MYOCARDIAL REVASCULARIZATION

STUDENT: KAREN DANIELA BAUTISTA

ESQUIVIA
CODE: 01210021064

SEMESTER: SEVENTH

TEACHER: LIDY HIGUERA

2024
 Clinical Case Cardiovascular Surgery
Patient’s Data:
• Name: Marisol Rodríguez Carvajal
• ID: 25835602
• Age: 79
• Sex: Woman
• Birthdate: 24/01/1945
• Civil status: Married
• Blood type: B+
• Address: 109 Street #45-25
• Occupation: Housewife
RECORD
• Pathological:

- Coxarthrosis - Arthritis - Hyperlipidemia

• Pharmacological:

ATORVASTATIN ACETYLSALICYLIC ACID BISOPROLOL FUMARATE DAPAGLIFLOZIN EVOLOVUMAB

• Surgical:

- Cesarean sections: 3

- Hysterectomy 30 years ago

DIAGNOSTIC EXAMS
• Diagnostic Images:
o Doppler ultrasound of venous vessels of lower limbs: Positive study for acute deep vein
thrombosis at the level of the solid muscular veins of the right leg, the measurements of the
arches and the great saphenous veins are dictated bilaterally, small-caliber great saphenous
veins at the infrapatellar level, which makes it difficult to display
o Doppler ultrasound of venous vessels of the upper limbs: Negative study for deep or
superficial vein thrombosis, measurements of the cephalic and basilic veins are dictated at the
level of the arms.
o Doppler of arterial vessels of lower limbs: A large number of calcium atheroma plaques are
observed in all supra- and infrapatellar arterial segments that do not generate significant
stenosis. At the level of the thighs and knees, a moderate amount of atheroma plaques are
identified; however, there is adequate permeability with preserved biphasic waves.
o Doppler ultrasound of neck vessels: Discrete increase in intima media thickness at the level
of both common carotids, mixed atheroma plaques of predominantly calcium at the level of both
bulboscarotids and at the level of both internal carotids with a smooth surface that does not
generate stenosis
o RX of chest: Widening of the upper middle mediastinum, in a probable vascular relationship,
there are no opacities of the lung fields or pleural effusions, there is no injury to the bone
structure
o Transthoracic echocardiogram: Left ventricle of normal size and systolic function, diastolic
function is indeterminate, mild left atrial dilation, right ventricle with normal structure and
systolic function, mild aortic valve insufficiency, mild mitral insufficiency, insufficiency
o Coronary arteriography with left catheterism: Obstruction of the left coronary artery with a
90% obstruction in the ascending anterior branch
 • Blood count
• Red blood cell morphology
• White Series
• Platelet Series
• Prothrombin Time
Paraclinics: • Almbunin
Laboratories • Urea nitrogen
• Ionized Calcium
• Chlorine
• Creatinine
• Potassium
• Magnesium
• Sodium
• Glycosylated hemoglobin
• T4 Free
• TSH
 Surgical Foundation

In the surgical procedure, the flow of blood flow to the heart will be corrected, removing the
saphenous vein and the mammary artery to create a bridge.

Describe Surgery

In the surgical procedure, blood flow to the heart will

be corrected, removing the saphenous vein and the
mammary artery to create a bridge where blood flow
will be provided to the ischemic heart network in the
appropriate way.
 PATIENT PREPARATION AND TABLES

• Type of washing
The patient is given a partial wash with alcohol and isopropyl alcohol.

• Type of anesthesia
General anesthesia is provided

• Position
Supine position

• Type of dressed
The patient is dressed, starting by placing the first lower sheet, then we place the lateral fields,
then the upper field that covers the lectern is placed, the perineal field is placed protecting the
patient's intimate area, we place the gaiters on the feet. of the patient, the umbilical field is
positioned, the upper sheet folded in half is positioned, we place the Ioban, finally we position the
general field.
 TABLES

MAY TABLE RESERVATION TABLE

 SURGICAL INSTRUMENTATION PROCESS

Surgical Planning:
• Body surface: 1,61
• Flow: 4,04
• Heparin dose: 4,06

Check list: (todo de manera gráfica)

• Instrumental (basket, separator ...)

• Equipment (defibrillator, saw, electro console ...)
• Basic medical devices (all the car)
• Specialized medical devices

• Perfusion devices
• Sutures

• Hemostats
Hemostats
SURGICAL PROCESS
PROCESS
Opening time: Skin incision and TCS are performed
on the left leg
The saphenous vein is located and its respective
extraction is performed.
The previous step is repeated until the saphenous
vein is completely removed.
Once the saphenous vein has been removed, its
permeabilization is carried out, binding any
possible leaks.
The incisions are closed to extract the saphenous
vein and the wounds are covered.
A sternotomy incision is made in the skin and TCS
in the chest until reaching the sternum
Sternotomy is performed
INSTRUMENTAL
We use MB 3 blade 15, electro scalpel, weithlander
separator, farabeuf separator
We use Electro scalpel, Weithlander separator,
ligature clips and 200 clips, cystic forceps,
Metzembaum scissors, Adson Kelly forceps with
pre-cut silk 1, May scissors
We use Electro scalpel, Weithlander separator,
ligature clips and 200 clips, cystic forceps,
Metzembaum scissors, Adson Kelly forceps with
pre-cut silk 1, May scissors
Bulldog clamp, arteriotomy cannula, 4/0 precut
silk, May scissors, baby mosquito clamp, 10cc
syringe with heparinized solution, blue fanny pack
We use saline solution, wet compress, dry
compress, vicryl 2/0, mayo scissors, monocryl 3/0,
elastic bandage
For this we use MB 7 blade 15, electro scalpel,
farabeuf separator, suction with yankawer cannula
With reciprocating saw

