Wiki Repair Innominate Vein


Munhall, PA
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Good Morning to all. I am looking for some help with this report. I think I have it and then I read it again and.... The repair of the innominate vein. Would you use 35241?

PREOPERATIVE DIAGNOSES: Severe aortic stenosis and morbid obesity.

POSTOPERATIVE DIAGNOSES: Severe aortic stenosis and morbid obesity.

PROCEDURE PERFORMED: Reoperative aortic valve replacement (23 mm St. Jude
Trifecta), repair of left innominate vein with native pericardial patch.

DESCRIPTION OF PROCEDURE: The patient was brought to the operative 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 it confirmed the above-noted finding of severe aortic stenosis. He had
severe left ventricular hypertrophy with preserved systolic function.

The patient was prepped and draped in the usual sterile fashion from chin to
toes. A reoperative midline sternotomy was made in the usual fashion using
the oscillating saw for the anterior sternal table and a straight Mayo
scissors for the posterior table. Of note, the LIMA graft was adherent to
the sternum. We meticulously dissected the LIMA off the sternum.
Additionally, the innominate vein was densely adherent to the manubrium, and
upon division of the posterior table of the manubrium, the innominate vein
was injured. This bleeding was easily controlled with a RayTec pack.
However, we elected to go on bypass using femoral arterial cannulation and
central venous cannulation to help facilitate repair of that prior to
proceeding with aortic valve replacement. Therefore, a 2 cm oblique incision
was made above the left inguinal crease. We then dissected out the left
common femoral artery at the level of the inguinal ligament
circumferentially. The patient was subsequently heparinized. We dissected
out the heart and then cannulated the right atrium at the right atrial
appendage with a dual stage. The patient was subsequently placed on
cardiopulmonary bypass and then an elliptical shaped native pericardial patch
was harvested. We then repaired the anterior wall of the left innominate
vein with this patch using running 5-0 Prolene suture. Next we centrally
cannulated the aorta. The descending aorta and proximal arch was dissected
out. Then the proximal arch cannulated. We then converted to central inflow
and we removed the left common femoral arterial cannula and repaired that
vessel primarily with interrupted 5-0 Prolene sutures. A counterincision had
been made to tunnel that catheter from the left anterior thigh.

Next a retrograde cardioplegia coronary sinus catheter was placed and an
ascending aortic catheter for antegrade cardioplegia. An aortic crossclamp
was then applied. Initial induction cold blood high potassium cardioplegia
was delivered antegrade to the aortic root to achieve an asystolic arrest.
From that point forward, we maintained myocardial protection using continuous
retrograde. A transverse aortotomy was made above the sinotubular junction
and extended into the noncoronary sinus. The aortic valve was inspected. It
was a tricuspid aortic valve which was severely calcified. It was excised
and the annulus debrided off all calcium. We then sounded the LVOT and
annulus to 23 mm, and a 23 mm St. Jude Medical Trifecta pericardial valve was
implanted using a supraannular technique with interrupted nonpledgeted 2-0
Tycron sutures. The aortotomy was then closed with running 4-0 Prolene. A
hotshot was administered retrograde, the left heart de-aired, the crossclamp
removed, and a period of reperfusion allowed. The patient was subsequently
weaned from cardiopulmonary bypass with preserved right and left ventricular
function. Blake drains were placed in the right pleural space and
mediastinum. Temporary atrial and ventricular pacing leads were placed.
After confirmation of hemostasis and reversal of all heparin, the sternum was
reapproximated with interrupted heavy gauge wire. The pectoralis fascia,
subcutaneous tissues, and skin as well as the left groin incisions were
closed in layers with running absorbable sutures. The patient tolerated the
procedure well. Postoperative TEE confirmed a well-seated bioprosthesis in
the aortic position with no perivalvular leak and no gradient across it. The
patient was transferred to the CT-ICU in stable condition.