EVAR after prehab

67-year-old man for re-consideration of EVAR

Background:

  • 5.5cm infra-renal AAA 
  • Previous perioperative assessment and CPET for this procedure
  • Deemed too high risk based on CPET results
  • Progress over last 6/12;
    • Optimised from cardiac perspective, has commenced Entresto and fluid balance improved
    • Commenced a daily exercise program 
    • 30 minutes daily on treadmill at 3.6km/hr
    • DASI 5.6 MET’s
    • 14kg weight loss

Issues:

  • IHD
    • Inferior MI 2008. Multiple stents to distal RCA 90% stenosis
    • Infrequent episodes of stable angina. On maximal medical therapy
    • SESTAMIBI – large, fixed perfusion defect in anterior wall with no reversibility demonstrated
  • HFrEF – 49%. Hypokinesis of inferior and posterior walls. Moderate Pulmonary hypertension, Increased LV filling pressures.
  • NIDDM – HbA1c = 6.7%
  • BMI 45, after recent 14kg weight loss
  • Severe OSA/OHS
    • compliant with CPAP. AHI = 97, SpO2 = 94% RA, HCO3 = 28
    • AHI reduced to 1 with CPAP however pressures inadequate and patient reluctant to increase. 
    • SpO2 82% overnight with CPAP
  • Asthma/COPD – post-BD FEV1 = 2.47 (84%), FVC = 4.2 (112%), DLCO = 67%
  • ICU admission 2021 with PR bleeding and type II respiratory failure requiring NIV

CPET:

1st CPET – April 2021

  • Sub-maximal test
  • Stopped after 2 minutes of cycling due to hypertension (SBP>180 as per AAA protocol)
  • Excessive ventilatory response – as demonstrated by VE/VO2 slope
Chart, scatter chart

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  • CPET MDT advised that patient was not a suitable candidate for any surgery. 
  • Recommended prehabilitation

2nd CPET – October 202

  • Sub-maximal test – RER 1.05                                         
  • Stopped due to SBP exceeding 200mmHg 
  • Peak VO2 12.2ml/kg/min
  • AT 1.5L/min or 9.2ml/kg/min
  • Nadir VE/VCO2 34.8 (using actual body weight)
  • HRR 7bpm
  • VE/V02 graph for second test:
Chart, scatter chart

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Discussion:

Optimisation

  • CPET results reassuring that patient has been optimised
  • Symptomatic HF treated – can now lie flat, previous orthopnoea
  • Exercise also beneficial physically and psychologically in this case
  • Remains a high-risk patient, RCRI 3, NSQIP risk of death 2%, cardiac complication 3.5%, and serious complication 15%.
  • Patient and family understand and are accepting of risks
  • Discussed with surgeon – surgery carries prognostic and QoL value even if life-expectancy limited.

CPET

  • Near-maximal test and values for peak VO2 and AT obtained on recent CPET
  • Retrospective data indicates poor long-term prognosis and life-expectancy based on inability to complete the test. See doi:10.1093/bja/aet193
  • Results are based on actual body weight and not modified for ideal body weight.
  • Maximal SBP values pre-determined in conjunction with vascular surgeon in cases of AAA to minimise risk to patient.

Plan:

  • Proceed to EVAR