Aneurysm - Help!!! - Thanks

Aortic fenestration with Bare-metal Stenting/Stenting for pseudocoarctation.

Is this anywhere close to code 34842. I have not done this before.

Thanks

PREOPERATIVE DIAGNOSES: Renal insufficiency, right renal arterial inflow

obstruction, abdominal pseudocoarctation, chronic aneurysmal type B aortic

dissection.

POSTOPERATIVE DIAGNOSES: Renal insufficiency, right renal arterial inflow

obstruction, abdominal pseudocoarctation, chronic aneurysmal type B aortic

dissection.

PROCEDURES PERFORMED: Thoracic endovascular aortic repair (Cook Zenith TX2

stent grafts-- 32 mm x 200 mm, 34 mm x 77 mm, 40 mm x 81 mm), abdominal

aortic fenestration with bare-metal stenting (Palmaz 39 mm stent dilated to

33 mm caliber), infrarenal abdominal aortic stenting for pseudocoarctation

(Palmaz 49 mm length stent dilated to 24 mm in diameter), thoracic

aortogram with radiologic supervision and interpretation, intravascular

ultrasound with radiologic supervision and interpretation, right common

femoral arterial cutdown with primary repair, general endotracheal

anesthesia.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite,

placed supine, induced with general endotracheal anesthesia. The abdomen

and groins were prepped and draped in usual sterile fashion. The 2 cm

oblique incision was made above the right inguinal crease and the right

common femoral artery was circumferentially dissected out for proximal and

distal control. The patient was heparinized to an ACT over 300 seconds and

then 18-gauge needle introduced in the right common femoral artery under

direct vision. The guidewire was advanced under fluoroscopic guidance

throughout the thoracoabdominal aorta and positioned in the aortic arch.

Again, exchanged that guidewire, which was a Glidewire for a pigtail

catheter and then exchanged the pigtail catheter for a Lunderquist Super

Stiff guidewire over which an intravascular ultrasound was performed and we

confirmed that we were within the true lumen from the right common femoral

artery up through the iliac artery, abdominal aorta and in thoracic aorta.

We were able to get this guidewire all through the true lumen, despite the

very tight pseudocoarctation at the level of the infrarenal abdominal

aorta. I then exchanged the Lunderquist Super Stiff guidewire for a

pigtail catheter, positioning its tip in the aortic arch and then performed

a thoracic aortogram to create a road map of the distal arch and right

subclavian artery in particular. We then exchanged the pigtail catheter

for a Lunderquist Super Stiff guidewire over which a 32 mm x 200 mm Cook

TX2 stent graft was advanced in its proximal aspect positioned right at the

distal edge of the left subclavian ostium. At this point, using the

aortogram as a road map, we then slowly deployed the TX2 stent graft with a

very precisely ending at the distal aspect of the ostium of the left

subclavian artery. It was fully deployed and then a Gore trilobed balloon

was advanced through the Cook sheath and we ballooned the proximal landing

site with a 40 mL Tri-Lobe balloon getting excellent apposition. Next, 2

additional modules of stent grafts were placed, first a 34 mm x 77 mm

distal extension Cook TX2 was advanced and placed with a single V-stent

overlap of the first module, it was deployed and then a third module 40 mm

x 81 mm distal extension was placed again with one Z-stent overlap relative

to the second module. After all 3 modules were placed, we then used a 40

mL colored balloon to balloon the overlapping modules and a Gore trilobed

40 mL balloon for dilatation of the distal most touchdown site. Then an

intravascular ultrasound was performed and with the IVUS, we confirmed that

there was still poor inflow to the false lumen at the superior mesenteric

and right renal arterial level and therefore, I planned to perform a

controlled fenestration at this level. This was done by placing a 39 mm

length, 10 mm BRAT Palmaz stent on top of a 33 mm x 4 cm Z-Med balloon.

The Palmaz was crimped down on top of the balloon and then a 20-French

Medtronic sheath was exchanged for the Cook sheath, being a shorter length

sheath. Through the Medtronic sheath, we then advanced the Palmaz stent

loaded on the 33 mm Z-Med balloon and positioned it right at the chronic

secondary tear just at the distal aspect of the final Cook TX2 module. I

then balloon dilated the secondary care to create a larger fenestration

with the Palmaz stent dilating the stent to the 33 mm caliber. This opened

up the inflow into the false lumen very well and a mesenteric aortogram was

then performed using a half strength contrast and this demonstrated widely

patent inflow to the right renal artery and the objective of improving

arterial inflow to the right renal artery was achieved. Next, we proceeded

to address the infrarenal abdominal pseudocoarctation, a 49 mm length Palmaz

stent (size 10 mm) was loaded on to a 24 mm x 4 cm Z-Med balloon, it was

crimped down on to the balloon and then the balloon with loaded Palmaz stent

was advanced into this segment of pseudocoarctation, which had been defined by

the previous aortogram. With the stent in place, we then balloon dilated the

pseudocoarctation up to 24 mm and got excellent result. A completion

arteriogram was performed, which demonstrated wide patency of the infrarenal

abdominal aorta with this Palmaz stent in place. At this point, the Medtronic

sheath was removed. Proximal and distal clamps were placed and the right

common femoral artery was repaired with running 6-0 Prolene suture. The

heparin was reversed with IV protamine and meticulous hemostasis confirmed in

the groin incision closed in layers with running absorbable sutures. The

patient tolerated the procedure well and the patient was transferred to the

CTICU in stable condition. Of note, I monitored the patient with continuous

EEG and SSEP and MEPs throughout the case and there were no changes in his

signals.

Aneurysm - Help!!! - Thanks