Aortic Root Repair/Reconstruction.......

conleyclan

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I could use a little help on this report.....please and thank you




PREOPERATIVE DIAGNOSIS (ES): ACUTE TYPE A AORTIC DISSECTION, RIGHT HEMISPHERIC
CEREBROVASCULAR ACCIDENT, MALPERFUSION OF THE GUT WITH HEMATOCHEZIA AND MELENA,
ACUTE OCCLUSION OF THE RIGHT COMMON CAROTID ARTERY WITH BOTH DYNAMIC AND STATIC
OCCLUSION OF THE CELIAC AND SMA, MODERATE AORTIC INSUFFICIENCY.

PROCEDURES: AORTIC ROOT REPAIR WITH NEOMEDIAL RECONSTRUCTION USING A TEFLON
FELT AND AORTIC VALVE RESUSPENSION, ASCENDING AORTA AND TOTAL AORTIC ARCH
REPLACEMENT USING 28 MM GRAFT, REPLACEMENT OF THE INNOMINATE ARTERY, RIGHT
SUBCLAVIAN ARTERY, RIGHT COMMON CAROTID ARTERY, AND LEFT COMMON CAROTID ARTERY
USING A 12 X 8 X 8 MM SPIELVOGEL TRIFURCATED GRAFT, PLACEMENT OF DESCENDING
THORACIC AORTIC STENT GRAFT (28 MM X 15 CM GORE CTAG), EXPLORATORY LAPAROTOMY.


DESCRIPTION OF OPERATION: The patient was brought to the operating suite,
placed supine and induced with general endotracheal anesthesia. A Swan-Ganz
catheter and radial arterial line were placed by the anesthesia team per
intraoperative monitoring. I placed the left common femoral arterial line for
lower body perfusion monitoring. The patient was prepped and draped in the
usual fashion from the chin to the toes. After I placed a left common femoral
arterial line using the Seldinger technique, a midline sternotomy was made in
the usual fashion. After pericardiotomy, we confirmed the diagnosis of acute
type A aortic dissection. Pericardial cradle was created and then the patient
heparinized. The patient was subsequently cannulated using a central
technique. The ascending aorta was cannulated using a Seldinger technique
whereby a 16-gauge needle was introduced into the true lumen under
transesophageal echocardiography guidance. We then advanced the guidewire into
the true lumen under TEE guidance. After confirmation of true lumen wire
placement, we then serially dilated that wire up and then placed a 20 French
Edwards Fem-Flex catheter using a Seldinger technique into the true lumen
centrally. The right atrial appendage was cannulated with a dual-stage
catheter and a coronary sinus catheter was placed for retrograde cardioplegia.
We monitored the patient with continuous EEG and SSEP to help direct a safe
period of deep hypothermic circulatory arrest.

