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Carotid Endarterectomy

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and placed on the table in supine position.  After induction of general anesthesia with endotracheal intubation, the left neck was prepped and draped sterilely.  An oblique incision was made overlying the anterior border of the sternocleidomastoid muscle and the carotid sheath was exposed.  The carotid sheath was incised vertically and the common carotid, external carotid and internal carotid vessels were isolated along adequate segments for performance of endarterectomy.  The hypoglossal and vagus nerves were identified and preserved.  The patient was then begun on a dextran infusion, and was given 14,000 units of heparin intravenously.  After adequate circulation of the heparin, the external carotid artery was clamped.  A needle transducer was placed in the distal common carotid artery and an arterial wave form was obtained.  The common carotid artery was occluded with a vascular loop.  Distal internal carotid stump pressure was measured and found to be approximately 53 mmHg and moderately pulsatile.  A fine vascular clamp was placed distally on the internal carotid artery.  The needle transducer was removed and a longitudinal arteriotomy was made from the common carotid onto the internal carotid with an 11 blade and Potts scissors.  The arteriotomy was extended well past the obstructive plaque, both distally in the internal carotid artery and proximally in the common carotid artery.  The arteriotomy was irrigated with copious amounts of heparinized normal salt solution.  A 10-French Argyle shunt was placed distally in the internal carotid artery, followed by proximally in the common carotid artery, restoring normal blood flow to the brain.  The endarterectomy was then performed using a dental tool, Freer elevator, fine Tungsten vascular forceps, and fine hemostats.  Good break-off points were obtained on the common carotid, internal carotid and external carotid vessels.  All debris was then removed from the endarterectomy site using fine Tungsten vascular forceps and mosquito hemostats.  After all debris had been removed, the arteriotomy site was irrigated with copious amounts of heparinized normal salt solution.  A Hemashield patch, which had been soaked in antibiotic solution, was then sewn to the arteriotomy with a running 6-0 Prolene suture.  Prior to completion of arteriotomy closure, the shunt was removed and a fine vascular clamp was placed distally on the internal carotid artery and arteriotomy closure was completed.  The common carotid was flushed into the external carotid, followed by release of the internal carotid vessel.  Hemostasis was achieved on the suture line with a single 7-0 Prolene suture.  Protamine sulfate was given to reverse heparin.  The incision was irrigated with antibiotic solution.  After adequate hemostasis was present, the carotid sheath was partially reapproximated with interrupted 2-0 Vicryl suture.  A medium Hemovac drain was placed in the subplatysmal space and secured inferiorly with a 2-0 silk suture.  The platysma was closed with a running 3-0 Vicryl suture, and the skin was closed with a running 3-0 Monocryl subcuticular skin stitch.  Sterile dressings were applied and the patient was returned to the recovery room in stable condition.
 
 
CABG  
DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and placed on the table in supine position.  After induction of general anesthesia with endotracheal intubation, a Swan-Ganz catheter was passed through the left subclavian vein and into the pulmonary artery for cardiac pressure monitoring.  The patient was then prepped and draped sterilely.  Saphenous vein was harvested from the legs.  Simultaneously, a midline sternotomy was performed.  The left internal mammary pedicle was dissected from the chest wall using Bovie cautery and blunt and sharp dissection.  The pericardium was opened and the ascending aorta and right atrial appendage were cannulated for bypass.  A separate pursestring was placed in the right atrium for passage of a retrograde cardioplegic cannula into the coronary sinus, which was done prior to bypass.  Utilizing single aortic crossclamp with intermittent cold blood antegrade followed by retrograde coronary sinus potassium cardioplegia, the distal anastomoses were performed with running 7-0 Prolene suture.  Cold cardioplegic solution was instilled into the vein grafts after each distal anastomosis.  Subsequent cardioplegic doses were instilled into the vein grafts.  The left internal mammary to anterior descending was a side-to-side anastomosis with running 8-0 Prolene suture.  The proximal anastomoses were then performed using a partial clamp.  After all anastomoses were completed and checked for hemostasis, the patient was rewarmed.  Left chest and mediastinal tubes were placed for postoperative drainage.  Temporary pacing wires were placed on the right ventricle.  The mediastinal pleura, fat and pericardium were divided laterally to allow the mammary pedicle to lie lateral to the sternum underneath the lung without tension.  After rewarming, the patient was weaned from bypass.  After satisfactory weaning, the aortic and atrial cannulae were removed and the pursestring sutures were tied.  The mediastinum was irrigated with antibiotic solution.  After adequate hemostasis was present, the sternum was closed with interrupted and figure-of-eight sternal wire.  The sternal fascia was closed with running Vicryl suture.  The skin was closed with skin staples.  Sterile dressings were applied.  The patient was returned to the intensive care unit in critical but stable condition on a low-dose nitroglycerin infusion.