62-year-old indigenous lady with complete occlusion of the distal aorta. 

Background

• PVD
  • 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
• Obesity

Issues

• 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

Discussion

Adrenal lesion

• 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

WCC 

• 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.