What are the pre‑operative considerations for a 78‑year‑old woman undergoing infrarenal abdominal aortic aneurysm repair?

Preoperative Considerations for a 78-Year-Old Female Undergoing Infrarenal AAA Repair

Surgical Risk Stratification and Mortality Assessment

This 78-year-old female patient requires comprehensive preoperative cardiac evaluation, careful assessment of her suitability for endovascular versus open repair based on anatomic criteria and comorbidities, and realistic discussion of age-specific procedural risks given that women over 75 have significantly higher mortality with open repair. 1, 2

Age and Gender-Specific Risk Factors

• Female gender independently increases 30-day mortality risk (assigned 2 points in validated risk indices), with women demonstrating lower survival rates (35.7%) compared to men (54.0%) in AAA repair series 3, 2
• Age >65 years adds 3 additional risk points to mortality prediction, and patients at 78 years have median post-repair survival of approximately 6-8 years, which must be weighed against rupture risk 2, 4
• Women over 77 years have particularly high procedural risk for open repair and should strongly be considered for endovascular approach or conservative management if not EVAR-eligible 4
• The 90-day mortality risk for open repair exceeds 5% in patients over 75 years, with more pronounced risk in women 4

Cardiac Evaluation and Optimization

Mandatory Cardiac Assessment

• Perform comprehensive cardiac risk stratification including noninvasive myocardial imaging or coronary arteriography, as 80% of successful AAA repair series utilized preoperative cardiac evaluation 5
• Preliminary coronary revascularization (CABG or PCI) favorably influences overall mortality (hazard ratio 0.76,95% CI 0.59-0.98) in patients with severe coronary artery disease 5
• Evaluate for active cardiac conditions including unstable coronary syndromes, decompensated heart failure, significant arrhythmias, and severe valvular disease that would require treatment before elective AAA repair 1

Perioperative Beta Blockade Considerations

• Patients with known coronary disease or multiple cardiac risk factors should be evaluated for perioperative beta blockade according to ACC/AHA guidelines, though this must be balanced against hemodynamic stability 1

Pulmonary Assessment

Critical Respiratory Risk Factors

• Screen specifically for dyspnea severity, as dyspnea at rest carries 8 risk points and dyspnea on moderate exertion carries 2 points in validated mortality prediction models 2
• Chronic obstructive pulmonary disease independently increases mortality risk (P = 0.012) and requires preoperative optimization 5
• Obtain baseline pulmonary function testing and arterial blood gas if significant respiratory disease is suspected 2

Renal Function Evaluation

Preoperative Creatinine Assessment

• Preoperative creatinine >1.5 mg/dL adds 2 risk points and independently predicts 30-day mortality 2
• Elevated creatinine levels adversely affect both early and late mortality (P < 0.001) after AAA repair 5
• Postoperative renal dysfunction (doubling of creatinine or need for hemodialysis) significantly compromises short- and long-term survival and increases risk of respiratory failure, spinal cord injury, and cardiac complications 6

Hematologic Assessment

Platelet Count Evaluation

• Abnormal platelet counts (<150,000/mm³ or >350,000/mm³) add 2 risk points to mortality prediction and require investigation and potential correction before elective surgery 2
• Assess baseline hematocrit, as low initial hematocrit associates with increased mortality in AAA repair 3

Vascular Disease Screening

Peripheral Arterial Disease Assessment

• History of peripheral arterial disease requiring revascularization or amputation adds 3 risk points and significantly impacts perioperative mortality 2
• Screen for other manifestations of atherosclerotic disease including carotid stenosis and coronary disease, as AAA patients have impaired survival with 5-year mortality rates significantly higher than the general population 7

Anatomic Evaluation for Repair Strategy Selection

EVAR Eligibility Assessment

• Obtain CT angiography to determine anatomic suitability for EVAR, which requires proximal neck length ≥10-15 mm, proximal neck diameter <30 mm, and favorable iliac access 8, 7
• EVAR demonstrates significantly lower 30-day mortality (1.7%) compared to open repair (4.7%) and should be strongly preferred in this 78-year-old female patient if anatomically suitable 8
• More than 50% of patients have anatomy unsuitable for conventional EVAR, though fenestrated EVAR extends treatment options for those with inadequate neck length 8

Open Repair Considerations

• Open repair remains indicated for patients who are good surgical candidates but cannot comply with lifelong EVAR surveillance requirements 8
• The 90-day mortality risk for open repair in women over 75 exceeds 5%, making EVAR strongly preferable when anatomically feasible 4

Risk Stratification Using Validated Index

Calculate Total Risk Score

Using the validated NSQIP risk index, assign points for: 2

• Dyspnea at rest: 8 points; on moderate exertion: 2 points
• History of PAD requiring intervention: 3 points
• Age >65 years: 3 points
• Creatinine >1.5 mg/dL: 2 points
• Female gender: 2 points
• Abnormal platelet count: 2 points

Risk categories: 2

• Low risk (<7% mortality): <8 total points
• Intermediate risk (7-15% mortality): 8-11 points
• High risk (>15% mortality): >11 points

Urgency Assessment and Timing

Elective vs. Symptomatic Repair

• Emergency AAA repair carries 2-5 times higher cardiac complication rates compared to elective operations, with mortality for ruptured AAA at 42% versus 3.5% for elective repair 1
• Symptomatic but intact AAA has 19% mortality rate, emphasizing the importance of elective repair before symptom development 1
• Any symptomatic AAA warrants urgent repair regardless of diameter, as symptoms indicate increased rupture risk 6

Life Expectancy and Surveillance Capability

Long-Term Considerations

• Patients with limited life expectancy (<2 years) should not be offered EVAR due to the need for lifelong surveillance and reintervention 8, 6
• EVAR requires mandatory lifelong imaging surveillance with higher reintervention rates (5.1% vs 1.7% for open repair) 8
• At age 78, median survival following successful repair is 6-8 years, which must be weighed against aneurysm size and rupture risk 4

Preoperative Optimization Measures

Modifiable Risk Factors

• Implement strict blood pressure control, as hypertension accelerates aneurysm growth and increases perioperative risk 7
• Initiate or optimize statin therapy for cardiovascular risk reduction in all patients with atherosclerotic peripheral arterial and aortic disease 7
• Smoking cessation counseling is essential, as smoking is the strongest modifiable risk factor for AAA expansion and rupture 7

Common Pitfalls to Avoid

• Do not underestimate the significantly higher procedural risk in elderly women compared to age-matched men, particularly for open repair 3, 4
• Avoid proceeding with open repair in women over 77 years without first confirming EVAR is not feasible, given their prohibitively high open surgical risk 4
• Do not offer EVAR to patients unlikely to maintain long-term imaging follow-up, as undetected endoleaks can lead to rupture 8
• Ensure the patient understands that EVAR requires lifelong surveillance every 6-12 months and has 10-17% endoleak rate at 30 days requiring potential reintervention 6