Open and endovascular aortic aneurysm repair


Munhall, PA
Best answers
Wow. I think I have this coded correctly, but have never had a situation where the dr did a total arch replacement and then had to do a thoracic endovascular aortic repair. The codes are hitting against each other. I could use an extra set of eyes to review this. I tried to attach the file, but it was coming up invalid. This is very lengthy.

Thank you to anyone brave enough to view this.

PREOPERATIVE DIAGNOSES: Marfan syndrome, ascending aortic and aortic arch aneurysm, severe aortic insufficiency, dilated cardiomyopathy, and severe left ventricular dysfunction.

POSTOPERATIVE DIAGNOSES: Marfan syndrome, ascending aortic and aortic arch aneurysm, severe aortic insufficiency, dilated cardiomyopathy, severe left ventricular dysfunction, and acute type B aortic dissection.

PROCEDURES PERFORMED: Reoperative ascending aortic and total aortic arch
replacement with an elephant trunk (a 26-mm Vascutek graft and 12 x 8 x 8
mm Vascutek graft for brachiocephalic reconstruction), aortic valve
replacement (29-mm St. Jude medical mechanical), thoracic endovascular
aortic repair with descending thoracic aorta (26 x 10 cm GORE TAG stent
graft, 28 x 15 cm GORE TAG stent graft, 28.5 x 3.3 cm excluder cuff, 28.5 x
3.3 cm excluder cuff) intravascular ultrasound.

