EVAR with COPD

Gabrielle Morris

83-year-old lady admitted to hospital with abdominal pain. Incidental finding of 6.4cm infra-renal AAA

Background

  • Severe COPD, recently commenced on home oxygen
  • Recent admission with infective exacerbation 
  • Type 1 respiratory failure, Room Air PaO2 = 55mmHg
  • Spirometry – FEV1/FVC: 0.99/1.48: 0.67. TLCO 37%
  • HFpEF. 1.5 litre fluid restriction
  • Pulmonary hypertension, moderate
  • Large hiatus hernia with uncontrolled GORD
  • Severe kyphosis

Issues

  • Incidental finding of AAA, suspicion of leak on scan
  • Ongoing abdominal pain
  • Haemodynamics and Haemoglobin stable

Discussion points

Should surgery proceed?

  • Large aneurysm, annual rupture rate around 10%
  • Respiratory physician opinion that survival from COPD is “a few years.”
  • Patient keen for procedure, has supportive family and great-grandchildren nearby
  • Not suitable for an open procedure
  • Patient and family fully aware of risks

Optimisation

  • Echocardiogram? Enable assessment of LV function and Pulmonary hypertension – not likely to change management

Conduct of Anaesthesia

  • Sedation vs GA vs epidural
  • Patient can lie flat without significant dyspnoea, but procedure expected to last around 90 minutes
  • Breath-holds required and can be painful
  • Aspiration a concern with sedation
  • GA may facilitate faster procedure
  • Aim to extubate at end of case
  • Epidural may prove difficult given kyphosis

Disposition ICU bed if GA/any complications