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An Image Guided Hybrid percutaneous extraction of residual inferior vena cava filter fragment embolized to the left ventricle
Odeaa Al jabbari, MD, Walid K. Abu Saleh, MD, John Bismuth, MD, Mahesh Ramchandani, MD.
Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA.
OBJECTIVE: We present our institutional experience of using intra-operative C-arm Cone beam CT (CBCT) image fusion Guidance in a major cardiac surgery. An otherwise healthy 54-year-old gentleman with normal coronaries presented angina like pain due to a small metal fragment broken of the inferior vena cave embolized the left ventricle(LV).
The patient was approached via minimally invasive technique using CT Angiographic guided imaging with the dynaCT in the hybrid room
METHODS: The procedure was performed in the hybrid room, under general anesthesia in supine positing. After retrieving the inferior vena cave via right internal jugular. DynaCT image fusion technique was included. A non-contrast rotational CT was performed prior to intervention and image fusion was utilized to fuse the previous obtained CT angiogram. Using the I-pilot software in the Syngo system the location of the metal fragment was electronically localized. The measurement was done vertically from the xiphiod process and horizontally on the skin service. Skin marks were applied to location of the fragment.
The xiphoid processes were excised and two-retractors were used to slightly elevate the sternum.
After the diaphragmatic surface was depressed down, Transverses pericardiectomy was performed. With the gentle displacement of the heart a small area of fresh clot located within the pericardial wall of LV where the fragment was expected to be. After the clot was suctioned, the object was clearly seen protruding via the inferior wall of the LV. The object was grasped via clamp and slided out carefully.
RESULTS: There was no bleeding from the puncture site. Patient extubated in the Operative room and transferred to the floor for recovery; patient was deemed stable and discharged home on postoperative day 3
CONCLUSIONS: C-arm Cone beam CT (DynaCT) image fusion affords the Cardiac surgeon a unique opportunity to use pre-operative images to advance intra-operative image guidance. Such image fusion strategies enhance routine 2D fluoroscopy by bringing 3D information of heart and the surrounding vasculature from pre-operative images and could play a potential role in minimizing the incisions required for approaching the targeted area in the heart.
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