Large aneurysms are clearly life-threatening problems and need to be dealt with in an expedited manner. Cancer patients also need rapid treatment. So, which problem do you treat first? And, how does an endovascular approach alter this paradigm?
I recently met a healthy, 70-year-old woman with a known aneurysm that was slowly growing in size. In addition, it was discovered that she had a pancreatic mass that likely needed to be removed with a Whipple procedure. Her AAA was 4.8 cm in maximum diameter and after reviewing her imaging I did not think she was a candidate for a traditional endovascular repair. She had very small iliac vessels with extensive calcification. In addition, she had an infrarenal neck that was less than 10 mm and had extensive calcium and thrombus.
I had a long conversation with the family as well as the surgical oncologist caring for this patient. I told them that I would not treat this aneurysm at the current size. In addition, she was a poor candidate for a standard EVAR. Therefore, the plan is to treat her pancreatic problem. In the very unlikely event that she would develop issues with her aneurysm in the postoperative recovery, then I would deal with her aneurysm at that time. If her course is as expected, I would plan on checking her again in 6 months from the last ultrasound.
The question comes up as to how this patient would be managed if she were an appropriate EVAR candidate that would not require adjuncts? I told my surgical oncology colleague that I would lean towards endovascular repair prior to the Whipple procedure if she had appropriate anatomy.
Therefore, I pose several questions to you for your comments:
- Do you agree with this approach?
- Would you fix the AAA with an open repair at the same time as another major abdominal operation if the anatomy appeared to be poor for an endovascular approach?
- Are you willing to use snorkels/chimneys and an iliac conduit to repair an aneurysm less than 5 cm in size in a patient that is undergoing another operation?
Please add any questions that you would like to discuss.