75-year-old man for assessment of open AAA Repair vs EVAR

Background:

• 5.5cm AAA, asymptomatic
• COPD – mild, no admissions. 38 pack year smoking history.
• Lumbar spine fusion
• Graves’ Disease

Issues:

• IHD – angiogram 03/21 shows moderate non-obstructive CAD and normal LV systolic function. Medical therapy only
• Bilateral foot trauma – work injury many years ago. Multiple surgeries
• DASI 5.3 MET’s
• Walks slowly with 4WW due to foot injuries but keeps active, plays lawn bowls.

CPET:

• Normal spirometry, TLCO 78%
• Near-maximal test: RER 1.05 and HRmax 122bpm (82% predicted)
• Test ceased due to knee pain and anxiety
• Peak VO2 = 14.6ml/kg/min (61% pred), AT 10.3ml/kg/min
• Nadir VE/VCO2 elevated at 41.1
• HRR 6bpm

Discussion:

Open vs Endovascular

• Consensus that an endovascular approach is preferred in this case
• Age is a significant limiting factor to open AAA surgery in this patient
• Discussed with the surgeon and they are keen to proceed with EVAR 
• Ultimately it is a surgical decision, however they value our collaboration in these complex patients
• CPET can help guide this decision-making 

CPET

• Performed well on the bicycle
• Limited by anxiety – elevated nadir VE/VCO2 and low CO2 are indicative of hyperventilation
• Useful test in this case as patient unable to walk any distance, easy to underestimate functional capacity

Rehabilitation post-procedure

• Unlikely to be required for EVAR
• Bicycle-based rehabilitation available at JHH and would be beneficial to this patient

Plan

• Prehabilitation with cycle-based approach
• Proceed to EVAR