DATE OF OPERATION:
November 30, 2004.

PREOPERATIVE DIAGNOSIS:
Cerebrovascular disease.

POSTOPERATIVE DIAGNOSIS:
Cerebrovascular disease.

PROCEDURE(S) PERFORMED:
1. Right femoral artery percutaneous access.
2. Arch and four-vessel arteriogram with cerebral artery runoff.

SURGEON:
Thomas Thomas, M.D.

ATTENDING:
William Williams, M.D.

ANESTHESIA GIVEN:
Local.

INTRAVENOUS FLUIDS:
500 mL

ESTIMATED BLOOD LOSS:
Minimal.

INDICATIONS FOR PROCEDURE:
The patient is a 62-year-old male who was found to have a right parietal infarct with left-sided hand weakness. Subsequent workup included a carotid duplex, which was unremarkable for the right carotid system, but suggested a 70% lesion in the left carotid artery. For that reason, he underwent a diagnostic arteriogram. After informed consent, including an explanation of the risks of bleeding with possible transfusions, infection, heart attack, arrhythmias, stroke, and death, the patient was explained the benefits of diagnostic arteriogram for further workup. He willingly gave consent and all of his questions were answered.

OPERATIVE COURSE:
After informed consent was obtained, the patient was taken to the operative suite and placed on the operating room table in the supine position. His arms were tucked to his sides and the patient's abdomen was prepped and draped in the normal sterile fashion. Approximately 20 cc of 1% lidocaine was injected into his left femoral region. Attempt was made to place a catheter needle in this groin, but we could not access the femoral artery. At this point, we injected about 20 cc of 1% lidocaine in the right groin. At that point, we were able to easily access the right femoral artery. Using fluoroscopy, a guidewire was advanced to the aorta. The needle was withdrawn and then a small stab wound was made over the wire. Following this, a 6-French percutaneous sheath was advanced over the wire using fluoroscopy and placed into the aorta. At that point, the small guidewire was removed, and then a 0.035 glidewire was advanced under fluoroscopy into the proximal aortic arch. At this point, a pigtail catheter was advanced over the glidewire and then positioned into the proximal aortic arch. This glidewire was subsequently removed. Following this, approximately 30 cc of Visipaque contrast was injected using the Oz. Unfortunately, we had a very poor aortogram. This was repeated using approximately 30 cc of Omnipaque. Again, we had a poor contrast, so we shot another arteriogram using 30 cc of Visipaque. At this point, we had a good visualization of the arch which revealed a bovine arch. The pigtail catheter was removed after the glidewire had been replaced. The wire was advanced so essentially it was in the brachial cephalic artery.

At this point, an H-1 catheter was advanced over the wire and positioned into the right common carotid artery. Subsequent shots of the patient's lateral neck as well as oblique views of his right carotid system revealed an approximately 30% stenosis at the bifurcation of the right internal carotid artery. Separate views were shot of the patient's lateral head, which revealed filling of the middle cerebral artery as well as the anterior cerebral artery. We shot additional Towne's views of the right cerebral circulation as well, which revealed filling of the anterior cerebral as well as the middle cerebral arteries. At this point, the H-1 catheter was pulled back until it was in the orifice of the left common carotid artery. Then 7 cc aliquats of Omnipaque was then injected using digital traction. We obtained lateral and oblique views of the left internal carotid artery which revealed an approximately 90% stenosis of the left internal carotid artery at the bifurcation. Additional lateral and Towne's views were obtained which revealed filling of the anterior cerebral as well as the middle cerebral artery.

At this point, the glidewire was readvanced through the H-1 catheter and the catheter was retracted over the glidewire and pulled out through the femoral sheath. The sheath was sutured into position using 2-0 silk suture.

Sterile dressings were applied and the patient was transported back to the hospital bed stretcher and taken to the recovery room in stable condition where he subsequently had the catheter removed after his ACT was less than 150. Please note that the patient was administered 6000 units of heparin intravenously after the sheath had been placed. Dr. Williams was present for the entirety of the operation. At the end of the case, all needle and lap counts were correct.

FEMORAL LINE PLACEMENT

PREPROCEDURE DIAGNOSIS: Acute respiratory failure with poor peripheral intravenous access.

POSTPROCEDURE DIAGNOSIS: Acute respiratory failure with poor peripheral intravenous access.

PROCEDURE PERFORMED: Right femoral central line placement.

SURGEON: Michael Smith, M.D.

ANESTHESIA/MEDICATIONS: Local.

ESTIMATED BLOOD LOSS: 20 cc.

SPECIMENS: None.

INDICATIONS FOR PROCEDURE: The patient is an 82-year-old white female who had been transferred early in the a.m. of 01/01/2002, with an episode of acute respiratory failure requiring ventilator management. She presented with poor peripheral intravenous access and required vasopressors. The decision was made to proceed with a central line placement.

