Vascular Case for the Students and Residents

[GassYous]

48 yo F pmh Ehlers-Danlos found to have hepatic artery aneurysm, planned procedure is coiling and stenting. Previous history significant for cva with residual weakness on the left and distal LAD dissection. Anesthetic considerations?

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[Volatile]

Prop, roc, tube. Access: Aline and a couple IV’s. BP w/ in 20% of baseline, consider keeping on the lower end due to hx of dissection and known aneurysm. Finish case and hit the golf course.... include the surgeon in the tee time so you’ll get out on time

 

[pocafx]

Limit neck extension 2/2 hyper mobility. Look into prev head CTA for aneurysm. Tight BP control. A line few large iv. T&S for blood

 

[GassYous]

Agree with keeping bp on the lower side. I like to keep my MAPs > 65, I don't do the within 20% of baseline. Surgeon asked for systolics around 140 to maintain organ perfusion. Do you agree to their request? If you need a pressor, what agent would you like?

Also, do you care about what type of ehlers danlos it is?

 

[MirrorTodd]

48 yo F pmh Ehlers-Danlos found to have hepatic artery aneurysm, planned procedure is coiling and stenting. Previous history significant for cva with residual weakness on the left, distal LAD dissection. Anesthetic considerations?

That dissection is repaired or still there? Need good neuro exam documented preop, go to sleep with a tube. 2x large bore IV, could even do pre-induction A line depending on how busy the day is (I dont think it's a big deal to put them in awake). Type of Ehlers Danlos definitely matters. I would need to look it up, but I think I remember the vascular type being much more severe. I'd see how the pt did with phenylephrine initially.

 

[GassYous]

It was being medically treated. Did a preinduction a line to make sure that the pressure didn't get too low to maintain perfusion to the brain and other organs while making sure that the sympathetic reaction to laryngoscopy didn't cause the blood pressure to shoot too high. Right radial was impossible so placed a left radial a line as well as a big IV. Performed videolaryngoscopy to not manipulate the neck too much and ensure first pass success to avoid bleeding as well as possible atlantoaxial instability.

There are several different types with vascular type and cardiac valvular types being the most relevant. Tried to keep the airway pressures low to decrease risk of pneumothorax. Risk of mitral regurg, conduction abnormalities and blood vessel problems (as this patient already had). There's a risk of organ rupture (OB). Had some blood type and crossed.

The surgeon wanted to keep sbp up to maintain organ perfusion so I ran some neo. I also ran some precedex to keep the heart rate on the lower side (near 60s) to decrease wall tension.

Surgery itself went okay until the end when the surgeon noted absent pulses in the LE and opened the groin to repair. They were able to get pulses back when the patient became progressively bradycardic and then hypotensive. ST depressions are noted on the monitor. What's your next step?

 

[Beeftenderloin]

It was being medically treated. Did a preinduction a line to make sure that the pressure didn't get too low to maintain perfusion to the brain and other organs while making sure that the sympathetic reaction to laryngoscopy didn't cause the blood pressure to shoot too high. Right radial was impossible so placed a left radial a line as well as a big IV. Performed videolaryngoscopy to not manipulate the neck too much and ensure first pass success to avoid bleeding as well as possible atlantoaxial instability.

There are several different types with vascular type and cardiac valvular types being the most relevant. Tried to keep the airway pressures low to decrease risk of pneumothorax. Risk of mitral regurg, conduction abnormalities and blood vessel problems (as this patient already had). There's a risk of organ rupture (OB). Had some blood type and crossed.

The surgeon wanted to keep sbp up to maintain organ perfusion so I ran some neo. I also ran some precedex to keep the heart rate on the lower side (near 60s) to decrease wall tension.

Surgery itself went okay until the end when the surgeon noted absent pulses in the LE and opened the groin to repair. They were able to get pulses back when the patient became progressively bradycardic and then hypotensive. ST depressions are noted on the monitor. What's your next step?

Acute RCA dissection vs plaque rupture? Do what you can to decrease dp/dt while still maintaining perfusion. Call cath lab. Maybe they’ll come up to you since you’re probably doing this case in a hybrid room.

 

[Planktonmd]

It was being medically treated. Did a preinduction a line to make sure that the pressure didn't get too low to maintain perfusion to the brain and other organs while making sure that the sympathetic reaction to laryngoscopy didn't cause the blood pressure to shoot too high. Right radial was impossible so placed a left radial a line as well as a big IV. Performed videolaryngoscopy to not manipulate the neck too much and ensure first pass success to avoid bleeding as well as possible atlantoaxial instability.

