Open AAA, high risk

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


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


  • 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


  • 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


  • 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. 


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


  • 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.