Ask Dr. Z

I'm getting hung up on this one…not quite sure about the debranching and hepatic to gda bypass.
I'm looking at 33881-51/33883-51/34812-51/36200-51/75957 and 35633-22 right now.
am I on the right track?
thank you!

PREOPERATIVE DIAGNOSIS:  8-cm descending thoracic aortic aneurysm.

POSTOPERATIVE DIAGNOSIS:  8-cm descending thoracic aortic aneurysm.

OPERATION PERFORMED:
1.  Thoracic endovascular aneurysm repair with a 32 mm x 32 mm x 160 mm Medtronic Captiva graft with a 36 mm x 36 mm 159 mm Captiva extension piece.
2.  Multiple aortograms
3.  Visceral aortic debranching with a gastroduodenal artery to replace right hepatic artery bypass.
4.  Right external iliac artery to replaced right hepatic artery bypass graft with an 8-mm Dacron.
5.  Left common femoral artery cutdown.

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  600 mL.

RADIATION:  765 milligray (19.9 minutes photo time).

CONTRAST:  57.5 mL of Visipaque.

INDICATIONS:  This 79-year-old female with descending thoracic aortic aneurysm, who is being worked up for possible endovascular intervention with Dr. Michael Lazar and myself.  Aortic debranching of the celiac artery and superior mesenteric artery was necessary for being able to perform this in an endovascular fashion as the aforementioned vessels came off the distal aneurysmal segment of the aorta.  I discussed with the patient that given her given her overall health that the least invasive option would be to utilize her replaced right hepatic artery anatomy and use this vessel via the gastroduodenal artery to connect the replaced right hepatic artery.  The superior mesenteric artery was while not in a particular aneurysmal section of the aorta would likely be necessary to debranch in order to gain distal seal zone.  Bypass and debranching was recommended.  The patient understood the risks and benefits and wished to proceed.  I recommended proceeding through her previous open cholecystectomy right upper quadrant incision.  All questions were answered and she agreed to proceed.

OPERATION:  Patient was brought to the hybrid operating room, placed in supine position.  After adequate general endotracheal anesthesia was achieved, the abdomen was prepped and draped in a sterile fashion.  The prior right subcostal incision was entered and peritoneal cavity slowly entered as there were significant adhesions present.  Because of the amount of adhesions present, this necessitated an additional 1 hour of operative time.  Ultimately, we were able to identify the colon at the hepatic flexure.  The white line of Toldt was mobilized and colon mobilized medially.  The gastrohepatic ligaments were divided and the space entered where I was able to gain control of the right hepatic artery and identified gastroduodenal artery.  This was a tedious procedure as well, but ultimately the vessels were able to be looped with vessel loops.  At this point, while with reflection of the ascending colon, I was able to palpate the celiac artery.  It was difficult to gain exposure for the use of the common iliac artery for a donor vessel.  At this point, I did then perform a right lower quadrant transplant incision and gained access into the retroperitoneum where the iliac bifurcation was encountered.  The distal right common iliac, internal iliac, and external iliac arteries were looped with vessel loops.  The artery was soft with an excellent pulse.  The patient was systemically heparinized with 5000 units of heparin.  An 8-mm Dacron graft was then anastomosed in end-to-side fashion to the iliac bifurcation.  This graft was then brought along the right gutter in the retroperitoneal space and brought up to the replaced right hepatic artery.  The anastomosis was then constructed also in end-to-side fashion.  During this point of heparinization, the gastroduodenal artery was divided and also anastomosed to the more proximal portion of the replaced right hepatic artery.  At one point, there seemed to be some slight tension on this anastomosis.  Wanting this to be tension-free, I tried to further mobilize the gastroduodenal artery, however this still did not provide a tension-free anastomosis and thus a small piece of bovine pericardium was used to patch this area to allow this to be tension free.  At this point, the hemostasis was achieved.
At this point, the patient was prepared for the endovascular stent placement.  I chose to perform a right common femoral artery cutdown  I chose to advance the endograft via the the left common femoral artery as I did not want the large graft sitting across the 8-mm Dacron graft anastomosis, which had just been created.  An oblique incision was made over the left common femoral artery and vessel dissected free from the surrounding structures and looped proximally with umbilical tape and distally with vessel loops.  Percutaneous access was gained here with a 5-French sheath followed by advancement of an 035 Bentson wire and pigtail catheter into the proximal descending thoracic aorta.  The pigtail catheter was then used to exchange out the Bentson wire for a curled 035 Lunderquist wire with the tip positioned near the aortic valve.  In a similar fashion, a 5-French sheath was then placed in the previous left right lower quadrant transplant incision where the 8-mm Dacron had been anastomosed.  I gained percutaneous access just distal to our anastomosis and a 5-French sheath was placed.  In addition, the 035 Bentson wire was advanced into the proximal descending thoracic aorta and a 5-French pigtail catheter placed.  A left transverse arteriotomy was then created after the 5-French sheath was removed.  The 32 mm x 32 mm x 160 mm Medtronic Captiva endograft was then advanced and positioned just proximal to the sole left renal artery.  A 36 mm x 36 mm x 159 mm extension piece was then used to build the graft proximally to cover the aneurysmal segment.  This landed several cm distal to the left subclavian artery.  At this point, completion aortogram showed no evidence of endoleak.  The bypass graft and debranching was visualized.  There was flow noted into the superior mesenteric artery, however this did not appear to be causing an endoleak and thus I did not feel that the superior mesenteric artery needed to be ligated.  We had previously gotten a 0 silk tie around the origin of the celiac artery and ligated this.  At this point, the patient had received 57.5 mL of contrast.  All sheaths and wires were then removed from the left common femoral artery cutdown and the arteriotomy closed with interrupted 5-0 Prolene suture, followed by running 3-0 Vicryl suture and 4-0 Monocryl to the skin.  The right lower quadrant transplant incision was then closed with looped PDS on the fascia followed by 3-0 Vicryl and 4-0 Monocryl to the skin.  The subcostal incision was closed in a similar manner with looped PDS on the fascia followed by 3-0 Vicryl and 4-0 Monocryl to the skin, followed by Dermabond.  At this point, the patient remained hemodynamically stable making urine and had received 57.5 mL of contrast.  The patient had palpable dorsalis pedis pulses.  I was present for the entire portion of procedure.