PROCEDURES PERFORMED:

1.  Left heart catheterization.
2.  Selective coronary arteriography.
3.  Left ventriculography.
4.  Saphenous vein graft arteriography.
5.  Right internal mammary artery arteriotomy.
6.  PTCA and stent to the right coronary artery.

INDICATIONS FOR PROCEDURE:

1.  Unstable angina.
2.  Coronary artery disease.

The patient is a (XX)-year-old female with known coronary artery disease who presented to the cardiology clinic with complaints of increasing intensity and frequency of chest pain. The patient is status post coronary artery bypass grafting in the past. Secondary to this, the patient was referred for left heart catheterization.

PROCEDURE IN DETAIL:  After informed consent was obtained, the patient was brought to the cardiac catheterization laboratory and prepped and draped in usual sterile fashion for left heart catheterization and other procedures mentioned above. The right femoral artery was anesthetized and accessed via the Seldinger technique. Catheters used for the procedure were Judkins left #4, Judkins right #4, pigtail catheter and a Judkins right #4 guide catheter.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  Less than 10 mL.

HEMODYNAMICS:  The patient’s aortic pressure was 130/70 with left ventricular pressure of 130/5 and left ventricular end diastolic pressure of 20. There was no gradient upon pullback of the pigtail catheter.

CORONARY ARTERIES:

1.  Left main coronary artery is angiographically normal.
2.  Left anterior descending was a small sized vessel. The left anterior descending had mild to moderate luminal irregularities, but no significant stenosis. There was distal thinning and a 40% stenosis noted in the distal left anterior descending. The first diagonal branch did have a subtotal occlusion. The distal portion of the first diagonal branch was filling with competitive flow.
3.  Left circumflex was a small vessel and was noted to have a 60% proximal stenosis and a 70% to 80% mid/distal stenosis. This was a very small vessel and 2 mm in diameter. There was a second obtuse marginal branch, which was 100% occluded.
4.  Right coronary artery dominant with stents noted in the ostial and proximal portion. There was an ostial 90% to 95% stenosis noted within the stents. There was no competitive flow noted in the distal vessel.

Saphenous vein graft to the first diagonal branch and then skipped to the second obtuse marginal branch was injected. The ostium body and touchdown site of the graft was free of significant disease. There was mild to moderate luminal irregularities noted in the diagonal branch itself. There was a mid 40% to 50% stenosis in the diagonal branch after the touchdown site. There were mild luminal irregularities noted in the second obtuse marginal branch itself.

Right internal mammary artery was injected. The ostium body and touchdown site of the right internal mammary artery to the distal posterior descending artery was intact. There was very faint backfilling of the posterolateral branch. There was a lot of competitive flow noted from the native vessel. There was no significant disease noted in the posterior descending artery.

Left ventriculogram was performed in the RAO projection, which showed normal left ventricular systolic function with ejection fraction 60%. There were no wall motion abnormalities. There was no gradient upon pullback of pigtail catheter. There was no noted mitral regurgitation.

After diagnostic cardiac catheterization was performed, the 5 French sheath was exchanged for a 6 French sheath. Heparin and Integrilin were given. We decided to go after the right coronary lesion. We did not feel like the right internal mammary artery was giving sufficient flow to the large dominant right coronary artery. Secondary to this, we used a Judkins right #4 guide catheter to insert into the ostium of the right coronary artery. Guide shots were obtained, which confirmed the 95% stenosis in the ostial right coronary artery which was in-stent. We used a BMW wire to cross the lesion. Predilation was done with a Monorail Maverick 3.0 x 9 mm balloon. This was taken up to 20 atmospheres for 15 seconds. This resulted in 40% residual stenosis in that area. We then stented using a Cypher 3.5 x 18 mm drug-eluting stent in the ostial and proximal portion of the right coronary artery. This was taken up to 25 atmospheres for 15 seconds. We then postdilated at the ostium with a 3.75 x 8 mm Quantum balloon taken up to 20 atmospheres for 15 seconds. This resulted in 0% residual stenosis. There was good flaring of the ostium of the right coronary artery. There was good flow noted in the right coronary artery and no residual stenosis noted.

