81-year-old for Fenestrated EVAR.
- 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
- ‘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