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Pulmonary / Vascular Samples

 

ENDOVASCULAR ANEURYSM REPAIR.

PREOPERATIVE DIAGNOSIS: Abdominal aortic aneurysm and iliac artery aneurysms, (abdominal aortic aneurysm, 3.8 cm; right iliac aneurysm, 4 cm; left iliac aneurysm, 2.5 cm).

POSTOPERATIVE DIAGNOSIS: Abdominal aortic aneurysm and iliac artery aneurysms, (abdominal aortic aneurysm, 3.8 cm; right iliac aneurysm, 4 cm; left iliac aneurysm, 2.5 cm).

OPERATION:
1. Bilateral femoral artery exposure.
2. Introduction of bilateral catheters into aorta with interpretation.
3. Endovascular aneurysm repair using 2 docking limb modular bifurcated stent graft (Zenith 32 x 88).
4. Distal stent graft extension of the right external iliac artery with interpretation.

CONTRAST USED: Gadolinium 80 ml.

ANESTHESIA: General.

ESTIMATED BLOOD LOSS: 100 ml.

INTRAVENOUS FLUIDS: 2 L.

COMPLICATIONS: None.

OPERATIVE FINDINGS: A high-grade left renal artery stenosis and moderate-to-severe right renal artery stenoses.

PROCEDURE: The patient was brought to the operating room and laid in a supine position, prepped and draped in a routine fashion. Bilateral femoral cutdowns were made. The fascia was dissected. The common femoral arteries were isolated and the patient was systematically heparinized.

A 19-gauge needle was used to puncture the right common femoral artery. Bentson wire and Berenstein catheters were advanced into thoracic aorta and the Bentson wire was exchanged for a Meier wire. Over the Meier wire, and 18-French sheath was advanced from the right femoral approach and positioned into the abdominal aorta. Similarly, from the left, a 19-gauge needle, Bentson wire, and Berenstein catheters were used to cannulate the descending thoracic aorta and the Bentson wire was exchanged for a Meier wire. Over the Meier wire, an 18-French sheath was advanced and positioned from the left femoral approach into the abdominal aorta. A micro flush catheter was advanced from the left 18-French sheath and positioned at the juxtarenal aorta and this was used to do aortogram. Gadolinium was used for aortograms.

A right pelvic arteriogram was done from a catheter in the right iliac artery which showed the right common iliac aneurysm, right internal iliac artery had chronic occlusion and the external iliac artery was patent.

Endovascular aneurysm repair using Zenith modular bifurcated stent graft. The Zenith stent graft was advanced from the right after removing the 18-French sheath and positioned at the juxtarenal aorta. Aortogram was done to mark the level of the aorta as well as the bifurcation. The aorta was ectatic just distal to the renal vessels measuring 3.2 to 3.4 cm in maximum diameter and approximately 3 cm distally narrowed down to 2.8 cm. This was used a proximal landing zone for fixation. The bare metal stent was placed at the infrarenal segment for fixation. The stent graft was deployed, and the contralateral gate was cannulated and its position was checked.

A modular component was advanced, positioned within the contralateral gate, and subsequently deployed. Distal landing zone was the left common iliac artery. 

Right pelvic arteriogram was done to mark the level of the right common iliac aneurysm and the right external iliac artery.  Additional stent graft (Gore excluder iliac limb) was advanced, positioned within the Zenith device, and subsequently deployed. Distal landing zone was midright external iliac artery. There was some stenosis of the proximal external iliac artery which was angioplastied from within the stent graft using a 10-mm x 4-cm angioplasty balloon.

All catheters and wires were removed. Bilateral femoral arteriotomies were closed primarily. Good Doppler signal was heard distal to the arteriotomy closure. Both groin incisions were closed and dressing was applied.

The patient tolerated the procedure well and was hemodynamically stable.