IMPRESSION:

1.  Severe three-vessel coronary artery disease.
2.  Small left circumflex with significant stenosis noted in the mid/distal portion. This was a small vessel at that area.
3.  Patent saphenous vein graft to the first diagonal and skip to the second obtuse marginal branch.
4.  Patent right internal mammary artery to distal posterior descending artery. This was a small vessel. No good backfills of the posterolateral branch.
5.  Normalleft ventricular systolic function.
6.  Elevated left ventricular end diastolic pressure likely secondary to hypertensive heart disease.
7.  Successful angioplasty and stenting of the ostial/proximal dominant right coronary artery with the Cypher drug-eluting stent resulting in 0% residual stenosis.

PLAN:  The patient will continue on Integrilin overnight and will continue on aspirin and Plavix. We will load her on Plavix today and continue her on 75 mg daily. The patient needs aggressive medical management. The patient will follow up in cardiology clinic in 1 to 2 weeks for further evaluation and treatment.

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DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Abdominal aortic aneurysm.

POSTOPERATIVE DIAGNOSIS:  Abdominal aortic aneurysm.

OPERATION PERFORMED:  Endovascular stent graft repair of infrarenal abdominal aortic aneurysm.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General endotracheal.

COMPLICATIONS:  None.

DRAINS:  None.

INDICATIONS FOR OPERATION: This is a (XX)-year-old Hispanic male with a past medical history significant for hypertension, high cholesterol and diabetes, who was incidentally found to have an aneurysm in his abdomen while he was getting an MRI of his back. His aneurysm was noted to be 6.2 cm in diameter. It was infrarenal in location, and he was felt to be a good candidate for endovascular stent graft closure.

DESCRIPTION OF OPERATION:  The patient was identified and placed on the operating table in the supine position. General endotracheal anesthesia was induced. The chest and lower extremities were prepped and draped in the normal sterile fashion. The patient was given IV antibiotics prior to start of the case.

Standard groin incisions were made bilaterally, and the common femoral arteries were identified and dissected free from the surrounding tissues bilaterally. The common femoral arteries on both sides had dense calcification and had evidence of severe disease. We isolated these up as high as we could and isolated the areas that we felt would be good for administration of the stent graft. It was obvious that the patient had diffuse peripheral vascular disease. We heparinized the patient with 5000 units of heparin and then passed guidewires up both groins under fluoroscopic guidance and passed a pigtail catheter up into the aorta and shot an angiogram and noted the level of the takeoff of the renal arteries.

We then passed the main body of the device up the left groin and located this just below the level of the takeoff of the renal arteries and deployed the graft just below the level of the renal arteries and got good fixation below the renal arteries. We then shot another angiogram, marked the level of the takeoff at the internal and external iliacs and passed a left iliac extension up through the groin and cannulated the opposite and passed the long iliac extension up through graft and deployed this just above the takeoff of the external and internal iliac arteries.

Once this was deployed, we then shot another angiogram and noted the takeoff of the right internal and external iliac and deployed a short extension down off of here. Once we had all of our extension and they had good landings above the iliacs and below the renal arteries, we then ballooned the areas and opened up all the stents in the overlapping areas and all their proximal and distal landing zones. Once it was done, we had great fixation of the graft. We then shot an angiogram and noted that we had excluded the aneurysm. There was no evidence of any leakage and no endoleaks, and we had excellent repair.

When we were sure everything was going well, we then removed our devices from both groins, and we closed both arteries using running 5-0 Prolene stitches and closed the transverse arteriotomies using running 5-0 Prolene stitches. Once we had these closed, we then checked Doppler flow. In both groins, we had excellent dopplerable flow, and we had excellent dopplerable flow in the posterior tibial arteries bilaterally. The patient has severe disease as stated earlier, but we did have excellent pulses at the end of the case. We checked the suture lines again. When we were sure there was no bleeding and we had excellent dopplerable flow, we then reversed the heparin with protamine.

We then held pressure for several minutes. When we were sure that there was no bleeding, we then injected Marcaine in the wounds and closed the wounds in three layers using absorbable stitches. The wounds were cleaned and dried, and sterile bandages were placed. All needle, sponge, and instrument counts were correct at the end of the case. The patient tolerated the procedure well, was extubated, and will be taken to the recovery room in stable condition. We will follow his pulses closely postoperatively. The patient tolerated the procedure well.

