pre operative assessment of AAA- protocols and form

1. Pre - operative assessment of
Elective AAA patients
Presenter: Dr Geetanjali Verma
Moderators: Dr S. Kathawaroo, Dr G. Fitzsimmons
Cumberland Infirmary, Carlisle

2. Topics
• Preop protocol
• Proposal of new assessment form
• V POSSUM

3. Protocol
• What we already know:
• Vascular society UK: AAQIP: Preoperative care
bundle; version 5 (July 2011)
Review: VSGBI AAA QIP 2018

4. Recapturing…
• 1. All patients should undergo standard pre-operative risk
assessment:
– Pre operative resting 12-lead ECG in all patients undergoing EVAR or
OSR within 30 days of planned treatment is recommended.
– In patients with active cardiac conditions, including unstable angina,
decompensated heart failure, severe valvular disease, and significant
arrhythmia, cardiology consultation is recommended before
EVAR or OSR.
– Patients with significant clinical risk factors, such as CAD, CCF, CVA,
DM, CRF and unknown or poor functional capacity (METS < 4), who
are to undergo OSR or EVAR, noninvasive stress testing is suggested.

5. – In patients with a drug-eluting coronary stent requiring open aneurysm repair,
discontinuation of Clopidogrel 7- 10 days preoperatively with continuation of aspirin is
suggested. Clopidogrel should be restarted as soon as possible after surgery. The relative
risks and benefits of perioperative bleeding and stent thrombosis should be discussed
with the patient.
– Smoking cessation for at least 2 weeks before aneurysm repair is recommended.
– Pre operative hydration in non dialysis dependent patients with renal insufficiency
before aneurysm repair is recommended.
• Normal saline or 5% dextrose/Sodium bicarb in patients at risk of contrast induced
nephropathy = EVAR.
• With holding metformin
– at the time of administration of contrast material among patients with an
eGFR <60 mL/min or
– up to 48 hours before administration of contrast material if the eGFR is <45
mL/min
– restarting metformin no sooner than 48 hours after administration of contrast
material as long as renal function has remained stable (<25% increase in
creatinine concentration above baseline.
– Perioperative transfusion of packed red blood cells if the hemoglobin level is <7 g/dL is
recommended

6. 2. All patients should undergo CT angiography for
assessment for OR or EVAR.
• If renal impairment is present further action may be needed,
based on the eGFR:
– eGFR > 60: no additional procedures required
– eGFR 30-60: ensure adequate oral rehydration before CT
– eGFR < 30: patient to be formally discussed at MDT to decide
if fit for intervention, prior to imaging.

7. 3. Patients should be seen by an anaesthetist with interest in
vascular anaesthesia prior to listing for surgery.
4. Patients should be assessed for surgery through a MDT
process involving surgeon and radiologist as a minimum, with
input from an anaesthetist interested in vascular anaesthesia.

8. • 5. All patients should be provided with an AAA
information leaflet detailing the risk,
complications and expected
outcomes/recovery periods of AAA treatment
options
• https://www.vascularsociety.org.uk/_userfiles
/pages/files/patient-information-leaflet-
treatment-of-aaa.pdf

9. 6. Consent
All patients should sign a consent form detailing
the risks, benefits and complications of the
procedure.
Standard agreed information should be included
along with any local risk figures.
All patients should be asked if their data can be
entered into the National Vascular Database.

10. An addition
7. Risk scoring using V-POSSUM for predicting
morbidity & mortality
• http://www.riskprediction.org.uk/vasc-
index.php

12. Proposal: Change of charts for anaesthetic
assessment for AAA
• Pros:
– Detailed: patient history, examn, invx
– Risk scoring included
– Clear , targeted
– Follow up details
• Cons:
– ?Time consuming : 4 vs 7 pages 

21. References:
• AAQIP: Preoperative care bundle; version 5
(July 2011); VSGBI 2012
• https://www.nice.org.uk/guidance/gid-
cgwave0769/documents/short-version-of-
draft-guideline
• https://www.jvascsurg.org/article/S0741-
5214(17)32369-8/fulltext#sec1.1
• Hqip.org.uk (2018)

22. • Thankyou