Hemostasis of the sternum is performed
Stemal separation is performed to look for the internal
mammary artery
The search, extraction and preparation of the internal
mammary artery is carried out, making it permeable.
The mammary separator is changed to the sternal
separator, incision and elevation of the pericardium is
performed.
Heparin administration
Vascular time (canulation)
The purse string is performed in the aorta artery
The purse-string is performed in the right atrium
The position of the aortic cannula is made and it is
connected to the arterial perfusion line.
The single venous cannula is positioned and connected to
the venous perfusion line.
We use electroscalpel, suction with a Yankee cannula,
bone wax
We use sternum protector and breast separator
Electro scalpel, ligalip clamp 100, clips 100 (2 in a row),
Metzembaum scissors, clips 200 at the end, Metzembaum
scissors, wet gauze, clip 100 at the end of the mammary
artery, fine vascular dissections, antegrade Potts
microvascular scissors
We use two sternal protectors, sternal separator, electro
scalpel, dissecting forceps, suction with a Yankee
cannula, silk or normal needle holder, May scissors
Dose: 4,06
With 2/0 polyester without plush, tomiquettes, mayo
scissors, curved Kelly tweezers, metzembaum scissors
With 2/0 polyester without plush, tomiquete, May scissors,
curved Kelly clamp
We use MB 7 blade 11, EOPA 20 cannula, tube clamp, dd
tourniquet kit, pre-cut silk 1, May scissors, rigid pericardial
suction, arterial perfusion line
We use vascular dissection forceps, MB 7 blade 11, single
34/46 venous cannula with 1/2-1/2 connector, tomiquette
presser, 1 pre-cut silk, May scissors, venous perfusion
line
 During the surgical procedure, before entering the pump, the Changing from #18 cannula to a #20 cannula
perfusionist informs the surgeon that there is no venous return.
The perfusion machine is checked to see if something was
failing and everything was fine. The surgeon informs that the
Aorta is very tense and swollen.

Entry in C.E.C : It goes into bomb

Clamping of the aorta artery is performed
A bag of tobacco for cardioplegia is made, the cardioplegia
cannula is positioned and connected to the perfusion line for
cardioplegia.
With satinsky total occlusion clamp
For this we use 4/0 polypropylene, tomiquete, May scissors,
curved Kelly clamp, cannula for antegrade cardioplegia,
protected mosquito clamp, perfusion line for cardioplegia with
cousine connector and three-way stopcock.

Perfusion line for cardioplegia

Cardioplegia is applied

Correction time steps are performed

Retraction of the heart is performed to look for the right coronary It is performed manually with radiopaque gauze.
artery
Surgical time: An incision is made in the right coronary artery to We use MB 7 blade 15, pottsanterograda microvascular
perform the respective anastomosis to the saphenous vein as a scissors, saphenous graft in blue coca, vascular dissection
free graft. forceps, dennis dissection

Proximal anastomosis of the free saphenous vein graft to the
right coronary artery is performed.
Before making an incision in the aorta, the vein graft is cut to the
necessary length
An incision is made in the aorta artery to perform the distal
anastomosis of the right coronary artery graft.
A distal anastomosis is performed of the graft previously
anastomosed to the right coronary artery and now in its distal
part to the aorta artery.
Patency of the internal mammary artery is performed by
removing the clip placed at its end ateriorly and testing patency,
the anterior descending artery is located and an incision is made
to perform the respective anastomosis to the internal mammary
artery.
Distal anastomosis of the pedicled graft is performed, from the
internal mammary artery to the anterior descending artery.
Remove clamp: It comes out of the pump, it is unclamped and
decannulated, tying the tobacco bags.
Pacemaker wire position and chest tube incision are made.
Prolene 7/0, vascular needle holder, dennis dissection, protected
kelly clamp, mayo scissors, dennis dissection, solution in 20cc
syringe
We use breast dissection forceps, antegrade scissors
We use HB # 11, MB #7, punch, wet compress (twice)
We use Prolene 6/0, vascular needle holder, dissection,
protected kelly clamp, mayo scissors, demnis dissection, solution
in 20cc syringe
We use Demnis dissection forceps, antegrade Potts scissors,
syringe with solution, bulldog clamp, MB 7 blade 15, antegrade
Potts scissors, vascular dissection forceps, Dennis dissection
We used Prolene 7/0, vascular needle holder, dissection, mayo
scissors, dennis dissection, 20 cc syringe with warm saline
solution
Removal of total occlusion clamp, vascular dissection clamp,
saline mayo scissors
Pacemaker thread 2/0, piece of perfusion line, needle holder,
polyester 2/0, MB 7 blade 15, electro scalpel, May scissors
The sternal separator is removed and final hemostasis of the Electroscalpel, bone wax, farabeuf separators and surgiccel
sternum is performed. power

The clean sternal separator is repositioned, the chest tube is

We use Kocher clamp, chest tube, polyester knot, Nelaton 14
positioned, the pleurovac is prepared and the compresses are
probe, suction rubber
performed and counted.
Compress, surgical steel 5, wire holder, wire cutter, Rochester
The separator is finally removed, and the sternum is sutured.
forceps

Asepto Syringe, dry compress, 20cc syringe with bupivacaine +

Washing and infiltration
hypodermic needle

TCS and skin are sutured Vicryl 0, monocryl 3/0, mayo scissors

Once the procedure is completed and the patient has been

cured, the expense sheet is created in the system and the
checklist in the counts is completed.
GRACIAS