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PREOPERATIVE DIAGNOSES:
1.  Myxomatous mitral valve, Barlow valve with type II P2, with severe insufficiency.
2.  Atrial septal defect.

OPERATION PERFORMED:
1.  Intraoperative transesophageal echocardiogram interpretation.
2.  Mitral valve repair with resection of P2 with posterior leaflet reconstruction utilizing sliding valvuloplasty and reduction annuloplasty and valve repair, 36 mm McCarthy myxomatous annuloplasty ring placement.
3.  Closure of atrial septal defect, primary closure.

SURGEON:  John Doe, MD

FIRST ASSISTANT:  Jane Doe, PA-C

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old male with the above-mentioned problems. He had progressive mitral insufficiency with known history of floppy valve syndrome. The patient now presents, at this time, after being seen in the office. He consented to the procedure as planned with a plan to repair his valve.

DESCRIPTION OF OPERATION:  The patient was brought in to the operating room and placed in the supine position. After general endotracheal anesthesia, he was prepped and draped in the usual fashion. Intraoperative transesophageal echo revealed billowing anterior and posterior leaflets. The rest of the examination was unremarkable. The aortic valve appeared to be normal. Left ventricular function was okay. The patient did have an atrial septal defect approximately 1 cm in size. It appeared to be intermittent; therefore, we suspected there was a flap over this as well. There was no evidence of any type of ventricular septal defect.

The patient was heparinized and cannulated in the usual fashion and then placed on cardiopulmonary bypass. The aorta was cross-clamped. Antegrade as well as retrograde cardioplegia arrest was obtained. The patient was also cooled systemically.

Attention was directed to the left atrium once it was opened in the conventional fashion. Retraction was placed, and valvular analysis was performed. The posterior leaflet was actually of four scallops. We cut off the middle two scallops. These were all redundant and prolapsed. This left this with quite a large deficit. We were able to take the P1 and P3 posterior leaflets off of the annulus and advance these using annular reduction sutures as well.

Once this was done, we reconstructed the posterior leaflet. It actually came together quite nicely with little to no tension present. The anterior leaflet appeared intact. At that point, we elected to use one of the newer rings, a McCarthy myxomatous valve ring, as this increased the anterior-to-posterior dimension with a decreased medial-to-lateral dimension. We used a 36 and sewed this in with horizontal mattress sutures. This seated nicely and demonstrated actually good coaptation of anterior and posterior leaflets. At that point, the left atrium was closed in two layers with 4-0 chromic suture.

At this point, the cross-clamp was removed. This patient was allowed to reperfuse while we were repairing his atrial septal defect. We did this in as primary closure with a running 4-0 chromic in two layers. At that point, the atrium was closed in a running two layer closure as well. At this point, the patient reperfused for some time and came off bypass uneventfully.

Postoperative echocardiogram revealed good functioning of the mitral valve with good coaptation of anterior and posterior leaflet. No evidence of insufficiency. The atrial septal defect at this point was now gone and totally closed. There were no abnormalities visualized.

Protamine was given to reverse heparinization. Two ventricular and one right atrial pacing wire were placed. One mediastinal and one left pleural chest tube was placed. The chest was closed in routine fashion, and the patient was transported to CVICU and postoperative room in stable condition.

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DATE OF DISCHARGE: MM/DD/YYYY

DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Bivalvular heart disease.

BRIEF HISTORY: The patient is a (XX)-year-old gentleman who had a significant aortic stenosis as well as mitral regurgitation and coronary artery disease. In view of multivalvular problems and coronary artery disease, Dr. John Doe recommended proceeding with surgical replacement of his aortic valve with concomitant mitral valve repair as well as surgical myocardial revascularization. For this reason, he was admitted.

PAST MEDICAL HISTORY:
1. Valvular heart disease.
a. Mitral regurgitation.
b. Aortic insufficiency.
2. Coronary artery disease.
3. Dilated ascending aorta, 4.3 cm.
4. History of prostate cancer with radiation seed implantation approximately 12 years ago.
5. Peptic ulcer disease.
6. Partial gastrectomy secondary to a benign tumor.
7. History of nephrolithiasis.

