76-year-old man for excision and reconstruction of right tibio-peroneal trunk, posterior tibial and peroneal aneurysms

Background

• Marfan-like syndrome – dilated aortic root, aneurysms, high-arched palate
• AF – apixaban and metoprolol
• OSA – compliant with CPAP
• CVA – right MCA in 2019. Residual Left hemiparesis
• Monoclonal gammopathy – surveillance

Issues

Type A aortic dissection  

• AVR and ascending arch repair in 2005
• Known residual aneurysm
• Aortic Root and Ascending aortic aneurysm increasing in size – reviewed by CTS and deemed unsuitable for further surgery. High complexity and multiple co-morbidities

Exertional dyspnoea

• Increasing in severity over last 7/12
• NYHA class 2
• Decreased exercise tolerance – 3.6 MET’s. Limited by dyspnoea
• No orthopnoea, PND, angina.
• Overtly fluid-overloaded with pitting oedema to both knees at clinic
• Admission in March with Dyspnoea – treated for Strep Viridans endocarditis
• ECHO/TOE – no evidence of endocarditis, Severely Dilated ascending aortic aneurysm (75mm), severely dilated AR (49mm), Moderate RA dilation, severe LA Dilation, LV and RV function normal.
• No regular cardiology follow-up

Lower Limb Aneurysms

• Asymptomatic
• Risk of rupture requiring emergency intervention
• Previous superior gluteal artery aneurysm rupture requiring repair with glue after failed embolization
• Option for surveillance

Discussion

Optimisation

• Current fluid overload concerning
• Cardiology review and optimisation of therapy required preoperatively
• Patient feels not at best baseline and keen to wait until cardiology review
• Surgery not time-critical

Conduct of anaesthesia

• Surgery will be long and complex
• GA recommended to provide optimal surgical conditions and minimise physiological stress response
• Spinal discussed however consensus that haemodynamic changes more difficult to control and surgery will require patient to lie very still for prolonged period.

Plan

• Cardiology review preoperatively
• Postpone surgery for 3 months