There are several different types with vascular type and cardiac valvular types being the most relevant. Tried to keep the airway pressures low to decrease risk of pneumothorax. Risk of mitral regurg, conduction abnormalities and blood vessel problems (as this patient already had). There's a risk of organ rupture (OB). Had some blood type and crossed.

The surgeon wanted to keep sbp up to maintain organ perfusion so I ran some neo. I also ran some precedex to keep the heart rate on the lower side (near 60s) to decrease wall tension.

Surgery itself went okay until the end when the surgeon noted absent pulses in the LE and opened the groin to repair. They were able to get pulses back when the patient became progressively bradycardic and then hypotensive. ST depressions are noted on the monitor. What's your next step?

Next step: Turn off the Precedex?

 

[dchz]

They were able to get pulses back when the patient became progressively bradycardic and then hypotensive. ST depressions are noted on the monitor. What's your next step?

I haven't been a resident in 15 months, hope I can answer. But I would drop TEE and call CT surgery.

 

[GassYous]

Everyone is free to participate, thanks for your thoughts.

So my anesthetic was iso, prop gtt, precedex gtt, fent, roc. At this point of the case, I was basically about to extubate. Prop had been off for about thirty minutes. Precedex had been stopped for about an hour. Neo was minimal. Gas was off. 4/4 twitches. Total fentanyl was maybe 150 or so. Of note, case was kinda long due to difficult anatomy.

Why is the patient hypotensive? Medication error? Fentanyl can cause bradycardia but unlikely to cause hypotension. Precedex and neo have been off. I haven't reversed yet though neostigmine and sugammadex can cause hypotension (with some reports of arrest in sugammadex).

Neurologic? Nah. Septic? Timing is off. Hypovolemic? UOP was good, bp had been good and would likely come with tachycardia. It's possible to cause a perf or have some bleeding at the access site or rp bleed but I felt like that would have been noticed. I'm thinking vascular vs cardiac (lad dissection in the past).

Gave some ephedrine and atropine. Noticed the t waves were getting wider and st depressions getting deeper. Hyperkalemia? Gave some calcium, insulin, glucose, albuterol.

Called cath lab.

While we were waiting, stabilized the patient, sent a gas, got an ecg and called for the TEE.

Thoughts on the ecg?

 

[Arch Guillotti]

Surgery itself went okay until the end when the surgeon noted absent pulses in the LE and opened the groin to repair.

Is a surgeon really doing this case? Or IR?

 

[GassYous]

Is a surgeon really doing this case? Or IR?

Vascular surgeon. But they did call in an interventional radiologist to help.

 

[MirrorTodd]

Metabolic byproducts from reperfusion washing out causing hypotension and transient t wave depression vs NSTEMI vs LAD dissection. On that Ekg, I see p waves, slightly tachycardia although regular with st depressions in the lateral and some in the inferior leads with what seems to be qt widening. Maintain blood pressure as best you can and see if you can do an echo, whatever is quickest imo and get pt to cath lab if there are new wall motion abnormalities?

 

[GassYous]

I thought about reperfusion as well. But the monitor was telling me st depressions of about 5 and it seemed out of proportion so it made me suspect something else was going on. Called for an interventional cardiologist to take a look.

While waiting we dropped a TEE probe.

The wall at the top of the picture that I shamelessly stole wasn't moving very well. What do you think is going on?

 

[MirrorTodd]

I thought about reperfusion as well. But the monitor was telling me st depressions of about 5 and it seemed out of proportion so it made me suspect something else was going on. Called for an interventional cardiologist to take a look.

While waiting we dropped a TEE probe.

View attachment 317507

The wall at the top of the picture that I shamelessly stole wasn't moving very well. What do you think is going on?

Should be RCA providing inferior circulation which probably plugged. Time for a cath?

 

[Helpmehelpyou2112]

Poor coronary perfusion secondary to decreased diastolic pressures after reperfusing extremity. Opposite physiology of a balloon pump.

 

[abolt18]

I thought about reperfusion as well. But the monitor was telling me st depressions of about 5 and it seemed out of proportion so it made me suspect something else was going on. Called for an interventional cardiologist to take a look.

While waiting we dropped a TEE probe.

