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A 72-Year-Old Man Is Referred for Preoperative Evaluation for Abdominal

question 201

Multiple Choice

A 72-year-old man is referred for preoperative evaluation for abdominal aortic aneurysm repair. He has had no chest pain, palpitations, shortness of breath, or syncope. The aneurysm was initially identified on routine screening when the patient was age 65. Since then, he has undergone yearly surveillance ultrasounds. The most recent study demonstrated an aneurysm with a diameter of 5.5 cm, an increase of 4 mm from the measurement at the ultrasound performed a year prior. He is not a candidate for minimally invasive endovascular stent graft repair due to the juxtarenal location of the aneurysm and need for left renal artery reimplantation. The patient has a history of hypertension, hyperlipidemia, type 2 diabetes mellitus, and mild aortic stenosis. Medications include aspirin, valsartan, amlodipine, high-intensity atorvastatin, metformin, and long-acting insulin. He is a former smoker but quit 15 years ago when he was diagnosed with diabetes. He does not drink alcohol and has no history of illicit drug use. The patient reports no difficulty with managing his activities of daily living, including briskly climbing up and down stairs in his 2-story home. A younger brother recently underwent coronary artery bypass graft surgery. Temperature is 36.7 C (98 F) , blood pressure is 142/80 mm Hg, pulse is 70/min, and respirations are 14/min. Pulse oximetry shows 99% on room air. Weight is 100 kg (220.5 lb) and height is 177.5 cm (5 ft 10 in) . BMI is 30 kg/m². Examination shows normal jugular venous pressure. Carotid pulses are 2+ and brisk bilaterally. The lungs are clear. On cardiac auscultation, S1 and S2 are normal and there is a soft midpeaking systolic murmur. A pulsatile mass is palpable on abdominal examination. There is trace pretibial edema bilaterally. On preoperative laboratory testing, the complete blood count is within normal limits. Glucose is 156 mg/dL and creatinine is 1.3 mg/dL. ECG shows normal sinus rhythm with nonspecific T-wave changes. Chest x-ray demonstrates a tortuous thoracic aorta but is otherwise normal. Which of the following is the most appropriate course of action?

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