TRANSCAROTID ARTERY REVASCULARIZATION (TCAR)CONVERSION TO RIGHT CAROTID ENDARTERECTOMY WITH PATCH ANGIOPLASTY
Indications and Findings: The patient is a 80 y.o. male with symptomatic RICA stenosis
Procedure Details: The patient was taken to the catheterization lab and placed in supine position. After GETA the patient was positioned identically as for carotid endarterectomy with shoulder roll, arms tucked, head turned to the contralateral side and Somanetics on his forehead. US was used to measure the distance of clavicle to the ipsilateral (right) carotid bulb and the depth of the artery from the skin. The triangle between the right sternocleidomastoid muscle were drawn out and the incision line drawn out. The ipsilateral neck and the contralateral groin were both prepped out and sterile draped. The contralateral femoral vein was accessed using modified Seldinger technique and flushed appropriately. The ipsilateral neck incision was made with a one inch vertical incision and carried down directly to the proximal common carotid artery. The most proximal extent of this vessel was carefully vessel looped for inflow control. IV heparin (100 units/kg) was then infused to keep the ACT > 250. The next more distal centimeter on the common carotid artery was used for access by placing a 5-0 Prolene U stitch. In a combined effort for vascular access the vessel was accessed with a guide needle and the Silk Road equipment to dilate and place the TCAR device for cerebral protection. Care was taken to make certain the SBP was between 140 - 160 mmHg and the HR was greater than 70 bpm.
It was noticed that the introducer wire and dilator were not able to be inserted into the right common carotid artery smoothly. By fluoroscopy it was thought that perhaps a dissection occurred. This stick site was tied off and a more proximal site (in the same field) was selected with a 5-0 Prolene U stitch for arterial access. Again this did not yield expected results by difficult passing the guide wire under fluoroscopy. This second site was tied off.
For safety reasons a right carotid endarterectomy was performed. The proximal right common carotid artery remain with a vessel loop to act as proximal control.
A separate slightly more cranial (about one inch) 4 inch incision was made along the anterior border of the right sternocleidomastoid muscle. The incision was carried down through the skin and subcutaneous fat in the platysmas muscle. The right sternocleidomastoid muscle was identified and rotated laterally. The common carotid, external carotid and internal carotid arteries were all carefully dissected and isolated. The artery was inspected for any external evidence of dissection. There was none.
Vessel clamps were then applied to the common, internal, and external carotid arteries. We followed the readings on the Somanetics device throughout the entire case. The carotid artery was then opened and an endarterectomy performed. No dissection flap was identified. A neo--intima was created that was glistening smooth and free of wispy elements that could cause stroke. The endarterectomy plaque was sent to pathology.
We then performed patch angioplasty. The patch was a bovine pericardial material that we sutured to the artery with a smooth surface down towards blood flow using a running 7-0 Gore-Tex suture. De-airing then ensued by removing the external carotid clamp, the internal carotid clamp, replacing the internal carotid clamp, then removing the common carotid clamp (very strong flow proximally into the patch/wound) and finally removing the internal carotid clamp. The Somanetics device readings were noted to stay at preoperative levels.
Irrigation ensued with copious amounts of normal saline. We then achieved hemostasis. A JP drain was inserted and then closure was performed.
For both incisions the closures started with 2 layers of 3-0 Vicryl in a running fashion on the platysmas muscle layer. Also a 3-0 Vicryl in the subcutaneous tissue. Finally 4-0 Monocryl suture for skin closure.
Thanks in advance
any help would be appreciated I am new with this kind of procedures coding
I am coming up with 37216?