We completed all the laboratory data, which you have received copies, and I reviewed them with the patient, specifically, his complete metabolic panel including liver test that were entirely normal except for a slight decreased renal function with creatinine 1.4 and BUN 23.  Urinary protein was markedly elevated at 4.5 g/24 hours.  I reassessed his renin-aldosterone system in view of his hypertension and found that curiously his aldosterone was in fact slightly elevated at 20.1 with a completely suppressed plasma renin, suggesting the possibility of primary hyperaldosteronism coming from his slightly enlarged adrenal described on CT, but I am not certain this is sufficient suspicion to investigate further.  His serum potassium was quite normal at 4.2.  The confounding effect of multiple medications he is taking has to be considered as well.  With regard to his pituitary function, we discovered that his testosterone level is in midnormal range at 464 ng/dL; however, I did not assess this with a sex hormone binding globulin or free testosterone level.  However, he has no symptoms of hypogonadism.  FSH was curiously minimally elevated at 8.9 and LH was quite normal at 3.5.  With regard to his adrenal function, we got a early warning serum cortisol of 9.9 before any medications, indicating that there is probably some adrenal function, although, curiously his ACTH was clearly elevated at 108, which is confounding since I had assumed previously that if he had any adrenal insufficiency it would be secondary to ACTH deficiency, either drug induced or due to some hypokalemic or pituitary problem.  These values suggest that in fact he has mild adrenal insufficiency as a result of the loss of one adrenal and possibly some malfunction of the second. 

CURRENT MEDICATIONS:  He is currently taking his Cortef 15 mg in the morning, 10 at midday, and 5 in the evening.  There was no particular change on this. 

He informs me that he is considering strongly a course of interleukin-2.  If this is the case and that induces as much nausea and vomiting, which I presume it will, he will certainly need to have some increased Cortef administration, possibly intravenously during that time to tide him through the acute stress and continued and taken over the following week. 

He informed me that the Avastin was stopped temporarily because of his markedly elevated protein and went it had dropped to 2.5 g/24 hours, it was restarted.  Whether it is actually helping his metastatic disease, it is not clear.  The patient remains relatively robust. 

Examination is otherwise not changed.  I informed the patient that he may need the extra hydrocortisone during periods of either psychological or physical stress, and if there is any question about these I would be happy to discuss this with any of his attending physicians. 

FEMORAL TO POPLITEAL BYPASS

PREOPERATIVE DIAGNOSIS: Thrombosed popliteal artery aneurysm.   

POSTOPERATIVE DIAGNOSIS: Thrombosed popliteal artery aneurysm. 

OPERATION: Right femoral to popliteal in situ bypass. 

ANESTHESIA: General endotracheal anesthesia.

PROCEDURE: The patient was taken to the operating room and placed under general endotracheal anesthesia. The patient’s right leg was prepped and draped in the usual sterile fashion. The saphenous vein was exposed from the upper thigh to the midcalf. The superficial femoral artery in its midportion was isolated. The popliteal artery above the aneurysm and below the aneurysm was also isolated. The patient was heparinized and the saphenous vein was transected at its cephalad exposed area. The superficial femoral artery was clamped proximally and distally and opened up with a vertical arteriotomy. The vein was sewn at this point with a running 6-0 Prolene suture in an end-to-side fashion. Branches were then divided between 3-0 silk ties and the valves were divided with a Mills valvulotome inserted through cut side branches which were subsequently ligated. This was carried down sequentially until the entire exposed vein was arterialized. The anterior tibial and tibioperoneal trunk arteries were controlled and arteriotomy made in the distal most popliteal artery into the beginning of the tibioperoneal trunk. The clot was extracted without the need of any embolectomy catheters. The vein was sewn to this point with a running 7-0 Prolene suture in an end-to-side fashion. Clamps were removed and flow was checked with Doppler and found to be satisfactory. The popliteal artery above and below the aneurysm was then hemoclipped. The wound was checked for hemostasis and then closed with a combination of 3-0 Vicryl fascial sutures and staples for the skin. A gauze dressing was applied.

 

 

AAA REPAIR

PREOPERATIVE DIAGNOSIS: Abdominal aortic aneurysm and atherosclerosis with claudication.

POSTOPERATIVE DIAGNOSIS: Abdominal aortic aneurysm and atherosclerosis with claudication.

OPERATION:
1. Bilateral femoral artery exposure.
2. Right iliofemoral endarterectomy.
3. Right femoral-to-femoral PTFE bypass (8 mm).
4. Placement of catheter into aorta, bilateral, with interpretation.
5. Endovascular aneurysm repair using Excluder abdominal aortic stent graft (28 x 14 x 14).
6. Distal stent graft extension, right common iliac artery with interpretation for endoleak.
7. Proximal stent graft extension, femoral aortic neck with interpretation for endoleak.
8. Left renal artery angioplasty and stent placement (Genesis 6 mm x 15 mm).

ANESTHESIA: General.

ESTIMATED BLOOD LOSS: 800 ml.

INTRAVENOUS FLUIDS: 5 L of crystalloid and 3 units of packed RBCs.

