conleyclan
Guru
Any suggestions would be greatly appreciated. Total arch repair..... Thanks ahead of time!
PREOPERATIVE DIAGNOSES:
1. Ruptured arch aneurysm.
2. Coronary artery disease.
POSTOPERATIVE DIAGNOSES:
1. Ruptured arch aneurysm.
2. Coronary artery disease.
PROCEDURE:
1. Total arch replacement with a 28-mm anteflow Vascutek graft.
2. Bypass of the left subclavian, left carotid, and innominate artery with
a 14 x 8 x 8 Spielvogel Vascutek graft, replacing the ascending aorta with
a 28-mm Vascutek graft, and resizing and repair of the aortic valve by
resizing a sinotubular junction with a 28-mm Gelweave graft.
3. Coronary bypass grafting x2 with reverse saphenous vein graft to the
LAD with a wide graft to the obtuse marginal.
CLINICAL NOTE: This is a male who presented with chest pain, hypertension,
had pericardial tamponade, and by CT scan it appears to rupture the distal
aspect of an artery aneurysm. He had an INR of 4, and I was able to
stabilize him for 12 hours to correct his INR, resuscitate him, and placed
him in a better position for a complicated aortic operation. By CT
scanning, he appeared to have proximal LAD and circumflex plaquing that
appeared flow-limiting on the angiogram. We thus planed for prophylactic
grafting of the left system. His operative findings did include a ruptured
distal arch aneurysm. The left subclavian was difficult to control, but we
were able to resect it. His pathology as before is whole arch replacement,
and replacement of the ascending aorta to the sinotubular junction. He had
some aortic insufficiency that improved at the sinotubular junction had
been resized. His EEG returned to baseline and his upper and SSEPs
returned to baseline. His lower extremity SSEPs were sluggish.
OPERATIVE NOTE: Once the patient was brought to operating suite, he was
prepped and draped in sterile fashion. Sternotomy was made with slight
extension to the right neck, pericardium was opened; blood was evacuated
from the pericardium as hemodynamics improved. His was heparinized. The
distal ascending aorta was cannulated using a Seldinger technique, a
20-French Edwards arterial cannula. A II stage venous cannula was placed
in the right atrium and cardiopulmonary bypass was initiated and the
patient was cool to electrical silence. During the period of cooling,
initially the innominate artery was isolated, divided, and sewn to 14-mm
Spielvogel graft, and this was perfused with antegrade perfusion monitoring
the pressure in the right radial artery. Then the similar technique was
used with the left carotid, which was stapled, divided, and revascularized
with an 8 mm Spielvogel limb. This was then brought online and perfused as
well. Then the cross clamp was applied. The ascending aorta was quite
ectatic. This was resected. The trileaflet valve was examined and felt to
be salvageable. We then resized it for approximately 28-mm and sewed a
20-mm Gelweave graft to the sinotubular junction, and this afforded better
coaptation of the aortic valve. Then the crossclamp was removed and a
period of body circulatory arrest was initiated while the head was perfused
with the antegrade cerebral cannula. The left subclavian was identified in
the aneurysm and revascularized with the remaining 8 mm limb. Then, we
proceeded to find the neck beyond the rupture and then sewed to this with a
28-mm anteflow graft using 3-0 Prolene suture. We then restarted the pump
at this time, the patient was rewarmed. The Vascutek Spielvogel graft was
then sewn to the anteflow graft to create a single inflow for the head and
the body. This was done with a 2-0 Prolene. We then turned our attention
to the ascending aorta in which the sinotubular graft was sewn to this
extension of the ascending aortic graft using 2-0 Prolene. Then, as we
continued to cool, we performed bypass graft to the distal third of the LAD
and a bypass graft to the obtuse marginal. Both these vessels looked quite
large and satisfactory. Then a Y graft was constructed with the circ vein
graft to the LAD vein graft using 7-0 Prolene and then a single proximal
anastomosis was performed at the aorta using ophthalmic cautery and 5-0
Prolene. After this had been completed, the crossclamp was removed, and
the patient was weaned from cardiopulmonary bypass, slowly over a period of
time once weaning criteria had been obtained. Factor VII products were
administered; and once hemostasis been achieved, chest was closed in
standard fashion. I was present for the entire duration of this operation.
