DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Aortic pseudoaneurysm, proximal anastomosis, thrombosed aortobifemoral bypass graft.
POSTOPERATIVE DIAGNOSIS: Aortic pseudoaneurysm, proximal anastomosis, thrombosed aortobifemoral bypass graft.
OPERATIONS PERFORMED:
1. Repair of aortic pseudoaneurysm with Gore-Tex Excluder endograft.
2. Left subclavian cutdown and repair.
3. Intraoperative angiograms pre, during, and post procedure.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed on the operating table in the supine position. After adequate induction of anesthesia, the left shoulder was prepped and draped in a sterile fashion. The previous axillofemoral incision was opened using a 15 blade knife. Electrocautery was used to divide the subcutaneous tissue down to the fascia of the pectoralis major, which was divided. The plane between the two heads of the pectoralis major was developed, allowing for exposure of the subclavian artery deep in the wound. The origin of the axillofemoral graft was not identified. The artery was carefully dissected for a distance of 4 cm and was found to be soft and workable.
At this point, the patient was given 5000 units of heparin after control had been gained proximally and distally with vessel loops. The artery was then punctured with a needle, and a wire was advanced into the aortic arch. A 10 French sheath was then inserted and advanced into the subclavian artery. A pigtail catheter was then advanced over the wire and used to direct the wire distally down the descending aorta.
After this had been performed, the measuring pigtail catheter was advanced over the wire and advanced distally. It was positioned just above the anticipated level of the renal arteries. A flush aortogram was performed. The renal arteries were marked on the screen. Surrounding landmarks were also identified and confirmed, including postsurgical clips from his aortobifemoral bypass graft, which were numerous. The wire was then readvanced through the pigtail catheter and used to engage the origin of the right common iliac artery. It was noted to be heavily diseased on a previous angiogram, and the pigtail catheter was exchanged for an angled taper Glidecath, which was used to advance further out into the iliac system, allowing for further advance of the stiff Glidewire. The stiff Glidewire was then exchanged for a Lunderquist wire, which was positioned in the iliac system.
The pigtail catheter was removed at this point, leaving the wire in place. The 10 French sheath was then removed, and a transverse arteriotomy was made. The 18 French Gore sheath was then inserted over the Lunderquist and advanced. It would, however, not easily traverse the curve of the aortic arch, and in order to prevent damage to the aortic arch or subclavian artery, it was withdrawn. It was decided to go “bareback” with the device without sheath protection. The device was then inserted over the wire and advanced slowly through the subclavian artery into the arch and followed distally into the aorta. It was advanced distally. Landmarks were reidentified, and it was decided to land the device just distal to the origin of the renal arteries using a surgical clip as a marker. Unfortunately, the device would not advance out into the right iliac system in order to allow for safe deployment below the renal arteries.
The device was then slowly withdrawn, leaving the wire in place. An 8 mm balloon was then chosen. It was advanced over the wire and taken out across the Lunderquist into the origin of the right common iliac artery. It was inflated to 8 mm without difficulty. The balloon was then deflated and removed. The device was then reinserted over the wire and advanced into position. At this point, we did extend inferiorly enough to allow for deployment in the infrarenal location. It was positioned and confirmed by fluoroscopy and then deployed in the standard fashion. The wire was left in place. The deployment device was removed. A Coda balloon was then advanced over the Lunderquist wire and positioned at the proximal portion of the graft. It was inflated to profile in order to anchor the graft. It was then removed, and the pigtail catheter was advanced over the wire and positioned just above the origin of the graft.
The wire was removed, and a flush aortogram was performed. It demonstrated no filling of the pseudoaneurysm. The bilateral renal arteries were intact. There was sluggish filling of the graft with minimal filling of the iliac system. It was felt that this represented good exclusion of the pseudoaneurysm and may progress in the future to an essential aortic occlusion with the stent graft in place. This was felt to represent a good result. The pigtail catheter was removed over the wire. The wire was then slowly removed, placing a clamp on the proximal subclavian artery.
After removing all the devices, the subclavian artery was evaluated and was felt to be of suitable condition to allow for primary repair. This was done end-to-end using interrupted 6-0 Prolenes in an interrupted fashion. Prior to completion of this repair, the artery was forward and backbled and flushed with heparinized saline. The anastomosis was tied and completed. Flow was restored to the arm. Hemostasis was obtained using Surgicel. A 7 mm Jackson-Pratt was placed in the wound and secured to the skin. The fascia of the pectoralis major was closed using two separate running 3-0 Vicryls. The subcutaneous tissue was closed using 3-0 Vicryl, and the skin was closed using a subcuticular stitch of 4-0 Vicryl. A clean sterile dressing was applied, and the patient was transferred to the recovery room in stable condition, having tolerated the procedure well.
