? for open AAA

Gabrielle Morris

60yo male. ? fitness for AAA repair for infrarenal AAA    

Background

  • IHD – RCA disease: stented 2020. Subsequent dobutamine stress ECHO normal. Awaiting sestamibi.
  • OSA – on CPAP
  • Obesity – 114kg
  • IDDM: HbA1c < 8.5%
  • Rheuamtoid arthritis – hands and feet only
  • DASI 5.5METs
  • Respiratory:
    • PFTs: FEV1 2.52L, FEV1/FVC ratio 0.84. Minor restrictive pattern
    • Current smoker
    • OSA on CPAP

Issues

  • Elevated perioperative risk
    • CPET:
      • Submaximal test. HR to 68% maximal (on beta-blocker). Limited by leg weakness
      • AT 4.78mL/kg/min, peakVO2 8.9mL/kg/min, V/VCO2 49.7 (all in high risk stratum)
      • No ischaemic ECG changes
      • Likely secondary to deconditioning and chronotropic limitation

Discussion

  • Group understanding was that open procedure preferred in this setting due to patient age
  • Chronologic age and physiologic age not equivalent
  • May benefit from prehabilitation – SBP remained < 180mmHg during CPET which means exercise is possible (in context of AAA).
  • Consideration for EVAR given high risk for open procedure

Plan

  • Prehabilitation
  • Smoking cessation
  • Await results of sestamibi
  • Discussion with surgeons regarding EVAR as option