DESCRIPTION OF PROCEDURE IN DETAIL: The patient was lying in the bed in the supine position. Initially, attempts were made at performing a right subclavian central line placement. The right upper chest and lower neck were prepped and draped sterilely. The skin and subcutaneous tissues in the right infraclavicular area were anesthetized with 1% lidocaine. A 14-gauge fine needle could be inserted into the right subclavian vein. A guidewire was passed without significant difficulty. However, we could not advance a line over the guidewire, presumably due to an acute angle under the clavicle. We then made an attempt to do a right internal jugular line. The skin and subcutaneous tissues in the right lower neck were anesthetized with 1% lidocaine. Multiple attempts were made to access the right internal jugular vein, but despite multiple passes of the needle, we could not localize the vein. Her neck was very obese and she had a weak carotid pulse. At this point, we made the decision to place a right femoral line. We prepped and draped the right groin sterilely. We anesthetized the skin in the right femoral area. We then advanced a 14-gauge fine needle into the right femoral vein and advanced a guidewire through the bevel of the needle. The vein was dilated with the dilator and then a 7-French triple-lumen catheter was then inserted into the right femoral vein to a depth of 15 cm of the skin. Dark venous blood could be aspirated from all three ports. All ports flushed easily. The line was sutured into place with 3-0 silk suture and a sterile dressing was applied. The patient tolerated this well and a chest x-ray is pending at this time to rule out a pneumothorax from the previous line attempts.

A-V THROMBECTOMY WITH PTFE GRAFT

PREOPERATIVE DIAGNOSES:
1.Subacute thrombosis right upper arm, arteriovenous graft.
2.Traumatic perforation with extravasation of the right axillary vein following an endovascular attempted thrombectomy.

POSTOPERATIVE DIAGNOSES:
1.Subacute thrombosis right upper arm, arteriovenous graft.
2.Traumatic perforation with extravasation of the right axillary vein following an endovascular attempted thrombectomy.

OPERATION PERFORMED:
1.Right upper arm arteriovenous graft thrombectomy. 2.A 6-mm polytetrafluoroethylene (PTFE) "jump graft" to the central axillary vein. 3.Operative angiography.

SURGEON:
Michael Michaels, M.D.

ANESTHESIA GIVEN:
Local monitored anesthesia care.

INDICATIONS FOR PROCEDURE:
The patient is an elderly gentleman who had a graft placed approximately two months ago. After approximately one month or six weeks, the graft failed and an attempt was made to open it by endovascular means at another hospital. Although they were able to achieve antegrade flow, they felt there was a defect at the venous anastomosis and completed a balloon angioplasty thus perforating the axillary vein and re-thrombosing the graft. He is brought back to the operative suite at this point to try to reopen the graft.

OPERATIVE FINDINGS:
At operation, the axillary anastomosis was explored and was considerably scarred, as one might expect from the previous perforation. We were able to identify and isolate a much more central aspect of the vein that was approximately 5 mm in diameter. The graft was reopened and there was resistant thrombus near the arterial anastomosis that, in combination with a Fogarty balloon with contrast in it, we were able to get the resistant clot loose and remove it, thus giving a perfectly smooth graft. There was a nice end-to-end anastomosis between the end of the Vectra graft and the axillary anastomosis and this lay without any tension and no chance of kinking. There was an immediate excellent quality thrill and a well maintained palpable radial pulse.

DESCRIPTION OF THE PROCEDURE:
The patient was brought to the operative suite and placed in the supine position. He was given sedation and the right upper quadrant was prepped and draped in the sterile fashion. One percent lidocaine was instilled and a longitudinal incision through the previous axillary anastomotic skin incision was created. The graft and underlying vein including a more central vein was isolated between Vesi-loops. A transverse graftotomy was created and a #4 and #3 Fogarty were utilized to remove the thrombus from the graft. Retrograde angiogram was completed with Isovue 200 and the filling defect near the arterial anastomosis was identified. With the aid of the #3 Fogarty filled with contrast, we were able to isolate this segment and ultimately pull this retained thrombus loose from the proximal aspect of the graft and flush it out. It was well organized. Retrograde followup study noted nice taper to the graft with no evidence of kink and excellent in flow by examination. At this point the graft was flushed retrograde and the patient was given 3000 units of systemic heparin. It was crossclamped at this point. The in flow and out flow to the isolated axillary vein segment was occluded and a longitudinal venotomy was created with a #11 blade and Potts scissors. Central circulation was flushed. A section of 6-mm polytetrafluoroethylene (PTFE) was chosen and a long tapered anastomosis was completed with 6-0 vascular Prolene. This gently curved into a straight end-to-end anastomosis with the previous section of Vectra. Flow was re-established and there was an immediate excellent quality thrill. Meticulous hemostasis was achieved utilizing thrombin and Gelfoam. The wound was then irrigated and closed in layers with absorbable suture including a monofilament absorbable for the dermal approximation.

ENDOVASCULAR RADIOFREQUENCY ABLATION (VENOUS CLOSURE PROCEDURE)

PREOPERATIVE DIAGNOSES:
1. Greater saphenous vein incompetence, right lower extremity.
2. Multiple varicose veins, right lower extremity, thigh, calf, and ankle.
3. Anterior greater saphenous vein branch incompetence, right lower extremity.
4. Greater saphenous vein incompetence, left lower extremity.
5. Varicose veins, left leg.

