Week 1 – Case 2
68 years old male patient, ex smoker with background of HTN CKD. He never had any cardiac symptoms. He was found to have 6.8 cm AAA on US that he has had for RUQ pain. All of his blood tests came back as normal apart for eGFR of 29. Patient is not keen on surgery.
How would you approach his consultation?
What is the risk of rupture?
What is your recommendation of treatment?
How would you assess his risk for surgery?
Is there any pre op medication that can be used to reduce the risk of surgery?
Patient had CPET to assess his general fitness
Main finding on this was, He stopped after a total of 9.44 minutes of exercise on reaching a peak work rate of 116 Watts . There is no ECG changes showed on exercise. Anaerobic threshold 15.1 ml.kg-1.min-1 and FEV1/FVC is 81%
please comment on these finding and indicate the suitable clinical plan.
What is the definition of Anaerobic threshold? what is the cut off that indicate higher risk for open surgery?
Q1
History
– detailed history of the patient’s current symptoms, including the nature, duration, and severity of the RUQ pain and associated symptoms.
-Review the patient’s smoking history
-Assess the patient’s cardiovascular risk factors, including hypertension and CKD.
-Inquire about any previous abdominal surgeries or interventions.
_obtain family history
2.Examination:
-Perform a thorough physical examination, focusing on the abdomen.
-Palpate the abdomen for pulsatile masses and assess for tenderness.
-Evaluate for concomitant peripheral vascular disease.
3.Investigations:
-Review the ultrasound report and confirm the size and location of the AAA. MRA for pre-operative planning.
-Evaluate renal function with consider further investigations for the cause of CKD.
-Assess cardiovascular risk factors with lipid profile,and ECG.
Q2
6%
Q3
(EVAR): minimally invasive procedure could be a good option, but his kidney function needs evaluation by a nephrologist to ensure suitability.
Open surgical repair: would be a last resort due to its invasiveness, but might be necessary if EVAR is not feasible. But open surgery is better than endovascular EVAR as soon as the patient is fit for surgery
Q4
Routine lab test including S.albumin
Radio isotope scan to asses function of the kidney+nephrology consultation
Respiratory function tests
Echo +cardiac perfusion tests
Anaesthesia consultation
Q5
proper BP control
Statin
Single anti platelet
Antibiotics before surgery
Epidural Anastasia is preferred
Q6
is the point during exercise when your body must switch from aerobic to anaerobic metabolism.
Q1 ask about abdominal pain , back pain bowel habits, family history
exclude pop aneurysm.. Examined prepheral pulsation
MRA scan without contrast to detect site of aneurysm and Exclude other aneurysms
Q3 open aortic repair is my recommendation after ensure of patient’s fittness
Q4 Cardiac consultation after ECG ECHO.. Nephrological consultation.. Chest consultation after PFT, CT Chest
Q5
B.p control medication
Improve renal perfusion
Q1
History :ask about abdominal pain , back pain bowel habits, family history
Examination:exclude popliteal aneurysm
Investigation: CT scan without contrast to detect site of aneurysm ( juxtarenal or infra renal or supra renal )
Q2
Risk of rupture is from 10_20% for diameter from 6_6.9cm
Q3 open aortic repair
Q4
Radio isotope scan to asses function of the kidney+nephrology consultation
Respiratory function tests
Echo +cardiac perfusion tests
Anaesthesia consultation
Q5
proper BP control
Statin
Single anti platelet
Antibiotics before surgery
Q1:
By history: I would ask about nature of RUQ pain to exclude any causes for this pain.
Also, ask about +ve family history.
By examination: full Vascular exam. and search for other arterial aneurysms especially pop. A. aneurysm.
By investigation: MRI with TOF (whole aorta and both LL) for pre opp planning.
Q2: According to the UK Small Aneurysm Trail: the risk of rupture in this patient is from 11 to 22% (Rutherford’s 9th edition).
Q3: I prefer to do open surgical repair as it is the 1st line of ttt (nice guidelines 2020) (ESVS 2023 – recommendation 61).
Q4:
According to ESVS 2023 guideline (recommendation 37): nephrology consultation is mandatory in this patient as he has stage 4 CKD.
Also, I would order other investigation and pre-operative labs: CBC, Coagulation profile, lipid profile, ECG, ECHO, lung function test, Hepatic function test, Albumin level.
Q5: pre-opp medication
– Station (4 w before surgery if possible) (ESVS recommendation 44, 21).