PROCEDURE: The patient was brought to the operating room and laid in a supine position, prepped and draped in a routine fashion.

Bilateral femoral cutdowns were made. The fascia was dissected. The common femoral arteries were isolated and the patient was systematically heparinized. The patient had extensive atherosclerotic occlusive disease of the right femoral artery, thus right external iliac artery was isolated.

A 19-gauge needle was used to puncture the right external iliac artery. A Bentson wire and Berenstein catheter were advanced into the aorta up to the level of the renal arteries. The Benson wire was exchanged for a Meier wire, over which an 18-French sheath was advanced from the right iliac approach and positioned into the abdominal aorta. Similarly, from the left a 19-gauge needle, Bentson wire, and Berenstein catheter were advanced into the aorta and the Bentson wire was exchanged for a Meier wire, over which an 18-French sheath was advanced from the left femoral approach and positioned into the abdominal aorta. A micro flush catheter was advanced from the left side and positioned at the juxtarenal aorta.

Aortogram was done which indicated infrarenal aortic aneurysm, the patient had high-grade (95%) left renal artery stenoses, right renal artery was patent, both internal iliac arteries were patent, and both common iliac arteries were ectatic. Both the external iliac arteries were patent.

Endovascular aneurysm repair using modular bifurcated stent graft. Through the right side, excluder bifurcated stent graft was advanced, positioned just below the lower most renal artery and subsequently deployed. Through the contralateral side, the short limb was cannulated and its position was checked.  The modular component was advanced, positioned within the gate and subsequently deployed. Distal landing zone was distal most left common iliac artery. A completion arteriogram was done which indicated an endoleak from proximal most fixation site, the stent graft had migrated approximately 1 cm distally and endoleak from distal fixation site from the right common iliac arteries. Additional stent grafts were needed.

Proximal stent graft extension with interpretation. A proximal stent graft was advanced, positioned within the excluder’s main body and subsequently deployed just distal to the lower most right renal artery. A compliant balloon was used to angioplasty the proximal fixation site.

A right pelvic arteriogram was done to mark the level of the hypogastric artery. Additional extension iliac limb was advanced, positioned within the gate and subsequently deployed. Distal landing zone was the distal most right common iliac artery. A completion arteriogram was done which indicated adequate proximal and distal fixation site without any evidence of endoleak.

The patient had high-grade left renal artery stenosis and for that, a Spartacore wire and a Sarns catheter were used to selectively cannulate the left renal artery.

Arteriogram was done to confirm its position and a Genesis 6 x 15-mm stent was advanced over the Spartacore wire, positioned across the high-grade lesion and angioplasty was done up to 8 atmospheres. A repeat arteriogram was done which indicated adequate fixation of the stent.

The patient had extensive iliofemoral occlusive disease on the right side and right external iliac to common femoral endarterectomy was done. The patient had extremely diseased distal right common femoral artery, and therefore a decision was made to replace this.

An 8 x 10-mm PTFE graft was used to replace the right common femoral artery. Proximal clamp was placed on the distal external, distal clamp was placed on the superficial femoral and profunda femoral arteries. The common femoral artery was transected and PTFE graft was used to construct the proximal and distal anastomosis onto the common femoral arteries in an end-to-end fashion. This was done using a 5-0 Prolene stitch. At the completion of the anastomosis, the graft and the artery were anteretrograde flush appropriately.

The patient tolerated the procedure well. His feet were well perfused.

After removing the left femoral sheath, a primary repair was done of the left common femoral artery. Both groin incisions were closed in multiple layers. Dressing was applied. The patient tolerated the procedure well.

Flexible Bronchoscopy

PREOPERATIVE DIAGNOSIS: Left spontaneous pneumothorax secondary to bolus emphysema.

POSTOPERATIVE DIAGNOSIS: Left spontaneous pneumothorax secondary to bolus emphysema.

OPERATION: Flexible bronchoscopy, left video-assisted thoracoscopic surgery, resection of apical bullae and mechanical pleurodesis.

ANESTHESIA: General endotracheal.

INDICATIONS: The patient is a 13-year-old female who presented this past weekend with her second episode of spontaneous pneumothorax. The first one was treated conservatively with thoracostomy tube management. The patient presented with spontaneous pneumothorax and a chest tube was placed. She was admitted and advised of an operation which would include thoracoscopy and resection of apical bullae. The parents were advised of the risks, benefits, and alternatives. They agreed and wished to proceed.

