Attempted Endograft

emoates

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Help! I am new to vascular coding. Any hints or helpful tips when coding vascular would be greatly appreciated. I am hopelessly lost figuring out the guides and glides and catheters and sheaths...give me back my basic CABG.

Procedures:
1. Left femoral and bilateral subclavian artery access
2. Placement of right femoral vein central lines.
3. Aortography, abdominal, thoracic, radiological supervision and interpretation
4. Left carotid to left subclavian bypass graft
5. Catheterization of the thoracic aorta with an attempt to place an endovascular graft.

Details of the Procedure:
In the operating room, the patient was placed in the supine position. She was mildly sedated and intubated by the anesthesiologist without complications. The operative field was prepped and draped in a usual sterile fashion. A right femoral vein was punctured and catheterized using standard Seldinger technique with the placement of the triple-lumen catheter. The right axillary and left subclavian artery were exposed through the transverse incisions parallel to both clavicles. The left carotid artery was exposed through the transverse incision just above the jugular notch. The right axillary artery was very large, soft, at least 12-14 mm in diameter, aneurysmal, without signs of atherosclerosis. The left subclavian artery was 5-6 mm in diameter,soft, without signs of atherosclerosis. Left common carotid artery was 7-8 mm in diameter, pulsatile, without significant atherosclerosis. First the"debranching" procedure of the left subclavian artery was performed by creating a bypass graft between the left common carotid artery and the left subclavian artery. A 10mm Hemashield graft was anastomosed end-to-side to the left common carotid artery and then it was tunneled through the subcutaneous subfascial tunnel and brought over the clavicle to the left subclavian area where it was anastomosed end-to-side to the left subclavian artery. The right axillary artery was punctured and catheterized using standard Seldinger technique and a #7-French sheath was placed with the insertion of the flexible guide wire and a pigtail catheter. In spite of multiple attempts of advancing the guidewire and the catheter into the aortic arch, we were unable to do so due to severe tortuosity of the innominate artery and aneurysmal changes at this level. We used multiple combinations of guidewires and catheters with different angles; however, they were not amenable to achieve advancement of the guidewire and/or the catheter into the aortic arch. Therefore we used the left subclavian artery for the arterial access. The artery was punctured and catheterized and the glidewire and the glide catheter were advanced into the aortic arch and the aortic arch angiography was performed following the propagation of the contrast into the descending aorta. The angiography revealed the fact that the patient had a Type B aortic dissection with the formation of the large descending thoracic aortic aneurysm impinging into the orifice of the left subclavian artery. In spite of multiple attempts to advance our guidewire and the catheter into the true lumen of the descending aorta, we were unable to do so due to the complex dissection fo the descending aorta, with the guidewire and catheter being trapped inside the dissected intima and in the false lumen of the aorta. An attempt was made to reach the true lumen of the descending aorta using a left carotid artery, where it was punctured and catheterized through the left carotid to left subclavian bypass graft with the retrograde advancement of the 6-French endovascular sheath into the lumen of the common carotid artery and the aortic arch. Again, however, multiple attempts to advance the guidewire into the true lumen of the descending aorta were not successful. A repeat thoracic aortography revealed the fact that the type B aortic dissection was almost completely occluding the true lumen of the aorta and the distal organ perfusion was maintained through the false lumen of the aortic dissection of the descending aorta. Considering these findings, we had to resort to the femoral approach in pursuing the goal of entering the true lumen of the thoracic aorta. Left femoral artery was exposed through transverse incision at the level of the left groin. the artery was moderately calcified, small, 6-7 mm in diameter, but pulsatile and suitable for catheterization. The artery was encircled with vessel loops. It was punctured and catheterized using standard, Seldinger technique and a #6-French endovascular sheath was placed. The guidewire and the glide catheter were advanced into the abdominal and subsequently distal thoracic aorta; however, again, in spite of multiple attempts and multiple combinations of different guidewires and angled catheters, we were unable to reach the true lumen of the descending thoracic aorta. It appeared that the flow to the distal organs was maintained through the false lumen of the descending aorta and the proximal abdominal aorta with the dissection extending into the abdominal aorta. An abdominal aortography was then performed that confirmed the diagnosis of extensive dissection that was propagating to the level of the abdominal aorta and aortic bifurcation. Considering these findings, we decided to abstain from placement of the endograft due to the high risk of creating malperfusion in this complex anatomy produced by the complex aortic dissection. Decision was made to limit the procedure to the debranching of the left subclavian artery and to defer the repair of the aorta to a later date after the patient undergoes further workup comprising CT Angiography and endovascular ultrasound. All catheters were removed under direct fluoroscopic guidance. All of the puncture sites in the arteries were closed with interrupted 6-0 Prolene sutures. Good pulses were reestablished throughout the area of exposed arteries. Thorough hemostasis was achieved using electrocautery and biological glue. There was significant amount of capillary bleeding from the area of the dissection of the right axillary and subclavian arteries due to presence of arteriovenous fistula and pressurized venous collateral branches. Bilateral Jackson-Pratt drains were placed in both axillary areas and also in the the left groin wounds. The incisions were irrigated with copious amount of saline containing antibiotics and closed in layers using standard technique. Sterile dressings were applied. The patient tolerated the procedure will and was transferred to recovery unit in stable condition.
 
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