TWilliam2019
Guru
1. Insertion of percutaneous right ventricular assist device (Impella Flex RP)
2. Insertion of pulmonary artery catheter
3. Ultrasound guided puncture, left subclavian vein
4. Transesophageal echocardiogram with visualization and interpretation
5. Fluoroscopy with visualization and interpretation
the left subclavian vein was visualized as patent and accessed with a single anterior wall needle puncture under real time ultrasound guidance and a guidewire inserted. Resultant images were placed on the chart. Using a modified Seldinger's technique, the vein was serially dilated. A 7Fr introducer sheath was then inserted over the wire and the wire removed. All ports flushed and withdrew with ease. Extended IV tubing was then passed off to anesthesia and their their vasoactive infusions switched to this access. Next, a swan-ganz pulmonary artery cathter was prepared and inserted via the sheath. The tip of the catheter was visualized within the superior vena cava on fluoroscopy. The cathter balloon was inflated. The cathter was then advanced through the vena cava and right heart, across the pulmonic valve and into the right pulmonary artery under fluoroscopy. A pulmonary artery waveform was confirmed. The cathter and its sheath were then secured.
Next, a second pulmonary artery catheter was then inserted via the previously placed right internal jugular vein and its catheter tip visualized within the superior vena cava on fluoroscopy. The balloon wa inflated and the cathter guided through the right heart and into the right pulmonary artery without difficulty. The balloon was deflated. Next, an 0.035 J tip guidewire was inserted into catheter access port and guided into the right pulmonary artery under fluoroscopy. Next, the cathter was removed. Next, the access at the right neck was serially dilated using a modified Seldinger's technique and the Impella RP working sheath inserted. A deep dermal suture of 0 PDS was placed around the sheath to aid in hemostasis. Next, the pulmonary artery cathter was inserted over the guidewire and the J wire exchanged for an 0.25 stiff wire. The pulmonary artery catheter was removed. The Impella Flex RP device was prepared and inserted over the stiff wire and into the working sheath. The device was then guided through the right heart without difficulty under real time TEE and fluoroscopic guidance, all the while with the aforementioned assistant providing wire control and traction. The wire was removed as the pigtail of the device was positioned in the main pulmonary artery. Impella support was initiated and flows of greater than 4Lpm were achieved. The working sheath was then exchanged for an implant sheath, which was secured to the right neck with silk suture. Final TEE was performed with findings as described above. The remnant skin incision was closed in layers with 0 vicryl suture. 4-0 monocryl was used to close the skin. Sterile dressings were applied.
33995
36014
76937 26
? 93503
2. Insertion of pulmonary artery catheter
3. Ultrasound guided puncture, left subclavian vein
4. Transesophageal echocardiogram with visualization and interpretation
5. Fluoroscopy with visualization and interpretation
the left subclavian vein was visualized as patent and accessed with a single anterior wall needle puncture under real time ultrasound guidance and a guidewire inserted. Resultant images were placed on the chart. Using a modified Seldinger's technique, the vein was serially dilated. A 7Fr introducer sheath was then inserted over the wire and the wire removed. All ports flushed and withdrew with ease. Extended IV tubing was then passed off to anesthesia and their their vasoactive infusions switched to this access. Next, a swan-ganz pulmonary artery cathter was prepared and inserted via the sheath. The tip of the catheter was visualized within the superior vena cava on fluoroscopy. The cathter balloon was inflated. The cathter was then advanced through the vena cava and right heart, across the pulmonic valve and into the right pulmonary artery under fluoroscopy. A pulmonary artery waveform was confirmed. The cathter and its sheath were then secured.
Next, a second pulmonary artery catheter was then inserted via the previously placed right internal jugular vein and its catheter tip visualized within the superior vena cava on fluoroscopy. The balloon wa inflated and the cathter guided through the right heart and into the right pulmonary artery without difficulty. The balloon was deflated. Next, an 0.035 J tip guidewire was inserted into catheter access port and guided into the right pulmonary artery under fluoroscopy. Next, the cathter was removed. Next, the access at the right neck was serially dilated using a modified Seldinger's technique and the Impella RP working sheath inserted. A deep dermal suture of 0 PDS was placed around the sheath to aid in hemostasis. Next, the pulmonary artery cathter was inserted over the guidewire and the J wire exchanged for an 0.25 stiff wire. The pulmonary artery catheter was removed. The Impella Flex RP device was prepared and inserted over the stiff wire and into the working sheath. The device was then guided through the right heart without difficulty under real time TEE and fluoroscopic guidance, all the while with the aforementioned assistant providing wire control and traction. The wire was removed as the pigtail of the device was positioned in the main pulmonary artery. Impella support was initiated and flows of greater than 4Lpm were achieved. The working sheath was then exchanged for an implant sheath, which was secured to the right neck with silk suture. Final TEE was performed with findings as described above. The remnant skin incision was closed in layers with 0 vicryl suture. 4-0 monocryl was used to close the skin. Sterile dressings were applied.
33995
36014
76937 26
? 93503