HOSPITAL COURSE: Following admission, the patient underwent a presurgical and preanesthetic evaluation for valvular heart disease. He was taken to the operating room one month ago. At that time, a coronary artery bypass graft operation x1 was performed. The left internal mammary artery was utilized to bypass the left anterior descending artery. The aortic valve was replaced with a #23 mm supraannular pericardial valve. Dr. John Doe did not feel that his mitral valve was a repairable valve as this was a type II P1 valve, but it was heavily calcified posteriorly, and thus the valve was replaced with a #33 mm porcine valve. The left atrial appendage was also ligated.

Postoperatively, he was taken to the CVICU in stable condition and no inotropic support. By the first postoperative morning, he was weaned from mechanical ventilation and extubated without any difficulty. He did require a short postoperative course of atrial pacing secondary to a junctional rhythm, but this did resolve.

At about the second postoperative day, we were able to remove his pacing wires and chest tubes. Unfortunately, during the postoperative course, he did have a thrombocytopenia and was found to be positive for a heparin antibody. Argatroban was initiated following hematology consultation. The patient also had some altered mental status. This was thought to be secondary to sedation as once this was held, he seemed to improve.

On about the postoperative day #4, he developed a hypotensive episode, which responded immediately to fluid. We did obtain an echocardiogram, and both aortic and mitral valve bioprostheses were functioning appropriately. There was no evidence of any cardiac tamponade. After a slightly prolonged hospitalization, secondary to the requirement of being appropriately anticoagulated as well as requiring aggressive physical therapy and pulmonary care, he was eventually discharged.

DISCHARGE CONDITION: Good.

DISCHARGE INSTRUCTIONS: The patient was appropriately instructed regarding wound care. He is not to lift any heavy objects of over 5 pounds or drive a car for the next month, to resume an American Heart Association Diet. The patient is to see Dr. Jane Doe in 2 weeks. Dr. John Doe will follow him up in 2 weeks as well. He will take amoxicillin, Plendil, and Coumadin. The patient is to call our office regarding increased chest pain, shortness of breath, fevers.

PROCEDURE PERFORMED: Mitral valve replacement, aortic valve replacement, and coronary artery bypass graft operation x1.

COMPLICATIONS: Postoperative heparin-induced thrombocytopenia.

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INDICATION FOR STUDY:  Shortness of breath on exertion, which might indicate anginal equivalent, history of hypertension, and hyperlipidemia.

PROCEDURE:  After informed consent was obtained, a baseline EKG was obtained that demonstrated normal sinus rhythm with one premature atrial contraction. The patient had a baseline blood pressure of 142/80 mmHg and a baseline heart rate of 66 bpm. The patient was given 11 mCi of 99mTc Cardiolite IV at rest, and after an appropriate delay resting, SPECT images were obtained.

The patient was then exercised for 11 minutes 54 seconds using the Bruce protocol. The test was terminated due to maximum effort and fatigue. One minute prior to terminating the exercise portion, the patient was injected with 30 mCi of 99mTc Cardiolite.

FINDINGS:  The patient achieved a maximum heart rate of 152 bpm, which was 87% of the maximum heart rate, and a blood pressure of 176/90 mmHg. A maximum of 1.7 mm of ST depression with a negative slope was observed. However, this was seen only in lead V3 and lasted only about 10 seconds. During the exercise portion, the patient experienced no angina, shortness of breath, dizziness or ventricular ectopy.

CONCLUSION:  Equivocal electrocardiographic evidence for significant ischemia was observed. Exercise tolerance was excellent. Blood pressure response to exercise was normal. The patient had Duke treadmill score of 3, which indicates 1% annual cardiovascular mortality and an a five-year survival rate of 93%.

Nuclear Stress Test Sample # 2

DATE OF STUDY:  MM/DD/YYYY

INDICATION FOR STUDY:  Edema, hypertension, and abnormal EKG in a patient scheduled for preoperative evaluation for right hip surgery.

