Thrombectomy

Can some one help me out with this.......

PREOPERATIVE DIAGNOSIS: Ischemic right lower extremity.

POSTOPERATIVE DIAGNOSIS: Ischemic right lower extremity.

PROCEDURE:

1. Redo right groin exploration.

2. Thrombectomy, revision of right ax-fem bypass graft.

3. Angiogram of the right subclavian artery and right ax-fem bypass graft.

4. Percutaneous transluminal angioplasty of the right ax-fem bypass graft

using a 7 mm x 150 mm balloon, completion angiogram.

5. Placement of a 7 mm x 15 cm Viabahn stent right proximal ax-fem bypass

graft.

6. Percutaneous transluminal angioplasty of the stent using a 7 mm x 150 mm

balloon, completion angiogram.

7. Thrombectomy of the right common femoral artery.

8. Thrombectomy of the right deep femoral artery.

9. Repair of right femoral artery aneurysm.

INDICATIONS: The patient is a 53-year-old man who presented to the hospital

with acutely ischemic right lower extremity. He had undergone already 15 to

20 revascularization procedures and previously undergone a left above the knee

amputation. He has been operated by multiple surgeons

He

has undergone multiple failed lower extremity bypass grafts. Just 3 weeks ago

on 01/14/2015, his graft occluded and he underwent redo thrombectomy as well

as angioplasty of the right ax-fem bypass graft. At that time, there appeared

to be a moderate amount of pseudointima, especially in the proximal aspect of

the ax-fem bypass graft. Benefits, risk of thrombectomy, possible angioplasty

and stent were discussed with the patient. Risks reviewed included pain,

bleeding, infection, permanent leg weakness, numbness, pain, distal

embolization which could lead amputation, infection of the graft, risk of

heart attack, allergic reaction, and death. The patient understood that there

is extremely high risk of rethrombosis in the future. He agreed to procedure.

DESCRIPTION OF PROCEDURE: Informed consent was obtained. The patient was

brought to the operating room and placed in supine position. Adequate

anesthesia was obtained using general endotracheal intubation. The patient's

prior right groin incision was opened up and dissection was carried down

through the subcutaneous tissue. Down to the right common femoral artery, of

note, there was a lot of scar tissue present making dissection difficult. I

was able to dissect out the distal aspect of the ax-fem bypass graft. This

was encircled with vessel loops. Because of the heavy scar tissue, I could

not dissect out the branches of the deep femoral artery and I did not want to

dissect deeper to injure these. The patient was given a bolus of heparin

10,000 units IV. Transverse graftotomy was made with 11 blade scalpel, #5

embolectomy catheter was first passed up the graft very distal. Half of the

graft cleaned up very nicely and thrombus was easily removed. There was some

difficulty passing #4 embolectomy catheter proximally and every time it will

pull down and there appeared to be a stenosis in the very proximal graft. An

11-French sheath was placed. Then, using a Glidewire and angled glide

catheter, I was able to pass both into the subclavian artery. Angiogram was

performed, which showed the proximal anastomosis was open. I then performed

balloon angioplasty of this proximal graft using a 7 mm x 150 mm balloon up to

8 atmospheres for 3 minutes. Over this area, I then placed a 7 mm x 15 cm

Viabahn stent. Balloon angioplasty was then performed of the Viabahn stent

using a 7 mm x 150 mm balloon again up to 8 atmospheres for 1 minute.

Completion angiogram showed excellent results of this proximal graft. There

was excellent brisk distal flow present. At this time, the graftotomy was

then closed using running 6-0 Prolene. The prior attention was then directed

to the right common femoral artery. This was aneurysmal in approximately a 3-

4 cm in dimension. The prior longitudinal incision was opened up and thrombus

was removed. During his last thrombectomy, there was good back bleeding from

one of the branches of the deep femoral artery. However, after removing all

the graft, there was no back flow from the deep femoral artery as well. I was

able to identify the branch to the deep femoral artery, which was in the

medial aspect. I passed #3 embolectomy catheter distally and removed short,

approximately 1-0.5 cm, segment of thrombus and there was excellent brisk

outflow after this. I passed the embolectomy catheter a few more times and

again good brisk outflow present. The balloon was then inserted and inflated

for to help with hemostasis. Because there appeared to be aneurysmal, I was

concerned that there may be thrombus forming on the walls of the terminal

aneurysm, which could either embolize distally early __________ for further

thrombosis. Therefore, I decided to trim up the medial, the lateral aspect of

the aneurysm, which appeared to have been patched previously with the bovine

patch, which was then trimmed up with 5-7 mm. The artery was then closed

using a 5-0 Prolene. Routine flushing maneuvers were carried out. There was

no thrombus present. No more small pieces of thrombus coming from the upper

graft. Wounds were irrigated out. Anastomosis was completed and secured.

Flow was then established distally. There was strong Doppler signals in the

distal graft. Wounds were then irrigated out. A #19 round Blake drain was

brought out and inferior aspect incision sewn in place with heavy nylon. The

subcu tissues closed in 2 layers of 2-0 Vicryl, followed by 3-0 Vicryl. Skin

was closed with 4-0 Vicryl. Benzoin, Steri-Strips were applied. Dressings

were applied. Estimated blood loss 350 cc. Sponge, needle, instrument counts

were correct at end of procedure. The patient had a very faint Doppler signal

in

posterior tibial artery. I could not hear signal in dorsalis pedis artery;

however, the foot was much pink and warmer. He was then sent to recovery in

stable condition.

Thrombectomy