The patient was subsequently placed on cardiopulmonary bypass and systemically
cooled to deep hypothermia. Upon ventricular fibrillation, an aortic
cross-clamp was applied and initial induction of cold blood high potassium
cardioplegia was delivered retrograde to achieve a ventricular fibrillatory
arrest at which time the ascending aorta was transected above the sinotubular
junction. We then delivered direct ostial antegrade cold blood high potassium
cardioplegia to both the right and left coronary arteries to achieve an
asystolic arrest. From that point forward, we maintained myocardial protection
using continuous retrograding as well as intermittent antegrade cardioplegia.
All the while we were systemically cooling and during systemic cooling, we made
a counter incision in the right neck along the sternocleidomastoid near the
angle of the mandible. We then dissected out the right common carotid artery
circumferentially at the level of the bifurcation. The vessel was thrombosed
up to the bifurcation having noted this both on CT angiography and upon direct
inspection of the vessel. We then obtained circumferential control of both the
proximal internal and external common carotid arteries on the right as well as
the common carotid artery. We then placed occlusive clamps on the internal and
external carotid arteries. We then transected the carotid artery right at the
level of its bifurcation. We then tunneled the 8 mm limb of a 12 mm x 8 mm x 8
mm trifurcated Spielvogel graft up from the mediastinum posterior to the left
innominate vein. It was tunneled along the course of the native right common
carotid artery. We then cut one of the 8 mm limbs to an appropriate length.
We then anastomosed it to the very distal right common carotid artery literally
at its bifurcation using running 5-0 Prolene suture following completion of
that anastomosis. We then de-aired the graft and right carotid system
retrograde. We then placed an 18 French Fem-Flex catheter into the proximal
portion of the 12 mm limb of the trifurcated graft and then connected that
cannula to the arterial inflow circuit and then began perfusing the
reconstructed right common carotid artery to ensure bilateral cerebral
perfusion. We also placed a 20-gauge arterial line in the right common carotid
arterial graft, and this was therefore used for monitoring the right common
carotid arterial pressure during cardiopulmonary bypass. Next, we drew our
attention towards the aortic root. We inspected the dissected root. The root
was dissected down and including all of the non-coronary sinus and most of the
right coronary sinus. The aortic valve was a tricuspid aortic valve, and the
leaflets themselves were in good shape. Therefore, we elected to repair the
aortic root. This was done by neomedial reconstruction placing a tailored
piece of Teflon felt within the dissected plane. We then packed the native
intima media Teflon felt and native adventitia to one another in that order
using a sandwich technique tacking the walls together with several interrupted
pledgeted 4-0 Prolene sutures placed in a horizontal mattress fashion.
Additionally, we resuspended each of the 3 commissures using same type of
pledgeted 4-0 Prolene suture. Next, a 28 mm Vascutek graft was anastomosed to
the reconstructed root using running 4-0 Prolene suture taking care to
intussuscept graft into the native repaired root using running 4-0 Prolene
suture. All the while we were systemically cooling and upon achieving
electrocerebral silence for greater than 4 minutes per our protocol at deep
hypothermia, a brief period of deep hypothermic circulatory arrest was
initiated. We maintained antegrade cerebral perfusion via the right common
carotid arterial graft during our circulatory arrest. We first drew our
attention towards the descending thoracic aorta. We were quite concerned about
the degree of flap occlusion of the celiac and SMA and therefore elected to
place a descending thoracic aortic stent graft using an antegrade technique
right through the open arch. A tailored Amplatz #7 super-stiff guidewire was
tailored in a pigtail shape and then advanced down the true lumen of the
descending thoracic aorta. Over that guidewire, we then advanced the Gore CTAG
28 mm x 15 cm stent graft down into the descending thoracic aorta. This stent
graft was then deployed. We then transected the aortic arch at the level of
the left subclavian artery. We then tacked the stent graft to the lesser curve
of the very distal aortic arch using several pledgeted 4-0 Prolene sutures. We
then took a 28 mm Vascutek graft and anastomosed it to the very distal arch
using running 4-0 Prolene suture taking care to intussuscept graft into the
native true lumen. The left subclavian ostium was incorporated in this
anastomosis. Following completion of the anastomosis, the distal graft was
cannulated. The graft and the descending thoracic aorta de-aired. We then
reconstituted flow down the descending thoracic aorta ending the period of
circulatory arrest. We then drew attention towards the left common carotid
artery. This was dissected up into its mid segment. We dissected out the left
common carotid at the base of the neck. We transected the carotid at this
point. We then took the second 8 mm limb of our trifurcated graft, cut it to
an appropriate length, tunneled it below the left innominate vein. After
cutting into appropriate length, it was anastomosed in an end-to-end fashion to
the left common carotid artery using running 5-0 Prolene suture. We de-aired
that limb of the graft and carotid retrograde and then reconstituted flow
through it restoring bilateral cerebral perfusion. At this point, we began
systemic re-warming. We then made an elliptical graftotomy on the arch graft
and cut the proximal aspect of the 12 mm trifurcated graft in a beveled fashion
and then anastomosed it in an end-to-side fashion to the arch graft using
running 2-0 Prolene suture. All the while we maintained perfusion through the
12 mm graft until the very final portion of that graft-to-graft anastomosis at
which time the grafts were de-aired. The perfusion cannula within the 12 mm
limb was removed. The anastomosis was completed and then flow restored via our
central cannulation of the arch through both carotid arterial graft and down
the descending thoracic aorta. Of note, all the while we were maintaining
myocardial protection using a continuous retrograde cardioplegia as well as
intermittent antegrade cardioplegia. Next, the distal aspect of the proximal
root graft was cut in a beveled fashion posteriorly, and the proximal aspect of
the arch graft was cut in a beveled fashion posteriorly and the 2 grafts were
anastomosed to one another using running 2-0 Prolene suture taking care to
recreate the normal curvature of the ascending aorta from the root to the arch.
Following completion of this anastomosis, we then administered a hot shot
retrograde, de-aired the left heart, and removed the cross-clamp and began
re-perfusion. The patient was all the while being systemically re-warmed since
completion of the arch. Next, we drew attention toward the right subclavian
artery. We followed the thrombosed and dissected innominate artery to its
bifurcation and then transected the proximal right subclavian artery. We then
took the distal end of the 12 mm limb of the trifurcated graft, cut it to an
appropriate length and anastomosed it end-to-end to the right subclavian artery
using running 5-0 Prolene suture. Following completion of this final
brachiocephalic anastomosis, the patient had achieved normal thermia and was
subsequently weaned from cardiopulmonary bypass with preserved right and left
ventricular function with the resuspended aortic valve which was now completely
competent.

