DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. High-grade right renal artery stenosis.
2. Nonhealing amputation site of the left leg.
POSTOPERATIVE DIAGNOSES:
1. High-grade right renal artery stenosis.
2. Nonhealing amputation site of the left leg.
OPERATION PERFORMED:
1. Left femoral to below-knee popliteal bypass with 6 mm Gore-Tex graft.
2. Right renal percutaneous angioplasty and stent using a 5 x 20 mm Genesis stent.
3. Left common femoral artery endarterectomy.
4. Intraoperative arteriogram.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: Minimal.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old male who was admitted with complaints of left hallux gangrene. He was then treated with an amputation for infection control, and this amputation site has failed to heal. The patient was also found to have a high-grade stenosis of the right renal artery. We discussed with the patient the risks, benefits, and alternatives to a femoropopliteal bypass as well as renal angioplasty and stent. The patient understood and agreed to proceed with surgery.
DESCRIPTION OF OPERATION: After the patient was taken to the operating room and adequate anesthesia was induced, the bilateral groins and the left leg were prepped and draped in the usual fashion. This was then followed by performing an oblique groin incision with a 15 blade and exposing the common femoral artery. At this time, we went ahead and identified a very calcified common femoral artery as well as external iliac artery and fully heparinized the patient with 10,000 units of intravenous heparin. After heparinization was completed, we went ahead and looped the common femoral, superficial femoral, and profunda femoral artery with loops for control. This was then followed by performing a longitudinal arteriotomy in the common femoral artery and performing an extensive common femoral artery as well as distal external iliac artery endarterectomy.
After this was done, we were able to then place 7-French sheath using fluoroscopic guidance into the external iliac artery and then a guidewire to the level of the diaphragm. We then went ahead and placed a guiding sheath through the 7-French sheath and selectively catheterized the right renal artery with a Cobra 2 catheter. A 0.014 guidewire was then placed. This was then followed by placing a 2 cm x 5 mm balloon and performing a renal angioplasty on the right, which did not show adequate results. This was then followed by placing a 5 mm x 20 mm Genesis stent over the guidewire, and using raw mapping, this was deployed in the right position. This was verified by a completion arteriogram that showed excellent results after the stent deployment. There was no dissection and no residual stenosis. At this time, we went ahead and removed the sheath from the left groin and then performed a longitudinal incision below the knee, on the left in the medial aspect, to expose the popliteal artery at the infrageniculate position. After this was done, it was looped with vessel loops for control.
We then went ahead and used the Kelly-Wick tunneler to tunnel a 6 mm Gore-Tex graft in the subsartorial space, and we then went ahead and performed our proximal anastomosis by performing an end-to-side anastomosis using 5-0 Prolene in the running fashion. This was then opened and the graft was clamped using Fogarty-Hydragrip. We then went ahead and performed a 2 cm longitudinal arteriotomy on the distal aspect to the popliteal artery, at the below-knee segment, and performed an end-to-side anastomosis using running 6-0 Prolene stitch. Prior to completion of the graft, all vessels were flushed. Then, the anastomosis was completed. Flow was opened proximally and then distally. Excellent Doppler signal was identified in the posterior tibial artery.
At this time, we obtained a completion arteriogram that showed adequate flow throughout the whole graft into the popliteal artery. After this was done, we partially reversed the patient’s heparinization with 50 mg intravenous protamine. After adequate circulation, we went ahead and placed Gelfoam and antibiotic ointment topically for control.
After this was done, we went ahead and irrigated both wounds copiously with antibiotic irrigation and then closed both wounds in two layers. The first layer was with running 2-0 PDS to approximate the subcutaneous tissue followed by interrupted 3-0 nylon to approximate the skin edges. At the end of the procedure, all counts were correct. The patient tolerated the procedure without any complication.
