Wiki repair of type I aortic dissection help

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202
Location
Greer, SC
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Preoperative diagnosis:
#1. Acute type I aortic dissection
#2. Ischemic right leg with absent flow to right iliac artery by CTA
#3. Right renal ischemia-acute due to type I dissection
#4. Abdominal pain-possible malperfusion syndrome
#5. Hyperlipidemia
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Postoperative diagnosis:
Same
*would this be ?
33860
33866
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Operation:
#1. Emergency repair of type I aortic dissection
#2. Right axillary artery cannulation
#3. Replacement of ascending aorta from sinotubular junction with hemi-arch repair (26 mm Hemashield graft)
#4. Temporary cardiopulmonary bypass with moderate systemic hypothermia, cold sanguinous antegrade and retrograde cardioplegia, temporary lower body circulatory arrest (26 minutes), unilateral antegrade cerebral perfusion
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Preoperative note:
Patient is a 53 y.o. African-American male with acute type I aortic dissection now being taken the operating room for emergency operative therapy.
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Operative findings:
#1. TEE independent interpretation-pre bypass: The left ventricular function was normal. The right ventricular size and function was normal. There was trace central mitral valve insufficiency with normal mitral valve leaflets. Aortic valve was a tricuspid valve with minimal incompetence in the long or short axis views. There was an obvious flap in the proximal ascending aortia but it appeared that the sinuses of Valsalva were free of any intimal tear. The atrial septum was intact.
#2. TEE independent interpretation- post bypass: The aortic valve remained unchanged and there was no evidence of any residual flap and the aortic root.
#3. Operative findings: The pericardium was free of any free fluid or blood. There were hemorrhagic changes in the proximal ascending aorta extending up into the arch. On opening the ascending aorta the initial opening (entry point) appeared to be right at the sinotubular junction. Anteriorly the tear started roughly 4 mm distal to the opening of the right coronary artery. The sinuses of Valsalva were free of any tears. Distal able to back the torn intima circumferentially to the medial adventitial portion of the aortic arch without difficulty. There was no evidence of any clot in the false lumen. The right axillary artery was free of any evidence of dissection.
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Description of operation:
Patient was placed on the operating table in the supine position and adequate general anesthesia was administered monitoring the arterial pressure, bilateral cranial Somanetics, bilateral upper extremity oximetry, pulmonary artery pressure, bladder temperature, and electrocardiogram. A transesophageal echocardiographic probe was placed by anesthesia and findings are described above. The entire chest, abdomen, and legs were prepped in a sterile manner. An incision was made 2 fingerbreadths below and parallel to the right clavicle was deepened down through the soft tissues and the pectoralis major was divided in its fibers. The pectoralis minor muscle was preserved. The right axillary artery was dissected out and encircled proximally and distally with vessel loops and prepared for cannulation. A primary median sternotomy was performed and the pericardium was opened and heparin was administered. The pericardium was marsupialized and pursestring sutures were placed. Following satisfactory heparinization with ACT greater than 450 seconds, right axillary artery and right atrial cannulation were effected and cardiopulmonary bypass was established. Systemic perfusion temperature was dropped to 24°C for approximately 20 minutes. The aorta was crossclamped and cold sanguinous cardioplegia was administered via the aortic root and diastolic arrest promptly ensued. Further myocardial cooling was obtained using topical slush and retrograde cardioplegia. Cardioplegia was administered every 20 minutes throughout the procedure. The aortic root was prepared by removing all dissected tissue leaving normal tissue to subsequently perform the proximal graft anastomosis. After approximately 30 minutes of cooling the patient was placed in steep Trendelenburg position and the head was protected with cooling packs. The innominate artery was occluded and unilateral antegrade cerebral perfusion was initiated. The aortic cross-clamp was released and the ascending aorta was resected up into its junction with the aortic arch. A 26 mm Hemashield graft was selected and sewn in end-to-side manner (hemi-arch technique) to the aortic arch with running 4-0 Prolene in both internally and externally placed Teflon felt strips to reinforce the anastomosis. The total lower body circulatory arrest time was 26 minutes. There was no interruption in cerebral blood flow in the unilateral method. The Hemashield graft was occluded proximal to the arch anastomosis and flow was reestablished to the lower body and rewarming was carried out. The proximal graft was then tailored to appropriate length and angle and sewn in an end-to-end manner to the sinotubular junction running 4-0 Prolene and externally and internally placed Teflon felt strips. A needle vent was placed in the Hemashield graft and rewarming was continued. Volume was infused and the patient and air was evacuated from the left ventricle and ascending aortic graft. Bilateral cranial Somanetics readings were greater than 60 throughout the lower body arrest period. were normal with removal for Volume was infused into the patient and air was evacuated from the left side of the heart and vein graft. The aortic cross-clamp was released and the heart was defibrillated. Following satisfactory rewarming cardiopulmonary bypass was gradually discontinued until satisfactory ejection was occurring and aggressive de-airing maneuvers were carried out in the usual standardized manner under TEE surveillance. Following satisfactory de-airing maneuvers cardiopulmonary bypass was completely discontinued in a gradual manner satisfactory rhythm and hemodynamics ensued. Protamine was administered, decannulation was effected(the axillary artery was repaired with running 7-0 Prolene) and hemostasis was obtained. It did take approximately 1 hour to achieve satisfactory hemostasis. Ultimately this was achieved. Temporary pacemaker wires were placed as well as 3 chest tubes. With satisfactory rhythm, hemodynamics and hemostasis the chest was closed in layers. Sterile dressing was applied, sponge count was correct ×2, and the patient was taken to the CVRU in critical condition.
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