Management of Peripheral Artery Disease and Abdominal Aortic Aneurysm in a Patient With Multiple Cardiovascular Comorbidities

Introduction Individuals with multiple cardiovascular comorbidities require careful procedural planning and long-term surveillance due to possible complications. This case highlights the complexity of balancing between maintaining femoral artery shunt patency and performing endovascular aneurysm repair (EVAR) in a high-risk patient. Case Presentation A 77-year old male with ischemic cardiomyopathy, severe heart failure (left ventricle ejection fraction 20%), prior myocardial infarctions, and chronic atrial fibrillation presented with worsening peripheral artery disease (PAD) symptoms. In 2021, computed tomography (CT) revealed left superficial femoral artery occlusion and an abdominal aortic aneurysm extending to the left iliac artery. Stenting was not viable due to accessory renal arteries. To restore lower limb circulation, the patient underwent a retrograde bypass implantation with deep femoral artery angioplasty. Later that year, he had a cardiac arrest from ventricular tachycardia and, post-resuscitation, underwent a CRT-D implantation. In 2023, follow-up CT revealed a bulging of the aortic wall with intimal flap dissection in the infrarenal region. Despite high risk, EVAR was performed successfully. CT angiography showed regression of aneurysm diameter in the right infrarenal region and near the left common iliac artery (from 5.3 x 4.9 cm to 4.5 x 3.7 cm), with no endoleak. However, a Type IA endoleak was noticed at the proximal stent junction near the left renal artery. Additionally, a new Bosniak IV cyst in the left kidney was identified. Discussion AAA affects 1.3–5% of men over 65 and is often linked to PAD, worsening prognosis [1]. PAD is present in approximately 23.8% of AAA patients, elevating cardiovascular risk [2]. Minimally invasive EVAR is preferred, lowering perioperative complications. [3] However, its success depends on patient-specific anatomical factors, as risks such as persistent endoleak, renal ischemia, and aneurysmal remodeling may still occur, requiring long-term surveillance. [4] Conclusions This case illustrates the challenges of managing PAD and AAA in a patient with severe cardiovascular disease, where procedural choices must balance aneurysm stability and systemic perfusion. Monitoring is key to prevent late complications and optimize outcomes.