EVAR, multiple comorbidities

Gabrielle Morris

Consult – 71-year-old man for consideration of EVAR

Background

  • 5.5cm AAA – incidental finding
  • Chronic right sided chest/flank pain. CT performed to investigate. 

Issues

  • CKD – Stage 4. Haemodialysis, oliguric, hyperkalaemia and anaemia. 
    • Currently being considered for renal transplant, AAA repair is a requirement pre-transplant
  • IHD – NSTEMI in 2020, admitted with APO
    • Angiogram showed 3-vessel disease, for medical management
    • Sestamibi – Area of reversible perfusion defect in inferolateral wall.
    • Echo – low normal ejection fraction, Mild aortic stenosis
    • Paroxysmal AF – Not anticoagulated due to PR bleeding and epistaxis
  • Chronic cough – Cryptogenic pneumonia in 2018. Underwent lung biopsy and VATs.
  • DASI = 5 MET’s, limited by right-sided pain. 
  • Recent review by HIPS for right-sided chest pain- concern that patient had significant signs of heart failure and referred to cardiologist
  • Patient not seen face-face as anxious to attend due to current coronavirus outbreak

Discussion

Optimisation

  • Cardiac assessment required regarding optimising therapy for IHD and CCF. Important to consider deterioration of aortic stenosis.
  • Multiple specialists involved for renal and respiratory. Regular review.
  • Renal transplant surgery could be extremely challenging

Risk assessment

  • NSQIP: 9.7% risk of cardiac complication, 8.7% risk of mortality
  • SORT: 2.7% risk of perioperative mortality
  • Patient aware of risks and keen to proceed

Plan

  • Cardiologist review as above
  • Liaise with nephrologist regarding current fluid balance
  • Review appointment with patient face-face to examine and consolidate discussion of perioperative risk.