– single antiplatelet (ESVS recommendation 45, 21).
– proper BP control (ESVS recommendation 21).
– Pre opp antibiotics (ESVS recommendation 46).
– Pre opp epidural analgesia (ESVS recommendation 47).
first i would ask for his medical history, family history and full vascular examination for exclusion of any other arterial aneurysm or any complication
then i would ask for nephrology consultation
and i will explain the condition to the patient and different treatment planes for him and tell him the different risks
risk of rupture is about 6%
my recommendation is open surgical repair if the patient is generally fit for surgery as results of his CPET shows
risk of surgery could be assessed after CPET , echo and ECG
full lab investigation which came normal apart from eGFR ( CKD )
that carriers high risk of renal faliure after endovascular intervention
pre operative medications is important to reduce cardiovascular risk as statins, antiplatelets, life style modifications , control and blood pressure monitoring ,
regarding CPET results peak work rate shows 116 watts which with the use of predicted work rate gives us indicator for patient condition and fittness
FEV1/FVC is 81% which is normal result and indicates no limiting lung condition
no ECG changes during test that means no significant or limiting myocardial ischemia is detected
anaerobic threshold is above 10.2 ml.kg.min ( 15.1 ml.kg.min )
according to these results patient is fit for open surgical intervention
anaerobic threshold is the point during exercise the body switch from aerobic to anaerobic metabolism to continue work and 10.2 ml /kg/ min is the limit below which there is high risk for surgery
very good answer Ahmed, Thank you
The anaerobic threshold is the intensity of exercise at which your body shifts from being able to produce energy through primarily aerobic metabolic pathways to the need to produce more energy through anaerobic glycolysis
It would be considered high risk surgery if anaerobic threshold less than 10 ml /kg/ min
Thank you so much
Honestly, I search for the definition of Anaerobic threshold.
It is the point during exercise when your body must switch from aerobic to anaerobic metabolism.
Thanks Eslam, That is the whole point of the question is to go and find out more about this
Accidentally found 6.8 cm AAA in patient has CKD stage 4
Risk of rupture about 10-20%
Management starts with work up for assessment of cardiac, pulmonary functions as well as nephrology consultation for the kidney disease.
As long as the patient does not prefer surgery so I would recommend EVAR that could lead to permanent renal failure due to contrast used during procedure. some measures can reduce kidney damage for instance using CO2 instead of contrast and the use of IVUS.
Anesthesia consultation for pre operative risk assessment according ASA classification. Cardiac, pulmonary and metabolic status would help in assessment in risk score for the patient.
Antihypertensive, antiplatelet, statins and good hydration specially before EVAR
First optain full history and full examination especially general and distal pulsations
Consulting nephrology for assessing risk of dialysis in case of dye injection
Discussing with the patient in prescence of nephrologist and also discussing surgical option if generaly fit
Rupture risk 10-22%
I recommend open surgical repair if the patient is generally fit especially if risk of dialysis is high
General fittnes will be assessed by anesthesiologist and discussed with the patient
Pre operative medications for control of hypertension and statins.
Thanks Ahmed, good answer
1. Approach his history by : personal and occupational history, history of current illness, family history of 1st degree relatives who had same symptoms or diagnosed as AAA .
Clinical examination in the form of full vascular examination to exclude pop artery aneurysm.. and exclude that the aneurysm is not tender on palpation.
Investigations : baseline blood tests including lipid profile… U/S .. MRA as the patient is CKD
2. Risk of rupture: about 6 %
3. Open repair or EVAR using co2
according to NICE guidelines 2020 : open repair is the 1st line of management in fit patients.
4. Assess his risk for surgery by: using CPET , ECG , ECHO , full labs including albumin level , pulmonary function tests.
5. The aim of pre op medications is to reduce cardiovascular risk factors . Such as : statins , antiplatlets , blood pressure controle , life style modifications .