PROCEDURE: The patient was brought to the operating room and placed supine on the operating table. After adequate general anesthesia was provided, the flexible bronchoscopy was performed to insure double lumen endotracheal tube placement. There was no evidence of endobronchial lesions or any evidence of any airway compression.
The patient was then positioned in the right lateral decubitus position with the left side up. The chest tube was removed and the patient’s left chest was prepped and draped in a standard surgical fashion.

A transverse incision was made of about 2 to 2.5 cm in length. This was made in the axillary hairline, and the skin was incised with a #15 blade. The subcutaneous tissue was divided using cautery and the intercostal space was entered using Bovie cautery. Through the thoracostomy incision, a camera port was placed and the camera was introduced and apical bullae were seen. Using the Endo GIA 45 stapler, the Endo GIA stapler was placed through the axillary incision along with a grasper. The apical bullae were removed using 2 throws of the Endo GIA 45 stapler. Once this was done, mechanical pleurodesis was performed using a sponge on a stick, and the upper half of the left hemithorax was irritated and there was some small petechial hemorrhage which was developed in reaction to the mechanical irritation. Once this was done, a #24-French chest tube was placed through the thoracostomy tube site and secured using an 0 silk suture. Once this was done, the axillary incision was closed in layers starting with 0 Vicryl and then terminating with 4-0 Vicryl for subcuticular suture and Dermabond was used for the dressing and a chest tube dressing was provided for the chest tube.

At the end of the case, sponge, needle, and instrument counts were correct.

Discharge Summary

ADMISSION DIAGNOSIS:
1. Cystic fibrosis exacerbation.
2. Left secondary pneumothorax.

DISCHARGE DIAGNOSIS:
1. Cystic fibrosis exacerbation.
2. Left secondary pneumothorax, resolving.

HISTORY OF PRESENT ILLNESS: This is a 36-year-old white female with cystic fibrosis presented with 1-week history of cough productive with yellow phlegm and dyspnea and a 3-day history of pleuritic chest pain on the left scapula. The patient also reported 7 pound weight loss over the last few months. She denied any fever, chills, or hemoptysis. Her CF is relatively stable with only 2 hospitalizations in the last 5 years.

PAST MEDICAL HISTORY: Cystic fibrosis, pancreatic insufficiency, uterine cancer post total abdominal hysterectomy and bilateral salpingo-oophorectomy, left upper extremity DVT related to a PIC line, left neck cyst removed, and osteoporosis.

MEDICATIONS: At-home medications included: DNASE, MT-20 with meals, Actonel, and erythromycin 3 times a week.

ALLERGIES: Penicillin hives. Sulfur anaphylaxis.

SOCIAL HISTORY: She does not smoke. She does not drink. She lives with her husband.

PHYSICAL EXAMINATION:
VITAL SIGNS: On admission, her temperature was 98.3, blood pressure 122/75, heart rate 106, 96% on room air.  
GENERAL: Alert, fully oriented, in no acute distress.
NECK: Neck without lymphadenopathy.
LUNGS: Lungs revealed crackles bilaterally anteriorly.
HEART: Regular rate and rhythm. No murmurs. No gallops.
ABDOMEN: Soft, nontender, nondistended. No active bowel sounds.
EXTREMITIES: Extremities with clubbing.

LABORATORY DATA: Chest x-ray revealed chronic changes and bronchiectasis with a 20% left pneumothorax.

CBC revealed leukocytosis with a white count 13.6, 12% bands. The rest of her labs were unremarkable.

HOSPITAL COURSE: The patient was admitted to the pulmonary service with admitting diagnosis of cystic fibrosis exacerbation and left secondary pneumothorax. She was started on IV antibiotics, ciprofloxacin. Because she was clinically stable, the decision was made to monitor if she had pneumothorax clinically and radiologically. She had serial chest x-rays that demonstrated improvement and almost resolution of the left pneumothorax. She also had a sputum culture sent which revealed pseudomonas and the methicillin-sensitive staphylococcus.

She had regular cystic fibrosis care and her DNASE, pancreatic enzymes, and erythromycin were continued.

During her hospitalization she had clinical improvement with resolution of her cough, clearing of her sputum, and total resolution of her left-sided pleuritic chest pain.

On the day of discharge, the patient had a right PIC line placed. She will be discharged on home IV antibiotics. She will continue the ciprofloxacin for 10 mores days to complete a total of 2 weeks.

The patient will follow up in the outpatient cystic fibrosis clinic.