~75yo lady with incidental finding of 6.6cm juxta-renal AAA. Not obviously amenable to EVAR. 

Background

• Unprovoked DVT – warfarin 
• PMR – 2.5mg pred for  years 
• Independent, walks 1km/day 
• Driving license automatically revoked due to AAA size causing social isolation and loss of independence for patient

Issues

• Patient wishes
  • She understands the risks fully and wants to proceed open AAA
  • Very distressed by the threat of rupture and by her current loss of independence

• Cardiac function/exercise tolerance
  • TTE and sestamibi normal
  • CPET results stratify to high risk category:
    • Low AT 8.4ml/kg/min, low peak VO2 10ml/kg/min
    • Symptomatic with Dizziness and fatigue
    • HR peaked early then decreased throughout test (very abnormal) – ? AF
    • DBP decreased
    • Reviewed at CPET MDT – high risk candidate for open procedure

• Open v. EVAR
  • Potential for custom made EVAR graft however 12 weeks manufacturing time -> risk of rupture (10-20% annually) and longer time without independence preop.

Discussion

• Potential for prehab but challenging with transport issues
• What is her goal from the surgery? Avoid rupture vs to return to previous function. How does the latter goal align with likely outcomes from an open AAA. 
• Cardiologists suggest AF (if present) not optimizable because she does not require rate control. 
• How do we balance patient wishes against risks and potentially futile procedures?

Plan

• Psychological support offered through CPET MDT
• Holter monitor and cardiology follow up organised
• Discuss with surgeon re. EVAR