Q4
Pre-operative risk assessment of surgery for an elderly male patient with large AAA (6.8 cm) symptomatic (RUQ pain??), HTN, CKD4?? with no hx. of cardiac events, will depend on an assessment of:
Medical history and examination.DDx of RUQ pain.Laboratory tests for this are all normal, apart from eGFR 29 (serum cystatin C to rule in/out CKD).Pulmonary function tests.Cardiac Assessment: ECG, echo.Imaging CTA with 3D reconstruction to classify AAA as infra-, juxta-, para-, or suprarenal and evaluate anatomical features may limit EVAR.Nephrologist, cardiologist, anesthesiologist consultations.I can assess the risk of elective AAA repair by using the British Aneurysm Repair (BAR) score, designed to estimate the risk of in-hospital mortality following elective AAA repair (OR or EVAR).
http://www.manits.org.uk/bars/Default.aspx
S. W. Grant, G. L. Hickey, A. D. Grayson, D. C. Mitchell and C. N. McCollum. National risk prediction model for elective abdominal aortic aneurysm repair. British Journal of Surgery 2013; 100: 645–653
https://pubmed.ncbi.nlm.nih.gov/23338659
1- I will start the consultation by explaining to the patient What is an aneurysm and the increased risk of rupture and the chances of survival if not treated and ruptured
I will clearly state that the intervention is life saving procedure that has to be done.
2-risk of rupture 6-6.9 cm in diameter is 10-20%
Aggarwal S, Qamar A, Sharma V, Sharma A. Abdominal aortic aneurysm: A comprehensive review. Exp Clin Cardiol. 2011 Spring;16(1):11-5. PMID: 21523201; PMCID: PMC3076160.
3- I will ask for nephrology consultation to decide the risk of dye administration, but hence the patient has CKD stage 4 it is preferred to go for open repair
Khoury MK, Thornton MA, Weaver FA, Ramanan B, Tsai S, Timaran CH, Modrall JG. Selection criterion for endovascular aortic repair in those with chronic kidney disease. J Vasc Surg. 2023 Jun;77(6):1625-1635.e3. doi: 10.1016/j.jvs.2023.01.185. Epub 2023 Jan 31. PMID: 36731756.
3-NSQIP (National Surgical Quality Improvement Program) universal surgical risk calculator
4- strict control of blood pressure, fluid therapy and N-acetyl cysteine could improve kidney function
Thanks for this case
1-Patient has abdominal aortic aneurysm reached threshold of repair >5.5 cm by US. Stage 4 CKD patient
*Nephrology consultation to improve kidney function and request CTA for elective repair and discuss with patient the importance and risk of this investigation.
2-Risk of rupture 11-22% (Rutherford)
3-Recommend EVAR with suitable anatomy as it has lower mortality and morbidity rates compared with open surgery .
https://pubmed.ncbi.nlm.nih.gov/22857808/#:~:text=CKD%20increased%20(P%20%3C%20.,EVAR%20and%2010.3%25%20for%20OAR
Thanks Muhamed for your answer
Q1
1.History
-Obtain a detailed history of the patient’s current symptoms, including the nature, duration, and severity of the RUQ pain and associated symptoms.
-Review the patient’s smoking history, including pack-years and duration of cessation.
-Assess the patient’s cardiovascular risk factors, including hypertension and CKD.
-Inquire about any previous abdominal surgeries or interventions.
2.Examination:
-Perform a thorough physical examination, focusing on the abdomen.
-Palpate the abdomen for pulsatile masses and assess for tenderness.
-Evaluate for signs of peripheral vascular disease.
3.Investigations:
-Review the ultrasound report and confirm the size and location of the AAA. MRA for pre-operative planning.
-Evaluate renal function with consider further investigations for the cause of CKD.
-Assess cardiovascular risk factors with lipid profile,and ECG.
Q2
Risk of rupture 6%
https://www.jvascsurg.org/article/S0741-5214(21)01693-1/fulltext
Q3
Close surveillance: Might be considered initially, but with more frequent monitoring due to the AAA size. This approach carries the risk of delaying intervention if rapid growth occurs.
(EVAR): minimally invasive procedure could be a good option, but his kidney function needs evaluation by a nephrologist to ensure suitability.
Open surgical repair: would be a last resort due to its invasiveness, but might be necessary if EVAR is not feasible.
https://www.jvascsurg.org/article/S0741-5214(23)00268-9/abstract
Q1 detailed medical ,surgical hx familly hx and peripheral vascular ex
CTA and prepare the pt for elective repair after full assessment and Nephrological referal
Q2 6%
Q3 EVAR if anatomically suitable
Q4 by assess cardiac, pulmonary, kidney function and nutritional status
Q5 statin and antilatelet
Q5
2_10:20%
Thanks Eman, Could you please provide the evidence for your answer? Could you please take some time to answer rest of the questions?