Case Study: Chapter 02

Chapter 2: Perioperative Management of Patients Undergoing Vascular Surgery and Endovascular Therapy

Bill PEI-CHIN HSIEH, MD; CYNTHIA C. TAUB, MD, FACC, FASE

CASE STUDY:

A 79-year-old male is referred to the cardiology out-patient clinic for a preoperative cardiac evaluation in preparation for open repair of an infrarenal abdominal aortic aneurysm (AAA).

The aneurysm was incidentally detected on a routine pelvic ultrasound performed for urinary frequency. A computed tomographic angiogram demonstrated a 7.9-cm abdominal aortic aneurysm with extensive luminal thrombus.

The patient is an active individual who normally can manage 5 blocks of walking and one flight of stairs without symptoms. He does not have any known risk factors for coronary artery disease. His medical history is notable for moderate stenosis (60%‒70%) at the proximal left internal carotid artery without history of TIA or stroke; mild chronic obstructive pulmonary disease (COPD); and locally confined prostate cancer in remission. The patient is taking aspirin and clopidogrel for cardiac and stroke prevention in the setting of carotid artery stenosis.

On physical examination, his blood pressure is 129/82 mmHg, heart rate is 73 bpm, and no carotid bruits are heard. Cardiac auscultation reveals regular rhythm without gallops or murmurs. His abdominal aneurysm is palpable, and his peripheral arterial pulsations are present but diminished.

An ECG shows sinus rhythm without Q waves. Laboratory studies reveal normal renal function and hemoglobin, and an LDL level of 92 mg/dL. An echocardiogram reveals normal wall motion, 60% left ventricular ejection fraction, and no significant valvular disease.

Case Study: Chapter 2

* 1.) What is the patient’s category of risk for developing a major cardiac event within 30 days after the surgery?
* 2.) What diagnostic test should be performed next?
* 3.) The consulting cardiologist decided to proceed with a pharmacologic nuclear perfusion study that revealed a moderate-sized, moderate-degree reversible defect at the inferoapical region.

This was followed by coronary angiography that revealed an 80% mid-right coronary artery stenosis, with normal left ven- tricular function and wall motion. What is the most appropriate means of managing the RCA stenosis?

* 4.) The patient did not undergo coronary revascularization. Seven days later, he underwent a successful repair of his AAA.

Which of the following medications is least likely to provide cardiovascular protection for this patient before the procedure?