68ys screen detected AAA male with a past history of hypertension and prostate cancer stage 3 under hormonal treatment for 4ys with stable PSA. No other significant medical conditions.
Fit and active walks 5 miles 3-times a week
Aneurysm now 5.7 on CTA and it was found to be anatomically suitable for EVAR.
Assume you assessed him clinically
1- What investigations you would like to request?
2- Patient read about both modalities of repair and asks for your advice, what would you recommend?
3- Taking your advice, he is more inclined towards OSR, do you agree or disagree and why?
4- He asks about recovery, possible risks ,follow up protocol of OSR and the likelihood of needing further interventions compared to standard infra-renal EVAR?
5- Could you please give comment on available evidence that you may use to make your decision?
A1..
I will ask for laboratory investigations as
CBC,LFT,KFT,Coagulation profile, and lipid profileinvedtigation to assess patient general condition as
ECG and ECHO for cardiac status
CPET exam for cardiac pulmonary and muscle evaluation
A2.. I will advice him for EVAR as it has less complications and more safe comparable to OSR
A3..
MY agreement or disagreement will depend on patient general condition and results of the investigation if he is fit generally for surgery and anaethesia and it is his desire so I will agree with him and the reverse is true
A4..OSR will require more post operative care than EVAR
In OSR patient will need post operative ICU admission with prolonged hospital stay while EVAR is more easy and will not required long hospital stay
OSR will have more complications as cardiac, pulmonary, renal, and bowel ischemia compared to EVAR
OF course EVAR has complications as endoleak and stent migration bur generally it is more favourable than open surgery if the patient has suitable EVAR. Criteria
A5…
The UK small aneurysm trial support that 5.5 cm is the cut off value for intervention and this patient aneurysm size is 5.7
Several trials were made to compare between EVAR and OSR AS EVAR1, OVER, and DREAM trials and all shows significant reducer 30 day mortality in EVAR will both long term results were nearly the same and also EVAR may require more reintervention than OSR
Thanks for your answer
1) do we need to Echo and CPET or we can only rely on CPET for pre-operative cardio-pulmonary assessment
2) Why EVAR is better (what is guidelines and evidence support your choice please)
3) Would EVAR does not hold cardiac, pulmonary,enal and ischemic complications and what is the mortality risk with EVAR please?
4) In what domain EVAR is easier for treatment, and would easier would be the standard to measure what is for patient best interest?