POSTOPERATIVE DIAGNOSES:
1. Greater saphenous vein incompetence, right lower extremity.
2. Multiple varicose veins, right lower extremity, thigh, calf, and ankle.
3. Anterior greater saphenous vein branch incompetence, right lower extremity.
4. Greater saphenous vein incompetence, left lower extremity.
5. Varicose veins, left leg.

PROCEDURES PERFORMED:
1. Right lower extremity percutaneous endovascular radiofrequency ablation (venous closure procedure).
2. Ligation of the right saphenofemoral junction including the anterior saphenous branch.
3. Stab avulsion of multiple varicose veins, right lower extremity, ankle, leg, and thigh (15).
4. Left greater saphenous vein venous closure procedure.
5. Stab avulsion of varicosities of left leg.
6. Intraoperative venous ultrasound, right and left lower extremity.

SURGEON:
Jimmy Stewart, M.D.

ANESTHESIA GIVEN:
General.

INTRAOPERATIVE FINDINGS:
The patient has grade 4 reflux bilaterally. She has more extensive disease on the right side with large varicosities in the ankle, calf, and thigh as well as a large anterior branch that is partially feeding the thigh varicosities out of the right groin. On the left side, she had grade 4 reflux of the greater saphenous vein, but more focal varicosities in the popliteal and the medial calf area. She has a number of mid- and smaller sized varicosities on the left that will injection sclerotherapy in the future.

TECHNIQUE:
The patient was brought to the operating room and general anesthesia was administered. The right and left lower extremity were prepped and draped in the usual sterile fashion. Intraoperative ultrasound was used for cannulation. Intraoperative ultrasound was used to identify the greater saphenous vein on the left. It was cannulated percutaneously and the introducer and guidewire were inserted. The radiofrequency guidewire was inserted to the saphenofemoral junction. Tumescent anesthesia was instilled with ultrasound guidance between the skin and the vein with local anesthetic. The guidewire was inserted and the patient was placed in Trendelenburg position.

Radiofrequency ablation was performed over 12 minutes from the left groin to the left calf. Followup ultrasound showed a thickened vein. The guidewire was removed and the introducer was removed. Pressure was held. Incisions were made with stab avulsion technique on three large varicosities in the medial calf and two in the popliteal area. The vessels were clamped, divided, and ligated with 3-0 Vicryl tie and the small incisions were closed with 5-0 Vicryl stitch. Steri-Strips were applied. On the right lower extremity, ultrasound was used to identify the greater saphenous vein and it was cannulated percutaneously and an introducer was placed into the vein. The radiofrequency guidewire was then placed in the saphenofemoral junction. This was confirmed by ultrasound. Tumescent anesthesia was instilled with a long spinal needle between the skin and the vein from the calf to the groin. Radiofrequency ablation was performed over 20 minutes in the right lower extremity. Stab avulsion was done at multiple large varicosities in the right ankle, right calf, right medial thigh, which had all been marked preoperatively. There were 15 of these. They were clamped, divided, and ligated with 3-0 Vicryl and each incision was closed with a subcuticular 5-0 Vicryl stitch.

In the right groin, after ultrasound identification, a small incision was made and the saphenofemoral junction was isolated. The saphenous vein was double ligated proximally. It had already been ablated. The anterior branch which also was into the thigh which had severe reflux and was feeding some of the varicosities was identified as it had not been ablated. It was ligated and divided. This wound was closed with 3-0 Vicryl and then a 5-0 Vicryl subcuticular suture.

Steri-Strips were applied to all incisions; 4 x 4s, Kerlix, and then Ace bandage wrap with a 4-inch Ace bandage for the foot, ankle, and calf, and a 6-inch Ace bandage for the calf, knee, and thigh were placed on each extremity. The estimated blood loss was less than 30 cc. The patient tolerated the procedure satisfactorily and was taken to the recovery room in stable condition.

Generic Sample Report of a Bone Marrow Biopsy and Aspiration

REASON FOR BONE MARROW: The patient was admitted to the hospital with acute myeloblastic leukemia in relapse. The patient has received induction chemotherapy. Marrow is done to check status of the disease.

PERIPHERAL BLOOD SMEAR: Findings show red cells are essentially normocytic, normochromic, with no anisocytosis or poikilocytosis. There is virtual absence of white cells on the peripheral smear, and the platelets are markedly decreased.

BONE MARROW ASPIRATE: The bone marrow is very hypocellular, with rare hematopoietic precursors seen. No megacaryocytes are present. Only cells seen are either lymphocytes, plasma cells, histiocytes, reticulum cells, and smudge cells. No blasts can be recognized. Iron stain cannot be interpreted.

CONCLUSIONS: Hypoplastic to aplastic marrow secondary to induction chemotherapy. The patient's disease is in remission, as can be determined on examination of the present aspirate.