Wiki need help with this procedure thanks

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Postoperative diagnosis:
1. Non-ST elevated myocardial infarction
2. Severe multivessel coronary artery disease
3. Acute systolic heart failure
4. New York heart association class IV heart failure symptoms requiring right femoral percutaneous left ventricular assist device
5. Right common femoral artery thrombus

Procedure:
1. Right femoral artery cutdown with:
A. Removal of percutaneous left ventricular assist device, separate and distinct session from insertion
B. Right femoral artery balloon catheter thrombectomy
C. Primary repair of right femoral artery
2. Right axillary artery cutdown with:
A. Placement of 6 mm Dacron conduit in an end-to-side fashion
B. Insertion of Impella CP percutaneous left ventricular assist device under fluoroscopic and TEE guidance
Indication:
75-year-old male presenting with non-ST elevated myocardial infarction on . He was found to have severe left ventricular dysfunction with an ejection fraction of 15 to 20% and multivessel coronary disease as identified on left heart catheterization. He underwent placement of a right femoral artery percutaneous left ventricular assist device for support of his cardiogenic shock and PCI to the right coronary artery. His postoperative course has been complicated by fevers of unknown origin. Early this morning, his ventricular assist device malfunctioned and was fortunate enough to be restarted. He presents for removal of his femoral Impella device and placement of new axillary device.

Intraoperative findings:
TEE:
His femoral Impella device was in good position across the aortic valve. The left ventricular function was severely depressed, estimated at 15%. There was global hypokinesis with severe hypokinesis of the lateral wall and borderline akinesis of the septum and anterior wall. There was moderate to severe mitral regurgitation centrally. Left atrial appendage was free of thrombus. The aortic valve was a trileaflet valve and had trace insufficiency, given the Impella coursing across the valve. Right ventricular function appeared normal. There is no tricuspid regurgitation. No PFO was identified.

Final TEE revealed the new axillary Impella well positioned across the aortic valve and functioning appropriately.

Hemodynamics:
-Impella device at P3 flowing 2 to 2.5 L/min
-PA pressures of 55/25
-With transient discontinuation of Impella support, PA pressures quickly climbed to 65 mmHg.
-CVP 20 mmHg

Fluoroscopy:
With fluoroscopy, the aortic valve was crossed with 0.015 guidewire and the axillary Impella was positioned in the distal ascending aorta. Under direct fluoroscopic guidance, the femoral Impella was removed from the heart and the axillary Impella was advanced into the left ventricle and found to be in good position.

Other intraoperative findings:
Extensive post implantation changes within the soft tissues of the right inguinal region. The femoral artery had a large amount of thrombus removed from the proximal common femoral artery. No thrombus was identified in the distal femoral artery. At the completion of the removal and repair of the artery, there was palpable SFA and dopplerable pulses within the right foot.

Procedure in detail:
The patient had his history and physical updated prior to the procedure. He was transferred to the operating suite placed on the operating table where he underwent general anesthesia. He was already endotracheally intubated. Monitoring lines were placed by anesthesia. TEE probe was placed by anesthesia. The patient was prepped and draped in usual sterile fashion using DuraPrep solution. Timeout was used to confirm patient identity as well as the procedure to be performed. Antibiotics given prior to the incisions.

Preprocedural TEE was performed with findings as described above. TEE was referred to throughout this procedure to confirm placement of the Impella device.

An incision was made over the right femoral artery and the soft tissues were dissected using electrocautery. There was extensive ecchymotic changes within the region. There was also edema and thickening of soft tissue surrounding the femoral artery. The Impella sheath was used as a dissection guide into the femoral artery was identified. The common femoral artery was then encircled with Vesseloops as well as the distal aspect of the common femoral artery.

Gloves were then changed. A right horizontal subclavicular incision was then made and the soft tissues were divided. The pectoralis major muscle was released from its attachments along the inferior clavicle. The underlying pectoralis muscle was retracted laterally. The axillary vein was identified and retracted inferiorly. The axillary artery was identified and carefully dissected out using Metzenbaum scissors. The artery itself measured approximately 5-1/2 to 6 mm and was small relative to the patient's size and body habitus. Throughout the dissection, multiple perforating veins and small arteries were clipped ligated. The brachial plexus was not directly identified. Some small pectoralis nerve branches were also ligated. Once the axillary artery was dissected out, it was encircled proximally and distally with Vesseloops. The patient was then heparinized and ACT was found to be greater than 250 seconds for the remainder of the procedure.

A 6 mm Dacron graft was then contoured for future anastomosis. Proximal distal control of the axillary artery along with the thyrocervical trunk which was controlled with a 0 silk was achieved using a combination of the vessel loops as well as direct artery clamps. A longitudinal arteriotomy was made and extended with angled scissors. The dacryon graft was anastomosed to the axillary artery using 5-0 Prolene.

The Impella introducer sheath was then placed within the graft. It was secured with 0 silk. Under direct fluoroscopic visualization, a J-wire along with pigtail catheter was advanced into the ascending aorta. I was unable to successfully cross the aortic valve using a J-wire. The femoral Impella was decreased to a P-2 level to allow for better ejection from the left ventricle and opening of the valve. A Glidewire was then used to cross the aortic valve and the pigtail catheter was advanced in the left ventricle as guided by fluoroscopy and confirmed by TEE. The Glidewire was removed and a 0.015 wire was placed within the left ventricle and the pigtail was then removed.

The new Impella CP was then inserted over wire and advanced under fluoroscopic guidance and positioned within the distal ascending aorta. Once this was complete, attention was then turned to the femoral Impella device. The femoral Impella was decreased to P1 level and carefully pulled back until confirmed out of the ventricle and positioned within the descending thoracic aorta under fluoroscopic guidance. The new right axillary Impella was then advanced over wire and positioned within the left ventricle. This was confirmed by fluoroscopy as well as TEE. The wire was removed and the Impella device was placed at P8 with flows of greater than 3 L/min.

The femoral Impella was then turned off and pulled back. It was then removed from the right femoral artery and proximal and distal control was achieved using a combination of the Vesseloops as well as direct vascular clamping. A 5 French Fogarty balloon was then passed proximally into the external iliac and pulled back with removal of a large thrombus, but reestablishing excellent flow through the common femoral artery. Given the patient's fevers, a portion of this thrombus was submitted for routine cultures. The Fogarty catheter was then passed into the distal common femoral artery and pulled back with no thrombus being removed. A direct femoral arterial repair was achieved using interrupted 5-0 Prolene in a figure-of-eight and single suture fashion. Prior to full closure of the artery, the proximal clamp was released to allow flushing of the artery with no further thrombus removed. After achieving hemostasis, the distal clamp was removed and flow was confirmed by both palpation as well as Doppler interrogation.

Again, gloves were changed and attention was turned to the axillary Impella. The peel-away sheath was removed and the graft was cut down until it extended just beyond the level of the skin. The new sheath was then inserted and secured with 0 silk. Fluoroscopy confirmed that there was no change in positioning of the Impella device once this was achieved. It was secured to the skin using 0 silk. Both femoral and axillary incisions were irrigated with antibiotic solution. The femoral incision was then closed using 0 Vicryl in a running fashion. The skin was closed with 4-0 Monocryl. The axillary incision was closed in a similar fashion. Dermabond was then placed over the wounds. The patient tolerated the procedure well was transferred to CVRU, but remaining in critical condition.
 
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