Positive sestamibi, ? EVAR

Gabrielle Morris

81-year-old for Fenestrated EVAR.

Background:

  • Juxtarenal AAA: 56x63mm
    • Complex procedure involving custom graft and sacrifice of left kidney via occlusion of L renal artery.
  • Peripheral vascular disease – Left SFA stent 2011
  • CVA – many years ago. Residual left arm and leg weakness
  • Ex-smoker

Issues:

  • IHD
    • ‘Silent’ MI in 2001
    • Sestamibi organised by surgical team as part of pre-op workup – LAD territory perfusion defect. Majority of defect is fixed but there is an area of low-grade reversible ischaemia
    • Echo shows normal LV size and systolic function. Mild segmental impairment.
    • Patient remains asymptomatic
    • Discussed at cardiology meeting – high-risk for perioperative MACE
    • Not a candidate for preoperative intervention given lack of symptoms, relatively normal LV function, and likely surgical CAD
    • Cardiologist advice was to proceed with surgery and contact perioperatively if any issues
  • Surgical discussion – above information discussed
    • Surgeon feels cardiac risk is significant
    • Advises a further perioperative visit to relay risk and discuss cancellation of procedure
    • Difficulty contacting patient – Time an issue as surgery in a few days

Discussion: surgeon reluctance to proceed, do most pt’s EVAR candidates have ischaemia, 5% mortality per year, AKI likely