Laboratory test results:

This patient presents with the concomitant diagnoses of CAD, peripheral vascular disease, COPD, obesity, and chronic kidney insufficiency. Additional tests like dipyridamole stress test and dobutamine stress echo have low sensitivity (20–30%), but high specificity (95–100%). Subjecting this patient to stress testing may prompt further investigation if positive and should lead to a final intervention with regard to the CAD. If this final intervention is not desirable or too high of a risk due to patient’s general condition, then these tests should be avoided. Each test the patient is subjected to in the process of preparation for surgery has its own risk, which is additive to the inherent risk of the planned surgical procedure. Risk stratification can occur postoperatively. However, optimal medication coverage should be instituted prior to surgery. The beneficial effects of statins and beta blockers in this patient population have been established. It is important to consider the type of anesthesia in this patient. General anesthesia (GA) has been associated with higher cardiovascular morbidity compared to regional anesthesia (RA) [1].

Isolated long-standing LBBB does not mandate further testing or treatment in this setting. If pulmonary artery catheterization is planned, precautionary measures to treat complete heart block should be in place. Catheter induced right bundle block is usually transient, but longer duration may result in prolonged asystole requiring CPR. The availability of resuscitative medications and external pacing capability is advised. It may be difficult or impossible to detect ST depression or elevation in a patient with LBBB.

An elevated creatinine and BUN in the setting of significant cardiovascular disease signify chronic renal impairment. It would be prudent to obtain the glomerular filtration rate (GFR) to assign the chronic kidney disease (CKD) stage. More advanced stages correlate with higher morbidity and mortality in the perioperative setting. The CKD stage is defined based on the glomerular filtration rate, age, gender, and race according to the formula: 186 × (Creat/88.4) − 1.154 × (Age) − 0.203 × (0.742 if female) × (1.210 if black).

Chronic kidney disease poses significant risk for renal dysfunction in cases where intravenous dye is used. A stage change in the renal insufficiency has been reported to occur between 18% and 29% of cases [2]. The presence of CKD should prompt further discussion with the patient and evaluation of recent changes in BUN, Cr, and GFR. A plan for preprocedural hydration should be considered.

Many elderly patients have COPD, particularly those with significant smoking history. It is important to evaluate the patient for evidence of exacerbation and optimal therapy. Significant reversibility on PFTs may signify the need for further therapy optimization. Significant pulmonary disease renders patients at much higher risk for mortality and significant morbidity due to diminished pulmonary reserve.

Associated bronchitis and sputum production should be assessed. History of intubation for COPD exacerbation may impact the type of anesthesia administered. An in-depth discussion of general versus regional or even local anesthesia should be performed. The patient’s preferences need to be respected but possibilities of prolonged intubation and related complications should be addressed. Home oxygen requirement, acute changes in symptoms, or baseline function should prompt the evaluation of arterial blood gases for baseline CO2 retention. Higher bicarbonate on the electrolyte panel may signify metabolic compensation for respiratory acidosis due to CO2 retention. Oral steroid use should be noted and replacement may be required.

COPD is another risk factor for prolonged postoperative ventilation and associated complications. Given the low invasiveness of the procedure, regional anesthesia should be considered. Loco-regional anesthesia has been associated with better perioperative pulmonary outcomes and shorter LOS. Edwards in 2011 showed a preponderance of pneumonia and failure to wean from the ventilator in the general anesthesia versus the regional anesthesia group [1]. Given a recent exacerbation of COPD in this patient, loco-regional anesthesia should be the preferred choice.

Obesity has been associated with worse outcomes in both open and endovascular abdominal aortic aneurysm repair as determined from the NSQIP study in 2007 by Giles [3]. Obesity is often associated with obstructive sleep apnea, hyperlipidemia, and type II diabetes. These associated comorbidities present additional risk for the surgical patient.

Patients who cannot walk up one flight of stairs or walk on ground level at 3 km/hour based on a 5 m walk test in 6 s, have increased incidence of adverse events [4]. The walk test has been established as an independent predictor of increased postoperative morbidity and mortality. The patients in the Afilalo study had more than 2 times adverse outcomes over those who were able to do walk the distance in less than 6 s.

Patients with renal impairment carry additional risk based on dye exposure and load during the procedure. Patients who have intravenous dye allergy are most commonly allergic to the iodine in iodine containing dyes. This scenario is best managed by avoiding iodine and substituting with nonionic dyes. In EVAR imaging iodine dye is used. Pretreatment with corticosteroids and H1/H2 blockers is advised. N-acetyl cysteine may have a role in renal protection. Adequate hydration should be performed before the procedure, but caution should be taken not to put this patient in acute congestive heart failure. Alternatively, intraoperative imaging may be performed with carbon dioxide as the contrast agent in patients at very high risk for renal impairment, weighed against the risk of significant gas embolism.

Advances in graft development allows for implantation of grafts which may cover the ostium of large arterial branches. Secondary stenting through fenestrations in the graft during the procedure allows for reestablishing perfusion in those branches. There are patient-specific fenestrated grafts with orifices for the renal, celiac, and superior mesenteric arteries. Additional vascular access through the brachial or axillary arteries may be required. This should be discussed with the surgeon pre-operatively.

A scoring system (see Tables 30.1, 30.2, 30.3 and 30.4) has been set up based on the aortic angle and tortuosity, and the presence of intraluminal thrombus. The scores are one through three points with higher total number of points signifying poorer EVAR outcomes [2].