PROCEDURE:  After informed consent was obtained, a baseline EKG was obtained that demonstrated T inversions in V1 and V2. The patient had a baseline blood pressure of 128/80 mmHg and a baseline heart rate of 78 bpm. The patient was given 11 mCi of 99mTc Cardiolite IV at rest, and after an appropriate delay resting, SPECT images were obtained. The patient was not a candidate for treadmill testing due to arthritis in both hips with inability to walk on the treadmill. The patient was given 54.7 mg adenosine IV over 4 minutes. After 2 minutes of adenosine infusion, the patient was given 30 mCi of 99mTc Cardiolite.

FINDINGS:  The patient achieved a maximum heart rate of 106 bpm, which was 62% of maximum heart rate and a blood pressure of 150/86 mmHg. A maximum of 0.2 mm of ST depression with a positive slope was observed. During the exercise portion, the patient experienced no angina, shortness of breath, dizziness or ventricular ectopy.

CONCLUSION:  Negative electrocardiographic evidence for significant ischemia was observed. Blood pressure response to exercise was hypertensive.

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PROCEDURES PERFORMED:
1.  Left heart catheterization.
2.  Selective coronary angiography.
3.  Left ventriculography.
4.  Complex PCI of the diagonal/LAD vessels.
5.  Intracoronary nitroglycerin use.

SURGEON:  John Doe, MD

INDICATIONS FOR PROCEDURE:  Acute lateral ST elevation myocardial infarction.

DESCRIPTION OF PROCEDURE:  The patient was transferred with complaints of five hours of chest pain. The patient was preloaded with Plavix 600 mg. The right groin was prepped and draped in normal sterile fashion after obtaining informed consent. The right groin was injected with lidocaine. A 6-French sheath was initially placed after obtaining access via Seldinger technique. The sheath was flushed with heparinized solution. Initial AO pressures were obtained. A pigtail catheter was then taken to LV and LVEDP measurements were obtained. The left ventriculogram was performed in a standard RAO view. Then, a JR catheter was used to engage the right coronary ostia and to image the right coronary system in multiple views. Then, JL catheter was used to engage the left main coronary ostium, and the left coronary artery was imaged in multiple views. Then, we proceed with PCI of the second diagonal branch as well as the mid LAD after the diagonal branch.

HEMODYNAMIC FINDINGS:  LVEDP was 12 with no pullback gradients.

ANGIOGRAPHIC FINDINGS:  The left ventriculogram performed showed preserved LV systolic function with lateral and mild anterior wall hypokinesis. The left main was angiographically patent. The LAD had 60% lesion right after the second diagonal branch. The first diagonal had minor intraluminal irregularities. The second diagonal was occluded proximally with evidence of thrombus. The left circumflex was a codominant vessel. There was a small, tiny ramus intermedius branch. The obtuse marginal branch had proximal 50% lesion. The LAD, after the second diagonal, had mild diffuse disease and distal intraluminal irregularities. The RCA was also a codominant vessel. There was a mid 50% lesion right after the RV marginal branch.

COMPLEX PCI OF THE SECOND DIAGONAL/LAD ARTERIES:  The 6-French sheath was exchanged to an 8-French introducer sheath. XBLAD 8-French guiding catheter was used to engage the left main. Heparin was already running, and ACT was optimal for intervention. Integrilin was used for antiplatelet therapy. The patient was already loaded with 600 mg of Plavix. A Luge wire was then used to cross the second diagonal lesion and then BMW wire was used to place in the LAD to protect. Then, a 2.0 x 8 mm Voyager balloon was used to dilate the proximal and the mid diagonal vessel. The vessel was about 2 mm in size, and the mid lesion was dilated several times to 9 atmospheres but with still 10% residual stenosis. The second diagonal branch; the vessel has a hole, was not a large vessel to which a stent could be placed. Just distal to the second diagonal, the LAD had an ulcerated 60-65% lesion. This lesion was then primarily stented with a Taxus 3.0 x 12 mm drug-eluting stent. This resulted in 0% residual stenosis of the LAD lesion and no compromise of the ostium of the second diagonal branch. Multiple images obtained revealed TIMI III flow, no evidence of thrombus or dissection.