View attachment 317507

The wall at the top of the picture that I shamelessly stole wasn't moving very well. What do you think is going on?

You have ECG and TEE evidence of coronary hypoperfusion. I think involving interventional cards is exactly the right decision.

 

[GassYous]

So interventional cardiology came by a few minutes later. By the time the cardiologist came in, the wall motion abnormality is mostly resolved, the heart rate and blood pressure are stable (HR 90s and SBP 120s respectively) and patient actually looks better. The cardiologist takes a look at the echo and thinks that the patient doesn't need to go to the lab. The entire time the surgeon is demanding that we can move the patient to pacu where cardiology can follow up because he has more cases. Should we go to pacu, wait for an unanticipated icu bed to become ready or push interventional to get the patient to the cath lab?

 

[Arch Guillotti]

Should we go to pacu, wait for an unanticipated icu bed to become ready or push interventional to get the patient to the cath lab?

PACU. Nothing to do if cardiology doesn't want it.

 

[dchz]

My top DDx was further LAD dissection, TEE would have proved it with anterior wall regional motion defect. But if your rescue TEE is showed inf wall motion abnormality then you have your diagnosis. Next question is can you stent a dissection or would you have to emergently bypass it?

Also please thank Josh Zimmerman for me. I subscribe to his emails.

 

[Hork Bajir]

Were they doing anything that might have introduced air into the arterial system around the time that this manifested? Air embolus to the RCA would look just like this

 

[GassYous]

I believe air into the RCA would come from the left heart since patient didn't have a pfo. I've never seen it outside of the open heart surgery case I read on this site. And I'm not sure that it would spontaneously resolve, I would guess that you need a needle in the artery to bleed it out or something.

So since the patient seemed to be pretty stable and cardiology did not think cath would help, the plan was to take the patient intubated to pacu for further observation and monitoring. Before the TEE probe was pulled, it was turned to the left and this was noticed:

 

[Arch Guillotti]

I believe air into the RCA would come from the left heart since patient didn't have a pfo. I've never seen it outside of the open heart surgery case I read on this site. And I'm not sure that it would spontaneously resolve, I would guess that you need a needle in the artery to bleed it out or something.

So since the patient seemed to be pretty stable and cardiology did not think cath would help, the plan was to take the patient intubated to pacu for further observation and monitoring. Before the TEE probe was pulled, it was turned to the left and this was noticed:

View attachment 317530

I thought you already had a cardiology consult?

 

[MirrorTodd]

I believe air into the RCA would come from the left heart since patient didn't have a pfo. I've never seen it outside of the open heart surgery case I read on this site. And I'm not sure that it would spontaneously resolve, I would guess that you need a needle in the artery to bleed it out or something.

So since the patient seemed to be pretty stable and cardiology did not think cath would help, the plan was to take the patient intubated to pacu for further observation and monitoring. Before the TEE probe was pulled, it was turned to the left and this was noticed:

View attachment 317530

I dont know much, but that looks ****y.

 

[Iso4ane]

View attachment 317530

or

 

[GassYous]

I thought you already had a cardiology consult?

Yeah they wanted to trend trops in pacu. But after seeing this aortic dissection, cardiac surgery was called and they took over the case. The dissection went up right next to the aortic valves without pericardial effusion or valvular involvement (aortic insufficiency, etc). Started some esmolol, central line was placed and patient was prepared for bypass. We don't really use hydralazine in the heart room but it's to be avoided because it's a direct vasodilator and can cause reflex activation of the sympathetic system.

Last time I looked it up, around 10-20% of type a dissections involves the coronary arteries. People with vascular type ehlers danlos are predisposed to developing aortic dissection but other related conditions include other connective tissue disorders like marfan or loey-dietz, hypertension, atherosclerosis etc.

 

[abolt18]

I believe air into the RCA would come from the left heart since patient didn't have a pfo. I've never seen it outside of the open heart surgery case I read on this site. And I'm not sure that it would spontaneously resolve, I would guess that you need a needle in the artery to bleed it out or something.

So since the patient seemed to be pretty stable and cardiology did not think cath would help, the plan was to take the patient intubated to pacu for further observation and monitoring. Before the TEE probe was pulled, it was turned to the left and this was noticed:

View attachment 317530

Holy crap.

