CAD/Aneurysm repair

Not sure if this is the appropriate forum or not.  My husband underwent a quadruple CABG surgery in April 2009.  He has had no problems since.  He was recently diagnosed with an abdominal aortic and an iliac aneurysm.  The one in the iliac artery is 3.5 cm and needs to be repaired, so they are going to also do the aortic aneurysm.  They are hoping to be able to do this as an EVAR.  My question is I guess if they have to convert to open repair, how much a risk is presented by his past surgery and heart problems?   He also has had a MI prior to surgery and possibly one before that he was unaware of.  Last stress test was fine, no enlargement of his heart and shortly after surgery his ejection fraction was at 45%. He has no angina or shortness of breath and is tolerant of moderate/heavy exercise.  He is 60 years old.  A second question, not sure you will be able to answer...how frequently does an EVAR end up urgently converted to an open repair?

[CCF HeartMD-1]

Because he was just recently revascularized (had CABG 2 years ago) and has no symptoms and does moderate/heavy exercise without any problems his risk of having a cardiovascular event if he has an open repair is most likely around 1-2% by a risk calculation we use as called the revised cardiac risk index as long as he doesn't have kidney disease or insulin-requiring diabetes which would increase this number some.  If he takes beta-blockers (such as metoprolol) through the period prior to surgery and after surgery this risk is even lower around 0.8-1%.   EVAR is much less risk and they do most of the operation through small incisions in the groins.  To be honest, I am not sure what percentage end up being urgently converted to an open repair.  I think this would depend on the institution and you should talk to the vascular surgeon.  The other issue is that EVAR is not perfect yet and sometimes patients can have leaks so he will need to be watched closely over the next few years with routine CT scans.  Why are they doing an EVAR rather than open repair? Do they feel like he is high risk?

[CFS56]

The vascular surgeon offered him the option of the EVAR rather than the open surgery and he is very much against the open surgery if he can avoid it. It was his choice.  He does understand that he will have to be followed closely forever. He has been taking metoprolol 100mg since the surgery.  
Thank you so much for your reply.  It made me feel a bit less worried.

[CCF HeartMD-1]

Sounds good.  Make sure the surgeons keep him on metoprolol for a goal heart rate between 60-70 through the surgical period (up to surgery and immediately following surgery and he should stay on it forever) and he should take a baby aspirin (81mg) during this same time period.  Some surgeons will say stay off an aspirin prior to surgery (they usually mean a big adult aspirin, 325mg) but he should at least be operated on with a baby aspirin to reduce his risk.  He should also be on a statin.

Hope this helps.  Good Luck!

[CCF HeartMD-2]

Just an added point, conversion rate in large clinical trials comparing EVAR To open repair is somewhere between 1-3%

[CFS56]

When the anesthesiologist's office called they told him to quit taking aspirin and fish oil one week prior to surgery.  I called the vascular surgeons office and they said absolutely not, to continue as normal.  He has also been instructed to take his beta blocker the morning of surgery.  He  is taking lipitor.  Thank you so much for the information, it is very much appreciated.  

[yarrow]

Nice, prompt answers to the lady's concerns.  It's kind of you.

[Howling8]

A related discussion, Do I need surgery now? was started.