. We then performed a completion aortogram, confirmed wide
patency of the SMA and both renals. We noted that there was continued
dissection of the celiac and I then made multiple attempts at cannulating
the celiac through the Palmaz using a combination of soft catheter, V1
catheter, multiple different guidewires including Whisper wire and a
Glidewires, multiple angled catheters. We were unable to secure a stiff
wire into the celiac to allow for celiac stent placement. I was able to
pass a Glidewire multiple times into the celiac demonstrating its patency;
however, I could not get a guide catheter over that Glidewire without
reflex of the wire back into the aorta. After multiple attempts, I
eventually terminated attempts at stenting the celiac due to the very steep
angle of the celiac and difficulty with adequately cannulating the
acceptable guidewire to facilitate stent placement. A final aortogram was
performed and we confirmed that the celiac was indeed patent with adequate
inflow. Given the desire to halt any further fluoroscopy time, I felt the
patient could be managed expectantly at this point and we reserved the
right to return at a later date for celiac stenting if the patient
developed any abdominal symptoms. The Medtronic sheath was removed from
the left common femoral artery. Proximal and distal clamps were placed and
the vessel was repaired primarily with running 6-0 Prolene suture. The
heparin was then reversed with IV protamine. Meticulous hemostasis was
confirmed. The groin incision was then closed in layers with running
absorbable sutures. The patient was awoken in the operating room with a
normal neurologic exam with normal motor strength to both lower
extremities.