70-year-old man for open AAA.  6cm supra-renal aneurysm. Asymptomatic

Background

• Carotid Disease – under surveillance. No CVA/TIA
• Non-hodgkins lymphoma

Issues

• IHD 
  • Recent angiogram in Private hospital – chronic occlusion of RCA with collaterals. Mild to moderate LAD disease. 
  • Works as a cleaner. DASI 7.6 MET’s
  • Non-specific infero-lateral ST depression (1mm) on baseline ECG
• Peripheral vascular Disease – aorto-iliac stents. Not suitable for EVAR
• Complex surgery
• Current Smoker – 28 pack year history. Normal Spirometry
• Chronic Renal Impairment – Stage 2a

CPET

• Sub-maximal test – HRmax152 (80%pred). Limited by assessor due to ECG changes.
• Up-sloping infero-lateral ST depression during exercise
• 1mm ST depression during recovery
• No chest pain/dyspnoea
• Patient happy to continue exercising.
• Peak VO2 = 1.5ml/kg/min
• AT 10.3ml/kg/min
• Nadir VE/VCO2 36.4
• HRR = 11bpm

Sestamibi 

• Requested due to sub-maximal CPET and ECG changes
• Reversible ischaemic changes in mid basal-inferior wall 
• Reduced ejection fraction (40%) post-stress

Urgent cardiology appointment via Rapid Access clinic

• Angiogram obtained from Private hospital (As Above)
• Sestamibi should be interpreted in the context of a chronically occluded RCA
• No angina despite good exercise tolerance
• Echocardiogram – normal LV systolic function and no regional wall motion abnormalities
• Nil further interventions required. 

Discussion

Increased risk of cardiovascular and renal complications

• RCRI 3 – 15% risk of MI, cardiac arrest, or death within 30 days of surgery
• Vascular Quality Initiative index:

• Existing renal impairment, supra-renal clamp, and predicted, complex surgery – increased risk of post-operative renal failure requiring long-term dialysis

Plan

• Discussed with surgeon and procedural anaesthetist – decision made to bring patient and family back to clinic for shared-decision making. 
• Convey increased risks outlined above and allow for family discussion before proceeding.