DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Life-threatening pulmonary embolism and lower extremity deep venous thrombosis.
POSTOPERATIVE DIAGNOSIS: Life-threatening pulmonary embolism and lower extremity deep venous thrombosis.
PROCEDURES PERFORMED:
1. Inferior vena cava filter, Greenfield type, via right internal jugular approach.
2. Intraoperative fluoroscopy with interpretation.
3. Venography.
SURGEON: John Doe, MD
FLUORO TECH: Jane Doe
ANESTHESIA: General via endotracheal tube.
ESTIMATED BLOOD LOSS: Less than 2 mL.
COMPLICATIONS: None.
SPECIMENS: None.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old gentleman who has undergone a pancreatic resection. He was admitted to the surgical intensive care unit early this morning with a life-threatening pulmonary embolus. He has been taken to the operating room by the cardiac surgery team and underwent an open pulmonary artery embolectomy. Because of the life-threatening nature of his pulmonary embolus, the primary surgical team has requested an interruption of the patient’s vena cava to minimize the risk of further pulmonary emboli.
DESCRIPTION OF PROCEDURE: On the date of the procedure, the patient remained in the surgical operating room after the completion of the cardiac surgery procedure. The patient’s right neck was prepped with dilute chlorhexidine and draped in a standard sterile fashion. The patient had been previously placed on a fluoroscopy bed.
A 0.035 guidewire was placed through the brown port of the patient’s indwelling right internal jugular triple-lumen catheter. This was monitored under fluoroscopy and was advanced past the heart into the abdominal vena cava and then out the left common iliac vein. The right internal jugular triple-lumen catheter was then removed. The subcutaneous tract was then serially dilated. The Greenfield sheath was then brought up onto the field. It was thoroughly flushed with heparinized saline, and the sheath dilator was placed. The dilator and sheath together were then placed over the guidewire using fluoroscopy for the entire length of this until this was positioned at approximately the L4 region.
The side port of the sheath was connected to a heparinized saline drip, which was allowed to run throughout the remainder of the procedure. The dilator from this was removed, and we re-fluoro’d the abdomen. The tip of the sheath appeared to lie at the L5-S1 interface. We could see contrast present in the renal collecting system from the previous pulmonary artery angiogram that had taken place. The renal bifurcation appeared to lie at approximately the level of L1. The tip of the sheath was then withdrawn to the body of L3 under fluoroscopy.
A hand injection of 30 mL of Conray was then performed under live fluoroscopy as an inferior vena cavagram. On our view of this, we could not localize the renal veins as we appeared to be below them. The cava was less than 2.8 cm by measurement. We then withdrew the sheath to the body of L2. We then performed an additional cavagram with a hand injection of 30 mL of Conray. The renal arteries were seen to enter at the level of L1. The Greenfield filter was then placed through the deployment device and was secured in place.
Under live fluoroscopy, the Greenfield filter was then deployed in the inferior vena cava in the infrarenal position. It was seen to expand nicely and did not appear to tilt. The sheath was then slightly withdrawn, and an additional cavagram was performed with an additional 10 mL of Conray, which revealed that we were infrarenally located. It appeared that the Greenfield filter was in excellent position. The sheath was then withdrawn, and pressure was held x20 minutes at the right internal jugular incision site.
There was no hematoma present at the conclusion of holding pressure. A sterile dressing was then applied. At the termination of the case, the patient was taken to the cardiac surgery intensive care unit in critical condition. Needle, sponge, and instrument counts were correct as reported immediately at the termination of the case.