IMPRESSION:
1.  Successful PCI with Plano balloon angioplasty.
2.  The second diagonal branch was below the 2.0 mm vessel.
3.  Successful PCI with one Taxus drug-eluting stent, primarily to the LAD.
4.  Moderate obtuse marginal 1 and RCA disease to be managed medically.
5.  Preserved LV systolic function with borderline LVEDP.

RECOMMENDATIONS:
1.  Aspirin and Plavix.
2.  Aggressive risk factor modification.
3.  Aggressive diabetes control.
4.  The patient is to follow up with us. The patient will be instructed to call the office and make an appointment.
5.  The patient will be arranged for cardiac rehabilitation thereafter.

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PREOPERATIVE DIAGNOSIS:  Severe sternal infection.

POSTOPERATIVE DIAGNOSIS:  Severe sternal infection.

PROCEDURE PERFORMED:  Sternal debridement and sternal wound debridement.

SURGEON:  John Doe, MD

CO-SURGEON:  Jane Doe, MD

ANESTHESIA:  General endotracheal.

COMPLICATIONS:  None.

INDICATIONS FOR PROCEDURE:  This is a (XX)-year-old African-American female with a complex past medical history, including morbid obesity, pulmonary hypertension, and sleep apnea, who is status post ascending aorta replacement, aortic valve replacement, and two-vessel bypass surgery done last year, who presented to an outside hospital with overwhelming sepsis and evidence of sternal wound infection. The patient has gone back to the operating room for several debridements and now appears to have good granulation tissue in her wound and appears to be stable for wound closure and flap closure. We will plan on taking her back to the operating room and consult with Plastic Surgery to close the wound with rectus and pectoral flap.

DESCRIPTION OF PROCEDURE:  The patient was identified and placed on the operating room table in the supine position. General endotracheal anesthesia was induced. The chest, lower extremities, and abdomen were prepped and draped in the normal sterile fashion. The patient was given IV antibiotics prior to start of the case.

We opened up the previously placed sternal wound and simultaneously Dr. Jane Doe from Plastic Surgery began mobilizing the rectus flap for his flap procedure. We opened up the wound. We debrided the rest of the left side of the sternum and completed the sternectomy. We then removed any other tissue that appeared to be necrotic. The patient’s wound overall was granulating very well. There was no evidence of any residual infection at this time. We checked for any other draining fluid. There was none.

When we were sure everything was going well, we then packed the wound, and we will now allow Plastic Surgery to complete the flap closure at this time. We did send off the tissue for culture as well as sensitivities. The wound was pulsavac’d with 3 liters of sterile saline solution and suctioned until clear. The plastic surgeons will complete the procedure at this point.

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PROCEDURES PERFORMED:
1.  IV sedation.
2.  Fluoroscopically guided implantation of right atrial and right ventricular leads.
3.  Implantation of dual chamber defibrillator.
4.  Interrogation and programming of defibrillator.

INDICATIONS AND HISTORY:  This is a (XX)-year-old female with severe nonischemic cardiomyopathy with ejection fraction less than 20% and episode of complete heart block in the hospital, which required resuscitation and intubation. Therefore, the patient has indication both for dual chamber pacing and defibrillator for prevention of sudden cardiac death.

CONSENT:  The risks, benefits, and alternatives of the procedure were explained to the patient. All of the patient’s questions were answered, and she understood and signed informed consent.

DESCRIPTION OF PROCEDURE:  The patient was brought to the electrophysiology lab in a fasting nonsedated state. IV sedation was provided with IV Versed and fentanyl. Prophylactic antibiotic was given. The chest was prepped and draped in the usual sterile fashion. After injection of 2% lidocaine in the left pectoral area, an incision was made and extended to pectoralis fascia using electrocautery and blunt dissection and a pocket was created. Using the previous roadmap from earlier this week, access to the right subclavian vein was achieved in two separate locations. Right ventricular lead was advanced under fluoroscopy to the right ventricular apex. This is a lead, model (XX), serial number (XX). R-waves measured more than 12.5, impedance was 452, and threshold was 0.75. The right atrial lead was advanced into the right atrial appendage. This is a Tendril, model (XX), serial number (XX). This was advanced under fluoroscopy through the right atrial appendage and P waves measured 2.4 to 3, impedance 462, and threshold 0.75. Leads were sutured to the muscle. There was no diaphragmatic stimulation. The leads were connected to the device, which was an Atlas DR, serial number (XX). Leads and device were inserted into the pocket and sutured to the muscle, and the pocket was vigorously irrigated with antibiotic solution. The pocket was then closed in two separate subcutaneous layers using 3-0 Vicryl and subcuticular layer using 4-0 Vicryl. The skin was covered with Steri-Strips and pressure dressing. Before the pocket was closed, a high voltage lead impedance was tested at 32 ohms. Also, we interrogated the device, which showed stable parameters, and it was programmed to VVI 60 with long AV delay to allow for intrinsic conduction. Tachy therapies were set at VF zone at 188 beats per minute with maximum therapy. The patient tolerated the procedure well, and there were no complications. DFT was not tested due to the presence of left ventricular thrombus.

