62-year-old indigenous lady with complete occlusion of the distal aorta.
- Thrombosed distal abdominal aorta and occlusive iliac artery disease
- Claudication and lower limb ischaemic neuropathy
- 50m on flat with 4WW -> rest
- COPD – moderate, NYHA class III, nocturnal cough, ceased smoking 1/12 ago, symptoms improving.
- NIDDM – good control
- PAF/flutter – on rivaroxaban and beta blocker
- HTN and Dyslipidaemia
- Chronic back pain
- Lifelong high WCC, up to 23, cause unknown
- Incidental finding of adrenal lesion
- Seen on CTPA done in context of chest pain and rapid AF (self-resolved). CTPA negative
- CT images suggest consistent with adrenal adenoma
- Common pathology – prevalence of 7% of people over 70yo (as per BMJ best practice)
- Investigate – Before non-emergency surgery, yes. Especially this surgery with consequent physiologic derangement.
- Need to exclude Cushing’s, phaeochromocytoma, and primary hyperaldosteronism
- Endocrine team requested – Plasma metanephrine and catecholamines, a dexamethasone suppression test, renin:aldosterone ratio, and DHEAS
- Haematology AT suggests could be due to obesity and smoking.
- Further pathology tests requested to exclude myeloproliferative disorder although thought unlikely.
Open v. Endovascular procedure
- For open procedure: SORT 2.59% risk of death (not adjusted for clinician assessment), ARISCAT 13.3% (moderate) risk of POPC, Gupta postop pneumonia 7.3% NSQIP risk of serious complications 16% v. 23% with open procedure.
- Proceed with open procedure if desired for surgical reasons, given the above risk indices.