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TrapEase IVC Filter Insertion Medical Transcription Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Left leg deep venous thrombosis.
2.  Contraindication to long-term anticoagulation.

POSTOPERATIVE DIAGNOSES:
1.  Left leg deep venous thrombosis.
2.  Contraindication to long-term anticoagulation.

PROCEDURE PERFORMED:
Insertion of TrapEase inferior vena cava filter.

SURGEON:  John Doe, MD

ASSISTANT:  None.

ANESTHESIOLOGIST:  Jane Doe, MD

ANESTHESIA:
Local with monitored anesthesia care.

ESTIMATED BLOOD LOSS:
Less than 10 mL.

COMPLICATIONS:
None.

DISPOSITION:
To the recovery room.

DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room and placed on the operating table in the supine position.  After induction of adequate IV sedation, the patient was prepped and draped in the usual sterile fashion.

The area in the right groin was infiltrated with 1% lidocaine.  The right femoral vein was percutaneously cannulated without difficulty and a Glidewire easily inserted.  This was carefully followed under fluoroscopy through the iliac vein into the inferior vena cava.  A small incision was made at the insertion of the wire.  The needle was removed and a dilator and sheath was then threaded over the Glidewire.  Again, this was followed under fluoroscopy into the inferior vena cava.  The level of L3 was identified.  The wire and dilator were removed.

A cavogram was performed through the sheath that noted patent inferior vena cava below the level of the renal veins.  The filter was placed into the sheath, and the pushing mechanism was used to place the filter to the appropriate level.  The sheath was then pulled back, fully deploying the filter at approximately the level of L3.  Again, this was completed expanded.  The sheath was removed and pressure was held on the groin for 5 minutes for hemostasis.  The small incision was closed with a Steri-Strip dressing, and gauze compressive dressings were applied.

The estimated blood loss was less than 10 mL.  The sponge and needle count was correct.  The patient tolerated the procedure well.  He was awakened in the operating room and taken to the recovery room in stable condition without any apparent complications.

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