 

[DrOwnage]

Man what a good case, thank you for sharing in such detail. This is why we learn differential diagnoses in the OR. You did all the right things. I have a feeling if someone else had the patient they might have just dumped them in the PACU after cards said nothing to do. Then that patient could have had tamponade, stroke, or a full blown STEMI; in that situation they're hosed. Its very likely this patient already had a chronic dissection with acute worsening (although I'm not sure what preop testing they had that revealed the LAD dissection). Sounds like your anesthetic was mostly stable with decreased chronotropy and sheer stress. As a recent grad one of my fears is having to throw a TEE in and suck major balls at it. I could get the basic views but definitely would not be super confident.

 

[vector2]

Yeah they wanted to trend trops in pacu. But after seeing this aortic dissection, cardiac surgery was called and they took over the case. The dissection went up right next to the aortic valves without pericardial effusion or valvular involvement (aortic insufficiency, etc). Started some esmolol, central line was placed and patient was prepared for bypass. We don't really use hydralazine in the heart room but it's to be avoided because it's a direct vasodilator and can cause reflex activation of the sympathetic system.

Last time I looked it up, around 10-20% of type a dissections involves the coronary arteries. People with vascular type ehlers danlos are predisposed to developing aortic dissection but other related conditions include other connective tissue disorders like marfan or loey-dietz, hypertension, atherosclerosis etc.

Next q....did you wake the guy up and risk the hemodynamic swings or consent the family for an emergent procedure with significant M&M?

 

[Beeftenderloin]

Next q....did you wake the guy up and risk the hemodynamic swings or consent the family for an emergent procedure with significant M&M?

Type A is an immediately life threatening condition. Patient is 48yo. If they are full code, you gotta fix this. Waking up isn’t really an option. I’d probably call family after I called my CV surgeon. Though in reality I’m probably not making either Phone call. Despite surefire attempts to blame anesthesia, the vascular surgeon probably caused this when he did his cut down/thrombectomy then it dissected retrograde, so he can call the CV surgeon as well as the family and let them know why the mortality rate of their loved ones surgery just sky-rocketed. Either way, definitely has to happen.

 

[dhb]

PACU. Nothing to do if cardiology doesn't want it.

I have a feeling if someone else had the patient they might have just dumped them in the PACU

 

[Ronin786]

Yeah they wanted to trend trops in pacu. But after seeing this aortic dissection, cardiac surgery was called and they took over the case. The dissection went up right next to the aortic valves without pericardial effusion or valvular involvement (aortic insufficiency, etc). Started some esmolol, central line was placed and patient was prepared for bypass. We don't really use hydralazine in the heart room but it's to be avoided because it's a direct vasodilator and can cause reflex activation of the sympathetic system.

Last time I looked it up, around 10-20% of type a dissections involves the coronary arteries. People with vascular type ehlers danlos are predisposed to developing aortic dissection but other related conditions include other connective tissue disorders like marfan or loey-dietz, hypertension, atherosclerosis etc.

Lovely case. Really well presented and you 100% played a role in this patient's outcome for the better.

FWIW this is why I teach my fellows and residents to do a full exam every single time you put the probe on the patient. TEE or TTE, our brains are so trained to focus on the outstanding abnormality that we can miss other things if we don't have a systematic approach. Radiologists do it all the time but I've seen many an ultrasonographer skimp out.

 

[GassYous]

Lovely case. Really well presented and you 100% played a role in this patient's outcome for the better.

FWIW this is why I teach my fellows and residents to do a full exam every single time you put the probe on the patient. TEE or TTE, our brains are so trained to focus on the outstanding abnormality that we can miss other things if we don't have a systematic approach. Radiologists do it all the time but I've seen many an ultrasonographer skimp out.

Smash the like button and don't forget to subscribe to my channel!

 

[vector2]

Type A is an immediately life threatening condition. Patient is 48yo. If they are full code, you gotta fix this. Waking up isn’t really an option. I’d probably call family after I called my CV surgeon. Though in reality I’m probably not making either Phone call. Despite surefire attempts to blame anesthesia, the vascular surgeon probably caused this when he did his cut down/thrombectomy then it dissected retrograde, so he can call the CV surgeon as well as the family and let them know why the mortality rate of their loved ones surgery just sky-rocketed. Either way, definitely has to happen.

