sandy06
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POSTOPERATIVE DIAGNOSES:
1. Coronary artery disease.
2. Left internal mammary artery to pulmonary artery fistula.
PROCEDURE PERFORMED:
1. Redo coronary artery bypass grafting x2 utilizing a right internal
mammary artery to the left anterior descending artery.
2. Saphenous vein graft to the right coronary artery.
3. Ligation of the left internal mammary artery and closure of
multiple left internal mammary artery to pulmonary artery and
right pulmonary artery fistulous and harvesting the left greater
saphenous vein.
SURGEON:
Dr
ASSISTANT:
DESCRIPTION OF PROCEDURE:
The patient was taken to the OR, placed in a supine position, prepped
in the usual fashion. A two-team approach was utilized, one team
harvesting the left greater saphenous vein while the other team
performed the mediastinal dissection. A median sternotomy incision
was performed. The incision was taken down through skin, the
subcutaneous tissue down to the midportion of sternum. An electrical
saw was utilized to perform a median sternotomy. Thereafter, an
oscillating saw was utilized to perform a median sternotomy. Upon
entering the anterior and posterior sternum, thereafter, the
adhesions adherent to the under surface of the sternum were dissected
free utilizing electrocautery. This allowing placement of mammary
retractor on the right sternal half and the right internal mammary
artery was dissected free from the chest wall in a routine fashion.
The IMA was ligated distally, transected. Adequate flow was noted.
This was flushed with papaverine solution, clipped, and left thoracic
cavity open and this will be closed later during the operative
procedure. Thereafter, further dissection the heart was performed
allowing placement of a sternal retractor and dissection of the left
side of the heart and identification of the left internal mammary
artery is performed. Thereafter, the patient was heparinized and
aortic venous antegrade and retrograde cardioplegia cannulation was
performed in a routine fashion. We then instituted a full
cardiopulmonary bypass. Further dissection the heart was performed.
The aorta was then cross clamped and cold blood cardioplegia was
given, both in antegrade retrograde fashion. The mammary artery was
then identified and then ligated, although due to the multiple
fistulas, the right heart continued to fill until the mammary artery
was ligated extremely proximal and there was a large branched
extending inferiorly, which was also ligated as well. The multiple
fistulas branching off of the left internal mammary artery were
identified and clipped and any large branches were sutured and
transected. Of note, the mammary artery was transected at its
anastomotic site as well. Of note, every 15 minutes further doses of
cardioplegia were given. We then identified the distal right coronary
artery. Arteriotomy is made in the same. This also had a 1.5 mm
intraluminal diameter. Then the vein was then anastomosed end-to-side
fashion utilizing a 7-0 Prolene suture. We then directed attention to
the left anterior descending artery, where the right internal mammary
artery was placed across the midline over the aorta to the left
anterior descending artery and sutured in an end-to-side fashion with
a 7-0 Prolene suture. At this point, the mammary artery was tacked
with a Prolene suture, and then the prior to removal of the
cross-clamp the antegrade cardioplegia cannula was removed and one
aortotomy was performed utilizing a 4 mm punch. Then the vein graft
to the RCA was anastomosed end-to-side fashion 6-0 Prolene suture.
When this was completed, the patient was placed in Trendelenburg. The
graft with the cross-clamp was removed. The grafts were de-aired.
Distal coronary anastomoses were inspected and noted to be dry.
Epicardial ventricular pacing wire was placed, as well as a
substernal chest tube and a right pleural chest tube. The patient was
then weaned from cardiopulmonary bypass. The venous cannula was
removed. The purse suture tied down. The patient was given protamine,
which he tolerated well. Then the arterial cannula was removed. The
purse suture tied down. Further hemostasis was obtained. Thereafter,
#5 steel sternal wires were placed, three in the manubrium, four in
the intercostal space beneath. The wires were proximally twisted. The
muscle, subcutaneous tissue, and skin were closed in routine fashion.
Please can someone help with the "Ligation Pulmonary Artery Fistula", I'm having such a hard time with this part of this Report, I'll realy appreciate in advance for any hint you can give me.