PREOPERATIVE DIAGNOSES:
1. Ruptured arch aneurysm.
2. Coronary artery disease.
POSTOPERATIVE DIAGNOSES:
1. Ruptured arch aneurysm.
2. Coronary artery disease.
PROCEDURE:
1. Total arch replacement with a 28-mm anteflow Vascutek graft.
2. Bypass of the left subclavian, left carotid, and innominate artery with
a 14 x 8 x 8 Spielvogel Vascutek graft, replacing the ascending aorta with
a 28-mm Vascutek graft, and resizing and repair of the aortic valve by
resizing a sinotubular junction with a 28-mm Gelweave graft.
3. Coronary bypass grafting x2 with reverse saphenous vein graft to the
LAD with a wide graft to the obtuse marginal.
CLINICAL NOTE: This is a male who presented with chest pain, hypertension,
had pericardial tamponade, and by CT scan it appears to rupture the distal
aspect of an artery aneurysm. He had an INR of 4, and I was able to
stabilize him for 12 hours to correct his INR, resuscitate him, and placed
him in a better position for a complicated aortic operation. By CT
scanning, he appeared to have proximal LAD and circumflex plaquing that
appeared flow-limiting on the angiogram. We thus planed for prophylactic
grafting of the left system. His operative findings did include a ruptured
distal arch aneurysm. The left subclavian was difficult to control, but we
were able to resect it. His pathology as before is whole arch replacement,
and replacement of the ascending aorta to the sinotubular junction. He had
some aortic insufficiency that improved at the sinotubular junction had
been resized. His EEG returned to baseline and his upper and SSEPs
returned to baseline. His lower extremity SSEPs were sluggish.
OPERATIVE NOTE: Once the patient was brought to operating suite, he was
prepped and draped in sterile fashion. Sternotomy was made with slight
extension to the right neck, pericardium was opened; blood was evacuated
from the pericardium as hemodynamics improved. His was heparinized. The
distal ascending aorta was cannulated using a Seldinger technique, a
20-French Edwards arterial cannula. A II stage venous cannula was placed
in the right atrium and cardiopulmonary bypass was initiated and the
patient was cool to electrical silence. During the period of cooling,
initially the innominate artery was isolated, divided, and sewn to 14-mm
Spielvogel graft, and this was perfused with antegrade perfusion monitoring
the pressure in the right radial artery. Then the similar technique was
used with the left carotid, which was stapled, divided, and revascularized
with an 8 mm Spielvogel limb. This was then brought online and perfused as
well. Then the cross clamp was applied. The ascending aorta was quite
ectatic. This was resected. The trileaflet valve was examined and felt to
be salvageable. We then resized it for approximately 28-mm and sewed a
20-mm Gelweave graft to the sinotubular junction, and this afforded better
coaptation of the aortic valve. Then the crossclamp was removed and a
period of body circulatory arrest was initiated while the head was perfused
with the antegrade cerebral cannula. The left subclavian was identified in
the aneurysm and revascularized with the remaining 8 mm limb. Then, we
proceeded to find the neck beyond the rupture and then sewed to this with a
28-mm anteflow graft using 3-0 Prolene suture. We then restarted the pump
at this time, the patient was rewarmed. The Vascutek Spielvogel graft was
then sewn to the anteflow graft to create a single inflow for the head and
the body. This was done with a 2-0 Prolene. We then turned our attention
to the ascending aorta in which the sinotubular graft was sewn to this
extension of the ascending aortic graft using 2-0 Prolene. Then, as we
continued to cool, we performed bypass graft to the distal third of the LAD
and a bypass graft to the obtuse marginal. Both these vessels looked quite
large and satisfactory. Then a Y graft was constructed with the circ vein
graft to the LAD vein graft using 7-0 Prolene and then a single proximal
anastomosis was performed at the aorta using ophthalmic cautery and 5-0
Prolene. After this had been completed, the crossclamp was removed, and
the patient was weaned from cardiopulmonary bypass, slowly over a period of
time once weaning criteria had been obtained. Factor VII products were
administered; and once hemostasis been achieved, chest was closed in
standard fashion. I was present for the entire duration of this operation.