Open v. Endovascular Aortic Recon

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


  • 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


  • 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


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


  • 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.