CONCLUSION:  Successful implantation of dual chamber defibrillator by nonthoracotomy method on the right side.

PLAN:
1.  The patient will be observed overnight and can be discharged home with followup in the clinic from an electrophysiologic standpoint.
2.  In terms of anticoagulation, we would start Coumadin tonight and also start heparin without bolus after about 12 hours.
3.  Particular care should be given to the care of the implant pocket to avoid any hematologic complication.
4.  Given usual post-implant care, including chest x-ray, antibiotic, and interrogation will be done.

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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.

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PREOPERATIVE DIAGNOSIS:  Peripheral vascular disease with claudication.

POSTOPERATIVE DIAGNOSIS:  Successful revascularization to the left common femoral artery and bilateral internal iliac artery occlusions.

PROCEDURE PERFORMED:
1.  Aortogram with runoff.
2.  Selective iliac artery injection.
3.  Selective common femoral artery injection.
4.  Percutaneous revascularization to the left common femoral artery.

OPERATOR:  John Doe, MD

COMPLICATIONS:  None.

DESCRIPTION OF PROCEDURE:  Following routine sterile preparation of both groins, the right groin was anesthetized with 2% lidocaine. The right femoral artery was then entered percutaneously and 6-French arterial sheath was placed. An angled pigtail catheter was used to perform abdominal aortography with runoff to the iliacs. Subsequently, an injection was performed to the right common femoral arterial sheath and then also with the internal mammary artery catheter in the more proximal vessels to fully delineate the course of the iliacs with runoffs to the foot. Subsequently, this same catheter was used with an angled glide catheter wire to cross over the aortic bifurcation. An injection was then performed in the left common iliac artery and the left common femoral artery with runoffs through the foot. After completion of diagnostic angiography, it was decided to proceed with percutaneous revascularization. A 7-French Destination sheath was placed over the guidewire and into the left external iliac artery. The Mailman guidewire was then placed down the vessel after systemic anticoagulation was performed with heparin. SilverHawk atherectomy catheter was used to perform atherectomy and post-balloon dilatation was performed with a 7 x 20 mm Powerflex balloon at 6 atmospheres. Excellent results were obtained, the procedure was terminated, and the patient was transferred to the holding area for line removal.

ANGIOGRAPHIC RESULTS:  The previous aortobiiliac bypass graft appeared to be intact and without significant blockage or obstruction.

RIGHT LOWER EXTREMITY:  The right internal iliac artery was noted to be obstructed at its ostium and filled by collaterals. The proximal portion of the right common femoral artery had diffuse 40% narrowing. The SFA was largely unobstructed. The posterior tibial artery was about 50% mid distal narrowing.

LEFT LOWER EXTREMITY:  The left internal iliac artery was noted to be obstructed at its ostium with distal collateral filling. The left proximal common femoral artery had a focal 70% obstruction. The remainder of the vessels, including the runoff at the ankles, was unobstructed. Following revascularization, the left common femoral artery obstruction was 0%. No attempts were made to reopen the chronically occluded bilateral internal iliac arteries.

IMPRESSION:
1.  Wide patency of the previous aortobiiliac bypass graft repair.
2.  Bilateral internal iliac artery occlusions with collateral filling.
3.  Proximal right common femoral artery obstruction of 40%.
4.  Proximal left common femoral artery obstruction of 70%.
5.  Fifty percent obstruction in the mid portion of the posterior tibial artery on the right.

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