Waking up (perhaps without extubating) absolutely is an option (not that the pt will necessarily be consentable at that point, more to let them know what is happening), it just might not be a great option without hemodynamic control. I'm calling the CT surgeon first as well, but odds are the vascular surgeon did not extensively discuss the risk of a retrograde TAD with the pt and thus without a reasonable effort to obtain informed consent (no, a blanket vascular consent with a thousand possible listed complications that the pt signed doesnt count), it's a bit callous to proceed to a potential circ arrest case immediately. Acute TAD is a surgical emergency, but with normalized vitals and no severe valvular pathology or tamponade on echo, you have time to obtain proper consent while the room is set up

 

[GassYous]

I wouldn't be too quick to blame the surgeon. These patients have a life expectancy around 48 years and the majority of them have some major event by the time they hit 40. This patient already had 3 spontaneous dissections and her tissue has only gotten worse.

I think that every minute you delay a repair of a type a increases the chance of tamponade, increased propagation of dissection, valvular issues so I would not wait to have a full discussion with the patient and their family. I've had patients crump on their way to the OR from the ED.

I also wanted to give a shout out to Dr Zimmerman at the University of Itah. The videos on his site are incredibly educational and his emails are fantastic. Here's the link if you want to subscribe, I am not affiliated with him or the University of Utah in any way:

https://lists.hsc.utah.edu/wws/info/periop-echo

 

[vector2]

I wouldn't be too quick to blame the surgeon. These patients have a life expectancy around 48 years and the majority of them have some major event by the time they hit 40. This patient already had 3 spontaneous dissections and her tissue has only gotten worse.

I think that every minute you delay a repair of a type a increases the chance of tamponade, increased propagation of dissection, valvular issues so I would not wait to have a full discussion with the patient and their family. I've had patients crump on their way to the OR from the ED.

I also wanted to give a shout out to Dr Zimmerman at the University of Itah. The videos on his site are incredibly educational and his emails are fantastic. Here's the link if you want to subscribe, I am not affiliated with him or the University of Utah in any way:

https://lists.hsc.utah.edu/wws/info/periop-echo

Unless you had an extra perfusionist, pump, circulator, scrub tech, TAD case cart, and full anesthesia set up all waiting around in an OR for some reason, this case isn't going for 30-45 minutes minimum. There is time to talk to the family and let them know that the procedure turned from something relatively routine into extremely life threatening.

 

[sethco]

Waking up (perhaps without extubating) absolutely is an option (not that the pt will necessarily be consentable at that point, more to let them know what is happening), it just might not be a great option without hemodynamic control. I'm calling the CT surgeon first as well, but odds are the vascular surgeon did not extensively discuss the risk of a retrograde TAD with the pt and thus without a reasonable effort to obtain informed consent (no, a blanket vascular consent with a thousand possible listed complications that the pt signed doesnt count), it's a bit callous to proceed to a potential circ arrest case immediately. Acute TAD is a surgical emergency, but with normalized vitals and no severe valvular pathology or tamponade on echo, you have time to obtain proper consent while the room is set up

On the other hand, since the inferior wall went down (presumably from RCA ischemia), I'm wondering if the pt dissected into the Right Coronary. Pt may not be as stable as one might assume and should be treated as very tenuous. I'm curious what the AV long axis and the Aortic Arch looks like in this patient

OP, at the time, why did you and the surgeon think the patient had lost lower extremity flow? Hindsight is obviously 20/20 with the patient's underlying connective tissue disorder, but I'm sure Acute Aortic Dissection was low on the list. Also, did the Cardiologist do the TEE exam or was it the Anesthesia team? Was a complete exam done or did they only look for Wall motion abnormalities?

 

[GassYous]

Lost dopplers in the foot. They thought maybe something happened at the access site but I'm not sure what they did other than exploration.

Cardiologist only looked at the wma. We found the pathology after they left.

 

[vector2]

On the other hand, since the inferior wall went down (presumably from RCA ischemia), I'm wondering if the pt dissected into the Right Coronary. Pt may not be as stable as one might assume and should be treated as very tenuous. I'm curious what the AV long axis and the Aortic Arch looks like in this patient

OP, at the time, why did you and the surgeon think the patient had lost lower extremity flow? Hindsight is obviously 20/20 with the patient's underlying connective tissue disorder, but I'm sure Acute Aortic Dissection was low on the list. Also, did the Cardiologist do the TEE exam or was it the Anesthesia team? Was a complete exam done or did they only look for Wall motion abnormalities?

You very well may be right. Still, every TAD I've had took a hot minute to come up to the OR just because so much set up is involved from so many teams.

