Open infrarenal aortic aneurysm repair in a patient with COPD, kidney disease and a coronary stent

A 71-year-old man, 92 kg and 175 cm, is scheduled for elective open repair of a 6.4 cm infrarenal abdominal aortic aneurysm through a midline laparotomy. The aneurysm neck is 8 mm long and angulated, so the vascular surgeon has ruled out endovascular repair and warns that the clamp may have to go above the renal arteries.

He has COPD from 60 pack-years of smoking; he quit six months ago, has had no exacerbation this year and climbs one flight of stairs slowly. He has stage 3b chronic kidney disease from hypertensive nephrosclerosis. Two years ago he had a drug-eluting stent placed in the right coronary artery for stable angina and has had no chest pain since. A stress echocardiogram last month showed no inducible ischemia. His cardiologist stopped clopidogrel seven days ago; aspirin continues.

Medications: aspirin 81 mg, metoprolol succinate 50 mg, atorvastatin 80 mg, amlodipine 10 mg, lisinopril 20 mg (held for 24 hours), tiotropium and fluticasone-salmeterol inhalers, albuterol as needed. Allergies: none known.

• Blood pressure 148/82 mmHg, heart rate 62, respiratory rate 16, SpO2 93% on room air, temperature 36.6 °C
• Hemoglobin 11.6 g/dL, platelets 210,000/µL, INR 1.0, aPTT 29 s
• Sodium 139, potassium 4.9, bicarbonate 27 mEq/L, BUN 34 mg/dL, creatinine 1.9 mg/dL (eGFR 36 mL/min/1.73 m²), glucose 112 mg/dL
• Room-air arterial gas: pH 7.38, PaCO2 47 mmHg, PaO2 68 mmHg
• Spirometry: FEV1 1.6 L (55% predicted), FEV1/FVC 0.58, minimal bronchodilator response
• ECG: sinus rhythm 62, Q waves in II, III and aVF
• Transthoracic echocardiogram: ejection fraction 50%, mild inferior hypokinesis, no significant valve disease
• CT angiogram: 6.4 cm infrarenal aneurysm, single renal artery on each side, iliac arteries calcified but not aneurysmal