Following weaning from bypass and decannulation, heparin was reversed with IV
protamine. Meticulous hemostasis was confirmed. Temporary atrial and
ventricular pacing leads were placed although the patient had an underlying
sinus rhythm.

After confirmation of hemostasis in the mediastinum, we then drew our attention
to the abdomen. A midline laparotomy was performed just above the umbilicus to
explore the abdomen. Given the marked hematochezia I had concerns about
ischemic bowel. Upon laparotomy, we inspected the stomach, small intestine,
and large intestine and these all appeared to be viable. The laparotomy was
closed in layers with running absorbable sutures. The overlying thymic fat and
pericardium were reapproximated from the level of the innominate vein to the
base of the heart protecting all graft material from scarring the sternum. The
sternum was reapproximated with interrupted heavy-gauge wire. The pectoralis
fascia, subcutaneous tissue, and skin were all approximated with running
absorbable sutures. Similarly, the right neck incisions were closed in layers
with running absorbable sutures.

The postoperative transesophageal echocardiogram demonstrated preserved right
and left ventricular function with a resuspended aortic valve which was
completely competent. Postoperative EEG and SSEPs demonstrated return to
baseline, although the baseline in this patient demonstrated marked slowing of
the right hemispheric EEG consistent with her preoperative stroke. The patient
was subsequently transferred to the CT ICU in stable condition.
 

jewlz0879

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I'm thinking 33860 and 33870-59. Per STS, "you should only bill 33870 if a direct anastomosis of graft to the descending aorta with a side of graft to end of head vessel island (including the grafting or re-implantation of the brachiocephalic, left common carotid, and left subclavian arteries) anastomosis is performed. Do not report this code when only the lesser curve of the arch is done as part of a beveled ascending aorta graft.

If the head vessels are not touched you should only bill for the AA graft (33860 or 33863 depending on whether the aortic root is replaced).

The head vessels include the brachiocephalic (or innominate) artery, left common carotid, and left subclavian arteries. The head vessels are done as an island graft or they are individually grafted, often using prosthetic grafts, back into the arch once the arch has been replaced. Either method of reimplanting the head vessels is included if the aortic arch is also replaced. 33870 should not be reported if a hemi-arch is also replaced.

HTH!
 
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