Lost dopplers in the foot. They thought maybe something happened at the access site but I'm not sure what they did other than exploration.

Cardiologist only looked at the wma. We found the pathology after they left.

So what happened to the guy?

 

[sethco]

Unless you had an extra perfusionist, pump, circulator, scrub tech, TAD case cart, and full anesthesia set up all waiting around in an OR for some reason, this case isn't going for 30-45 minutes minimum. There is time to talk to the family and let them know that the procedure turned from something relatively routine into extremely life threatening.

Funny you should say that. This story happened to me about 3 months ago. Had a pt getting a Lung Biopsy through Left VATs. Procedure went as planned without complication until we were done andI resumed two lung ventilation with a Valsalva maneuver. Usually, the pressure will quickly normalize after a brief decrease, but not this time. My SBP went from 110s pre-valsalva to 40. This pressure was persistent and unresponsive to Phenylephrine, Ephedrine, and low dose Epi. Ct Surgeon was just about to walk out of the room before he asked me if everything is OK. He was about start a CABG in the next room, but the patient hadn't been brought back yet because of hospital policy (some hospitals the patient would have been brought back while he was closing). I told him not to go anywhere. Luckily, the pts Cardiologist and CT surgeon wanted me to do a TEE before the procedure for some reason I can't remember, so I still had the TEE in the room. I put in the probe and my first view was of the descending aorta. It was completely opacified with air bubbles. I turned over the probe to look at the four chamber and the LV function was maybe 5% and completely filed with bubbles. Nothing in the RV. We called the perfusionist next door (with an already set up machine) and crashed on bypass. Within a couple seconds of going on pump, all of the bubbles completely cleared. We gave him a couple minutes on pump warm beating and then easily came off pump without any support. Normal function like never happened. Woke up later that day and wondered why he now has a big incision down the middle of his chest. Our assumption to why it happened was that somehow CO2 was insufflated into a micro tear of a pulmonary Vein and just stayed there until I did the Valsalva maneuver. Weird complication and luckily everything fell into place for the best pt outcome

 

[sethco]

Lost dopplers in the foot. They thought maybe something happened at the access site but I'm not sure what they did other than exploration.

Cardiologist only looked at the wma. We found the pathology after they left.

So, my (somewhat cynical) take aways for this case for Residents/Fellows...

1) For those that have have a basic understanding of TEE (and are able to obtain standard views), if you go through the trouble of getting a TEE machine in the room and assume the risk of TEE Insertion, PLEASE do a complete exam. Every time I insert a probe per surgeon request, even for a simple Pericardial Window, I always do a complete exam. When you do enough of these, it takes less than 5 minutes of your time. Tunnel vision was extremely high in this case and the Cardiologist completely whiffed on the diagnosis, which brings me to my second take away...

2) The vast majority of Cardiologist suck as doing their own TEE. Not saying they aren't good at what they do and there aren't some exceptions, but this is not really in their skill set (even for the ones that regularly do TEEs for their Cardioversions)

Otherwise, good catch on the Dissection. Was it a Type A that required surgical repair or was it confined to the descending aorta?

 

[Arch Guillotti]

Every time I insert a probe per surgeon request, even for a simple Pericardial Window

ELI5. Why do you "need" a TEE for a pericardial window?

 

[sethco]

ELI5. Why do you "need" a TEE for a pericardial window?

Personally, I don't need it. Surgeon requested. Point being, if I'm going to go through the risk of Insertion, I'm doing a complete exam

 

[Arch Guillotti]

Personally, I don't need it. Surgeon requested. Point being, if I'm going to go through the risk of Insertion, I'm doing a complete exam

Point taken. Just don't know what it adds. Also, what if the case is done under local/sedation?

 

[sethco]

Point taken. Just don't know what it adds. Also, what if the case is done under local/sedation?

In that situation...

 

[Arch Guillotti]

Nice. So on the sickest patients it doesn't really need to be done. Makes perfect sense!

 

[GassYous]

The ascending aorta looked something like this but without the dilation:

I can't find a good picture for the arch online but I seem to remember it twisting from left side of the screen, to the top and then to the right by the time we got to the left subclavian.

I believe the cardiac surgeon was getting ready to start a cabg but they switched over to our OR. They attempted a repair with a gelweave graft with anastomoses to the neck vessels.

We also perform TEE for pericardial effusions, surgeon preference. They like to see that they got everything.