I was looking at 37616 but I'm not sure
Thanks......
1. Coronary artery disease.
2. Left internal mammary artery to pulmonary artery fistula.
PROCEDURE PERFORMED:
1. Redo coronary artery bypass grafting x2 utilizing a right internal
mammary artery to the left anterior descending artery.
2. Saphenous vein graft to the right coronary artery.
3. Ligation of the left internal mammary artery and closure of
multiple left internal mammary artery to pulmonary artery and
right pulmonary artery fistulous and harvesting the left greater
saphenous vein.
SURGEON:
Dr
ASSISTANT:
DESCRIPTION OF PROCEDURE:
The patient was taken to the OR, placed in a supine position, prepped
in the usual fashion. A two-team approach was utilized, one team
harvesting the left greater saphenous vein while the other team
performed the mediastinal dissection. A median sternotomy incision
was performed. The incision was taken down through skin, the
subcutaneous tissue down to the midportion of sternum. An electrical
saw was utilized to perform a median sternotomy. Thereafter, an
oscillating saw was utilized to perform a median sternotomy. Upon
entering the anterior and posterior sternum, thereafter, the
adhesions adherent to the under surface of the sternum were dissected
free utilizing electrocautery. This allowing placement of mammary
retractor on the right sternal half and the right internal mammary
artery was dissected free from the chest wall in a routine fashion.
The IMA was ligated distally, transected. Adequate flow was noted.
This was flushed with papaverine solution, clipped, and left thoracic
cavity open and this will be closed later during the operative
procedure. Thereafter, further dissection the heart was performed
allowing placement of a sternal retractor and dissection of the left
side of the heart and identification of the left internal mammary
artery is performed. Thereafter, the patient was heparinized and
aortic venous antegrade and retrograde cardioplegia cannulation was
performed in a routine fashion. We then instituted a full
cardiopulmonary bypass. Further dissection the heart was performed.
The aorta was then cross clamped and cold blood cardioplegia was
given, both in antegrade retrograde fashion. The mammary artery was
then identified and then ligated, although due to the multiple
fistulas, the right heart continued to fill until the mammary artery
was ligated extremely proximal and there was a large branched
extending inferiorly, which was also ligated as well. The multiple
fistulas branching off of the left internal mammary artery were
identified and clipped and any large branches were sutured and
transected. Of note, the mammary artery was transected at its
anastomotic site as well. Of note, every 15 minutes further doses of
cardioplegia were given. We then identified the distal right coronary
artery. Arteriotomy is made in the same. This also had a 1.5 mm
intraluminal diameter. Then the vein was then anastomosed end-to-side
fashion utilizing a 7-0 Prolene suture. We then directed attention to
the left anterior descending artery, where the right internal mammary
artery was placed across the midline over the aorta to the left
anterior descending artery and sutured in an end-to-side fashion with
a 7-0 Prolene suture. At this point, the mammary artery was tacked
with a Prolene suture, and then the prior to removal of the
cross-clamp the antegrade cardioplegia cannula was removed and one
aortotomy was performed utilizing a 4 mm punch. Then the vein graft
to the RCA was anastomosed end-to-side fashion 6-0 Prolene suture.
When this was completed, the patient was placed in Trendelenburg. The
graft with the cross-clamp was removed. The grafts were de-aired.
Distal coronary anastomoses were inspected and noted to be dry.
Epicardial ventricular pacing wire was placed, as well as a
substernal chest tube and a right pleural chest tube. The patient was
then weaned from cardiopulmonary bypass. The venous cannula was
removed. The purse suture tied down. The patient was given protamine,
which he tolerated well. Then the arterial cannula was removed. The
purse suture tied down. Further hemostasis was obtained. Thereafter,
#5 steel sternal wires were placed, three in the manubrium, four in
the intercostal space beneath. The wires were proximally twisted. The
muscle, subcutaneous tissue, and skin were closed in routine fashion.
Please can someone help with the "Ligation Pulmonary Artery Fistula", I'm having such a hard time with this part of this Report, I'll realy appreciate in advance for any hint you can give me.
I was looking at 37616 but I'm not sure
Thanks......