Major vascular surgery and angina

49-year-old lady for complete endovascular reconstruction of Aortic bifurcation, endoluminal graft, and reconstruction of aorto-iliac segment.

Background

Significant peripheral vascular disease – intermittent claudication, limiting all exercise.
Wheelchair bound outside home
Morbid obesity
NIDDM. HbA1c = 5.8%

Issues

Recurrent episodes of angina on minimal exertion over the last 3 months
Exercise stress echocardiogram performed – submaximal test due to leg pain. Exercised 3-4 METs and reached 69% of predicted heart rate
Chest pain during test, normal ECG and no exercise-induced Regional Wall Motion Abnormalities or reduction in end-systolic volumes
CTCA recommended by treating cardiologist
CTCA – Left main disease. ‘Extensive CAD with at least 50-69% stenosis in left main and mid RCA.’ Calcium score 439 (above 95^th percentile)
Discussed at cardiology meeting. Plan to postpone and perform coronary angiogram

Discussion

CTCA

Discussion as to the value of the test in this patient
Young patient but high calcium score not unexpected given existing vascular disease
Coronary CTA VISION study – evaluated role of CTCA in perioperative risk stratification.
Results showed patients were x 5 times more likely to have an inappropriate over-estimation of surgical risk based on RCRI after coronary CTA
Coronary angiogram likely to be a better test in this patient

LM disease

CABG vs PCI discussed
Traditionally, left main disease was an indication for CABG
Extensive area of myocardium involved with increased potential for morbidity and mortality
Evolution of practice, newer generation of DES, and improved adjuvant drug therapy has created better outcomes for PCI in LMCA
2 recent RCT’s EXCEL and NOBLE compared revascularization with PCI to surgical techniques with conflicting results.
Both trials showed similar long‐term survival rates to CABG surgery, particularly in those with low and intermediate anatomic risk.
However, patients undergoing PCI had higher need for repeat revascularization in the future.
Which patients are suitable for PCI? Current guidelines from AHA state they ‘strongly recommend surgical revascularization for LMCAD (class IA) with PCI considered a reasonable alternative (class II) in select patients with less complex anatomy and clinical characteristics that predict an increased risk of adverse surgical outcomes.’
https://www.ahajournals.org/doi/10.1161/JAHA.117.008151

Plan

Perioperative Talk