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churst21
08-26-2011, 10:19 AM
PROCEDURE PERFORMED:
1. Aortic coarctation repair with Palmaz 5010 balloon expandable stent.
2. Open exposure right common femoral artery.
3. Aortogram from left femoral artery access.

PROCEDURE IN DETAIL:
The patient was brought to the operating room and general endotracheal
anesthesia was induced by the anesthesia service. Radial art line and
right jugular vein central line were placed. Preoperative antibiotics had
been given. Bilateral groins, abdomen, chest and left arm were prepped and
draped in sterile fashion.

Oblique right groin incision was made. Dissection was carried deep to the
common femoral artery. The common femoral artery was dissected free and
encircled with the vessel loops proximally and distally. It was soft and
disease free at this level.

The right femoral artery was then accessed with an 18-gauge Cook needle and
Bentson wire passed into the abdominal aorta under direct fluoroscopic
visualization. A 5-French sheath was introduced. A glide catheter was
then introduced and used to cross the aortic coarctation without difficulty
over an angled glidewire to the ascending aorta. We placed glide catheter
in the ascending aorta, a wire exchange was performed for a Lunderquist
double curve wire which was advanced to the ascending aorta without
difficulty.

Percutaneous access was then achieved in the left common femoral artery
with an 18-gauge Cook needle and a Bentson wire advanced into the abdominal
aorta under fluoroscopic visualization. 5-French sheath was introduced. A
straight flush catheter was then introduced and a gradient was measured
across the aortic coarctation. This measured approximately 50 mmHg. A
steep LAO projection was obtained and the catheter was advanced to the
transverse arch. A thoracic aortogram was then performed. The aortic
coarctation was precisely identified.

A Mullins 12-French sheath was then introduced on the Lunderquist wire from
the right common femoral artery open access. This passed without
difficulty. This was advanced under fluoroscopic visualization past the
aortic coarctation.

A Palmaz 5010 stent was then mounted on a MaxiLD 14 x 60 mm balloon. This
was then introduced into the Mullins sheath without difficulty. The stent
was then placed in the right position across the aortic coarctation. The
Mullins sheath was then withdrawn. The balloon mounted Palmaz was then
inflated to approximately 4 atmospheric pressure. The proximal and distal
portions of the stent were flared with a 14 mm balloon.

The straight flush catheter had previously been withdrawn distal to the
coarctation. It was then reintroduced over a wire through the Palmaz stent
just proximal to the coarctation. An injection was performed which
demonstrated a mild residual stenosis at the site of the coarctation. A
gradient was measured which measured 10 mmHg.

A 14 mm balloon was then introduced and balloon angioplasty was performed
of the central portion of the Palmaz stent. Completion angiogram was
performed which demonstrated excellent reexpansion of the coarctation and
with repeat gradient measurement demonstrated no gradient across the
coarctation.

Glide catheter was reintroduced and the Lunderquist wire was withdrawn. A
Bentson wire was reintroduced and the Mullins sheath was withdrawn. There
were no significant blood pressure changes.

The wire was then removed and the right femoral artery with an access was
repaired primarily in a transverse arteriotomy fashion with a 6-0 Prolene
suture. This was flushed retrograde and prograde prior to completing the
suture line with good hemostasis of the suture line. 50 mg of protamine
were given. The right groin, incision was then inspected, there was
meticulous hemostasis throughout. The right groin was closed in layers
with 2-0 Vicryl suture, interrupted 3-0 Vicryl suture, and 4-0 subcuticular
Monocryl suture. The left femoral artery access was withdrawn and manual
compression applied for 20 minutes with good hemostasis. The patient
tolerated the procedure well. There was strong palpable 2+ pedal pulses at
the completion of this procedure. He was taken from the operating room to
recovery room in stable condition.