ANESTHESIA: General endotracheal.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite, placed supine, induced with general endotracheal anesthesia. A Swan-Ganz catheter and radial arterial line were placed by the anesthesia team for
intraoperative monitoring. A transesophageal echocardiogram was performed,
and this confirmed the above-noted findings of severe aortic insufficiency
with severe left ventricular dysfunction. There was no regional wall
motion abnormalities noted. He had no significant mitral regurgitation.
The patient was prepped and draped in the usual sterile fashion from the
chin to the toes. A reoperative midline sternotomy was made in the usual
fashion using an oscillating saw for the anterior sternal table and a
straight Mayo scissors for the posterior table. There were very dense
adhesions throughout the mediastinum. In particular, there was evidence of
previous bioglue application creating some significant amount of scar
around the ascending aorta and previous graft placed at the level of the
aortic root. After lysing these adhesions and obtaining control of the
ascending aortic graft, the right atrium and the right ventricle, the
patient was heparinized and then cannulated for cardiopulmonary bypass via
the distal ascending aorta and right atrial appendage. A superior vena
caval catheter was also placed for potential use for retrograde cerebral
perfusion and a coronary sinus catheter was placed for retrograde
cardioplegia. The patient was placed on cardiopulmonary bypass and then
systemically cooled to deep hypothermia. We monitored the patient with
continuous EEG and SSEPs to help direct safe period of deep hypothermic
circulatory arrest. During systemic cooling, an aortic cross-clamp was
applied, and initial induction cold blood high potassium cardioplegia was
delivered retrograde until a ventricular fibrillatory arrest at which time,
we transected the ascending aorta and then delivered direct ostial
antegrade cold blood high potassium cardioplegia to both the left and right
coronary arteries. We then inspected the aortic root from within and
confirmed that the previous reconstruction appeared to be a Yacoubian or
remodeling technique as there was a residual native aorta at the annular
level. The aortic valve was severely insufficient due to fenestrations in
the right and noncoronary cusps and effacement of the aortic annulus. It
was deemed unacceptable for re-repair given the degree of fenestrations.
The valve was excised and then we sounded the LVOT and annulus to 30 mm and subsequently implanted a 29-mm St. Jude medical mechanical aortic valve
using an intra-annular technique with interrupted pledgeted 2-0 Prolene
sutures placed in a horizontal mattress fashion. As we could be achieved
electrocerebral silence for greater than 4 minutes, we drew our attention
toward the aortic arch. We planned sequential reconstruction of the arch
to minimize the cerebral ischemic time. We first drew our attention to the
innominate artery. This was circumferentially controlled and then the
innominate artery was clamped proximally and distally and then divided. We
then took a 12 x 8 x 8 mm-trifurcated graft (Spielvogel-type). We trimmed the distal 12- mm limb to an appropriate length and then anastomosed it in an end-to-end fashion to the innominate using running 5-0 Prolene suture. Following completion of that anastomosis, we then connected the proximal limb of the 12-mm portion of the trifurcated graft to a separate wide circuit of the arterial inflow of the cardiopulmonary bypass circuit. We deaired that system and then began antegrade cerebral perfusion through the innominate. Of note, we then began antegrade cerebral perfusion to the innominate. We then at this point, began a brief period of deep hypothermic circulatory arrest to the lower body and opened the arch. We then circumferentially dissected out the left common carotid artery and transected it at its ostium. We then clamped the left carotid distally and then trimmed 1 of the two 8-mm branches of the trifurcated graft to an appropriate length and anastomosed it end-to-end to the left common carotid artery. Following completion of that anastomosis, we deaired
the left carotid via that graft and then began bilateral cerebral perfusion via the 12-mm inflow graft. Next, we drew attention towards the left subclavian
artery. This vessel was circumferentially dissected out and then
transected at its ostium. We then trimmed the second 8-mm limb of the
trifurcated graft in appropriate length and anastomosed it to the left
subclavian artery using running 5-0 Prolene suture. As that anastomosis
was completed, we then reconstituted flow into the left subclavian artery.
Next, we took a 26-mm Vascutek graft created an elephant trunk measuring 5
cm in length and placed that down into the descending thoracic aorta after
having transected the aorta just beyond the left subclavian. We then
completed an elephant trunk anastomosis to the proximal descending thoracic
aorta using running 3-0 Prolene suture. The proximal portion of the trunk
was pulled out of the descending thoracic aorta. We then cannulated that
graft just proximal to the elephant trunk anastomosis and began perfusion
of the lower body terminating the circulatory arrest to the lower body. We
then made an elliptical graftotomy on the greater curve of the 26-mm arch
graft using the ophthalmic cautery device and then we trimmed the proximal
12-mm limb of the trifurcated graft in a beveled fashion while maintaining
perfusion through it. We then anastomosed the 12-mm graft to the arch
graft on the rightward greater curve using running 2-0 Prolene suture. We
maintained antegrade cerebral perfusion throughout this anastomosis until
the final stitch at which time, we deaired the system and terminated inflow
through the 12-mm graft, completed tying down the anastomotic suture line
and then reconstituted flow via our central cannula, which was on the arch
graft. We began systemic rewarming at this point and then cut the proximal
aspect of the 26-mm arch graft proximal to anastomosis to the trifurcate
graft, transecting the graft of a larger graft obliquely and then we
trimmed the previously placed root graft to a level at the sinotubular
junction and then anastomosed the 2 grafts to one another using running 2-0
Prolene suture, taking care to recreate the normal curvature of the
ascending aorta from the root to the arch. Upon achieving normothermia
with systemic rewarming, the patient was subsequently weaned from
cardiopulmonary bypass with a well-seated mechanical valve in the aortic
position. Following weaning from bypass, the patient was decannulated. We
then interrogated the heart and aorta and the heart function was preserved
relative to its preoperative state. The right ventricular function was
normal. We then noted that there was in new type B aortic dissection, with
a primary tear site at the level of the terminal point of the elephant
trunk in the proximal descending thoracic aorta. This tear site was
expanding and giving rise to significant amount of flow into a false lumen.
There was a false lumen compression of the true lumen down into the
abdomen. We could not see the terminal point of this type B dissection,
but it appeared to be in the abdomen. This raised great concern given the
degree of compression of the true lumen and therefore we elected to proceed
with stent grafting the descending thoracic aorta. This was done via an
antegrade approach. We utilized the arch graft cannulation site to place
an #18 French Gore DrySeal sheath through which we deployed several stent
grafts as described below. First, we needed to obtain wire access to the
entire true lumen. To do this we placed a 5-French sheath in the right
common femoral artery using a Seldinger technique. We then advanced an
endovascular snare through the #18 French DrySeal sheath. From the right
groin, we advanced a guide wire up into the true lumen. We then exchanged
the 5-French sheath for a 9-French sheath in the right common femoral
artery. We then advanced an IVUS unit up over top the guide wire and
confirmed that we were in the true lumen up all the way to the primary tear
site. We then advanced the snare through the #18 French sheath proximally
in the arch and then grasped the guidewire we had advanced from the right
common femoral artery and pulled out through the #18 French DrySeal sheath
in the aortic arch and then we confirmed with IVUS that we were within the
true lumen along the entire course of the wire from the right groin up into
the aortic arch. Now with the working wire, we were able to deploy several
stent grafts. First, we advanced a GORE TAG 26 mm x 10 cm, which was
deployed across the distal elephant trunk and the primary tear site. We
then interrogated the aorta with a transesophageal echocardiography. We
confirmed some expansion of the true lumen, but there was still significant
compression of false; therefore, we elected to place a second more distal
stent graft using the IVUS via the right common femoral artery. We
identified an acceptable distal landing site. We then advanced a 28 mm x
15 cm tag from the antegrade #18 French sheath. We advanced that and then used C-arm fluoroscopy to confirm the distal position of the tag relative
to the IVUS unit and confirmed that the 3 cm overlap relative to our 26 x
10 cm tag. We then deployed a second stent graft. With the second
deployment, we had an excellent expansion of the true lumen, now with stent
graft coverage down to the distal third of the descending thoracic aorta.
Upon further interrogation more proximally, we felt there was still some
type 1 endoleak with some swelling flow in the false lumen around the
elephant trunk; therefore, we placed a 2 additional GORE excluder cuffs
28.5 x 3.3 cm. We deployed 2 of these using an antegrade approach again
over our guidewire that was within the true lumen. We deployed 1
proximally near the elephant trunk anastomosis and then a second one
slightly more distal to achieve overlap with the 26 mm x 10 cm primary
graft. After these 2 additional excluder cuff were placed, we were
satisfied that we had exclusion of the false lumen proximally with adequate
coverage of the primary tear site and adequate expansion of the true lumen
more distally. The heparin was then reversed with IV protamine.
Meticulous hemostasis was confirmed in the entire operative field with
protamine and 1 mg of factor VII. Chest tubes were placed in the left pleural
space in the mediastinum as well as the right pleural space. Temporary atrial
and ventricular pacing leads were secured, and the chest was then closed in
layers. We took great care in covering all the graft material with the
overlying thymic fat pericardium from the level of innominate vein to the base
of the heart such that there was no graft material in contact with any of the
sternum. Sternum was then reapproximated with interrupted heavy gauge wire.
The pectoralis fascia, subcutaneous tissues, and skin were all approximated
with running absorbable sutures. We then pulled the 9-French sheath and held a direct pressure over the right common femoral artery for 50 minutes. The patient was transferred to the CTICU in stable condition.
I was present and participated through the entire procedure.