slc112071
Networker
Could someone please help me with this? I am thinking that the stent removal is included in the CEA, but not sure. The stent was partially placed by a cardiologist the day before this procedure and this CV surgeon was called in on the case when it did not fully deploy. Any and all help is very much appreciated.
PREOPERATIVE DIAGNOSES:
1. Left internal carotid stenosis.
2. Incompletely deployed left carotid stent.
3. Cardiomyopathy.
POSTOPERATIVE DIAGNOSES:
1. Left internal carotid stenosis.
2. Incompletely deployed left carotid stent.
3. Cardiomyopathy.
PROCEDURES PERFORMED:
1. Emergency left carotid endarterectomy with Vascu-Guard pericardial patch.
2. Removal of carotid stent.
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old female who is high
risk for carotid intervention due to ischemic cardiomyopathy. The patient has
been followed for carotid stenosis. She underwent a left carotid stenting
yesterday. It was difficult to get the stent deployed and there was only
partial deployment. CT angiogram suggested incomplete deployment of the stent
with severe obstruction of the proximal internal carotid. For this reason
alternatives, benefits and risks of carotid endarterectomy and stent removal
discussed with the patient. She appeared to understand and agree to the
procedure. She was taken to the OR today for urgent intervention.
OPERATIVE FINDINGS: The patient had about 80% proximal left internal carotid
stenosis. The patient had a carotid stent that was deployed into the internal
carotid, seemed to be obstructing the proximal internal level of the plaque.
OPERATIVE NOTE: The patient brought in the OR, placed on table in supine
position. Appropriate monitoring devices were placed including arterial
catheter. After general anesthetic induction, intubated, prepped and draped
for carotid endarterectomy. Standard incision was made over the
sternocleidomastoid muscle. Dissection was carried down the carotid sheath
and was fairly deep. There was a very low bifurcation. The vagus nerve was
identified and preserved. This was fairly lateral. Hypoglossal nerve also
identified and preserved. Fairly easy to mobilize the long segment of the
internal carotid, well above the stent. Ligaloops placed around the common,
external and internal carotid. 75 units of heparin was given and allowed to
circulate. ACT was checked. We then secured the Ligaloops beginning with the
internal, common, and external. Arteriotomy was made beginning in the common.
The stent was partially deployed at the bifurcation up in to the internal.
Cut through the stent with of pair of scissors. This went up high up the
internal. The entire stent was then easily removed. Endarterectomy was
performed in the appropriate plane beginning in common a centimeter and half
from the bifurcation and up about 5 cm up into the internal carotid. It
seemed to have a decent endpoint, although <<Missing Text>> flaps that
tentatively formed distally. This may have been due to the stent. We did
place a temporary 8-French shunt. The back bleeding appeared to be fairly
minimal in the internal. Once we had good endpoints on her endarterectomy, we
irrigated out the carotid with saline and some concentrated heparin. We then
closed the artery with a Vascu-Guard pericardial patch and 6-0 Prolene. Prior
to taking the last few sutures we then removed the shunt and took our last few
sutures and tied it down. De-airing allowed flow reestablished into the
external carotid, then into the internal carotid. The patient is still in the
OR just waking up from anesthesia. Thus far, no complications. Hemovac drain
was also placed. We closed the wound in layers with a running Vicryl for
platysma, Monocryl for the skin. Dressing was applied.
PREOPERATIVE DIAGNOSES:
1. Left internal carotid stenosis.
2. Incompletely deployed left carotid stent.
3. Cardiomyopathy.
POSTOPERATIVE DIAGNOSES:
1. Left internal carotid stenosis.
2. Incompletely deployed left carotid stent.
3. Cardiomyopathy.
PROCEDURES PERFORMED:
1. Emergency left carotid endarterectomy with Vascu-Guard pericardial patch.
2. Removal of carotid stent.
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old female who is high
risk for carotid intervention due to ischemic cardiomyopathy. The patient has
been followed for carotid stenosis. She underwent a left carotid stenting
yesterday. It was difficult to get the stent deployed and there was only
partial deployment. CT angiogram suggested incomplete deployment of the stent
with severe obstruction of the proximal internal carotid. For this reason
alternatives, benefits and risks of carotid endarterectomy and stent removal
discussed with the patient. She appeared to understand and agree to the
procedure. She was taken to the OR today for urgent intervention.
OPERATIVE FINDINGS: The patient had about 80% proximal left internal carotid
stenosis. The patient had a carotid stent that was deployed into the internal
carotid, seemed to be obstructing the proximal internal level of the plaque.
OPERATIVE NOTE: The patient brought in the OR, placed on table in supine
position. Appropriate monitoring devices were placed including arterial
catheter. After general anesthetic induction, intubated, prepped and draped
for carotid endarterectomy. Standard incision was made over the
sternocleidomastoid muscle. Dissection was carried down the carotid sheath
and was fairly deep. There was a very low bifurcation. The vagus nerve was
identified and preserved. This was fairly lateral. Hypoglossal nerve also
identified and preserved. Fairly easy to mobilize the long segment of the
internal carotid, well above the stent. Ligaloops placed around the common,
external and internal carotid. 75 units of heparin was given and allowed to
circulate. ACT was checked. We then secured the Ligaloops beginning with the
internal, common, and external. Arteriotomy was made beginning in the common.
The stent was partially deployed at the bifurcation up in to the internal.
Cut through the stent with of pair of scissors. This went up high up the
internal. The entire stent was then easily removed. Endarterectomy was
performed in the appropriate plane beginning in common a centimeter and half
from the bifurcation and up about 5 cm up into the internal carotid. It
seemed to have a decent endpoint, although <<Missing Text>> flaps that
tentatively formed distally. This may have been due to the stent. We did
place a temporary 8-French shunt. The back bleeding appeared to be fairly
minimal in the internal. Once we had good endpoints on her endarterectomy, we
irrigated out the carotid with saline and some concentrated heparin. We then
closed the artery with a Vascu-Guard pericardial patch and 6-0 Prolene. Prior
to taking the last few sutures we then removed the shunt and took our last few
sutures and tied it down. De-airing allowed flow reestablished into the
external carotid, then into the internal carotid. The patient is still in the
OR just waking up from anesthesia. Thus far, no complications. Hemovac drain
was also placed. We closed the wound in layers with a running Vicryl for
platysma, Monocryl for the skin. Dressing was applied.