Wiki Aortic Dissection/Total Arch Repair/Bypass


Munhall, PA
Best answers
Once again I could use any help coding this charge. I am struggling with the bypasses. Thanks for any help.

PREOPERATIVE DIAGNOSES: Right hemispheric stroke, type A aortic dissection
with thrombosis of the right carotid and near thrombosis of the left

POSTOPERATIVE DIAGNOSES: Right hemispheric stroke, type A aortic
dissection with thrombosis of the right carotid and near thrombosis of the
left carotid.

PROCEDURE: Emergency repair of type A aortic dissection with total arch
replacement using a 26 mm Gelweave graft, bypass of the left internal and
external carotid artery, bypass of the right internal and external carotid
artery and bypass of the right subclavian artery using a 14 x 8 x 8
Spielvogel graft, replacement of the ascending aorta using 26-mm Gelweave
graft and aortic valve repair and reconstruction of the root using a 26 mm
Gelweave graft with resuspension of the trileaflet valve.

CLINICAL NOTE: This is a woman who presented to Neurology Service with an
acute right hemispheric cerebrovascular accident. CTA revealed a type A
aortic dissection, thrombosis of the right carotid and near thrombosis of
the left carotid. He was taken to the operating room emergently, where she
had a reconstruction. We were able to reconstitute both carotids at their
confluence. She had an improved EEG on the right side and her cerebral
oximetry improved bilaterally, although at that time ____ the operation,
her complete neurologic status was unknown. She had resuspension of the
valve and reconstruction of the root with no aortic insufficiency. LV
function is preserved.

OPERATIVE NOTE: Once the patient was brought to the operative suite, she
was prepped and draped in sterile fashion. Sternotomy was made with
extension to the right neck. Bilateral neck incisions were made. It was
clear that there was thrombosis of the common carotid arteries bilaterally.
Using a Seldinger technique, we cannulated the true lumen and distal
ascending aorta after the patient had been heparinized and instituted
cardiopulmonary bypass. The patient was cooled immediately. Then, we
divided the innominate artery and bypassed the right subclavian artery with
the 14 mm limb of a 14 x 8 x 8 Spielvogel graft. The most distal 8 mm limb
was then tunneled up to the right neck, where the confluence of the
external and internal were divided in a beveled fashion to exclude the
dissection and then anastomosed to this portion of the artery and this
graft was then perfused via a Y to the arterial head. Then, using a
similar technique, the second limb of 8 mm graft was tunneled to the left
neck and again a similar technique, a beveled anastomosis was performed.
By this time, the patient had been cooled to electrical silence. The body
circulatory arrest was performed and then a 26 Ante-Flo graft was sewn just
at the origin of the left subclavian artery. The dissection here was
repaired with a pledgeted 4-0 Prolene suture. The pump was then restarted
for the body by cannulating of the Ante-Flow limb and then a graft. The
graft was then sewn to the origin of the Spielvogel graft to maintain
single flow through the arterial head. The right radial and femoral artery
pulses also equalized. The patient was then rewarmed and during the
rewarming interval, we repaired the root, in which a trileaflet valve was
resuspended and neo-media was placed from the left coronary to the right
coronary with reconstruction of the noncoronary sinus. Then, a 26 mm graft
was sewn to the sinotubular junction to resize the annulus. Then, a
graft-to-graft anastomosis was performed, hot shot was administered and the
crossclamp was removed. The patient was weaned from cardiopulmonary bypass
once weaning criteria had been attained. Protamine factor VII were
administered, and once hemostasis had been achieved, the chest was closed
in a standard fashion. Biphasic flow was documented in both carotid
arteries. I was present for the entire duration of this operation.