A 64-year-old man with morbid obesity, diabetes, chronic kidney disease, and chronic obstructive pulmonary disease (COPD) who takes at-home nebulizer treatments requests preoperative clearance for femoral popliteal bypass surgery to treat severe peripheral artery disease.
Physical examination reveals distant but clear lung sounds, mild jugular venous distention, and 1+ bilateral pitting lower extremity edema. A pulmonary function test conducted the previous year showed a mixed obstructive and restrictive pattern. Echocardiogram done a month ago showed mild left ventricular hypertrophy with normal left ventricular systolic function. The right ventricle was mildly dilated with elevated right ventricular systolic pressure of 52 mm Hg.
Which factors place this patient at highest perioperative risk?
A. Noninsulin-dependent diabetes
B. Chronic kidney disease with a baseline serum creatinine level of 1.5 mg/dL
D. Moderate pulmonary hypertension
E. Morbid obesity with a body mass index of 37