Inferior mesenteric artery replantation does not decrease the risk of ischemic colitis after open infrarenal abdominal aortic aneurysm repair

Abstract

Background: Ischemic colitis after an open abdominal aortic aneurysm (AAA) repair remains a serious complication with a nationally reported rate of 1% to 6% in elective cases and up to 60% after an aneurysmal rupture. To prevent this serious complication, inferior mesenteric artery (IMA) replantation is performed at the discretion of the surgeon based on his or her intraoperative findings, despite the lack of clear evidence to support this practice. The purpose of this study was to determine whether replantation of the IMA reduces the risk of ischemic colitis and improves the overall outcome of AAA repair. Methods:Patients who underwent open infrarenal AAA repair were identified in the multicenter American College of Surgeons National Surgical Quality Improvement Program Targeted AAA Database from 2012 to 2015. Emergency cases, patients with chronically occluded IMAs, ruptured aneurysms with evidence of hypotension, and patients requiring visceral revascularization were excluded. The remaining elective cases were divided into two groups: those with IMA replantation (IMA-R) and those with IMA ligation. We measured the 30-day outcomes including mortality, morbidity, and perioperative outcomes. A multivariable logistic regression model was used for data analysis, adjusting for clinically relevant covariates.Results: We identified 2397 patients who underwent AAA repair between 2012 and 2015, of which 135 patients (5.6%) had ischemic colitis. After applying the appropriate exclusion criteria, there were 672 patients who were included in our study. This cohort was divided into two groups: 35 patients with IMA-R and 637 patients with IMA ligation. There were no major differences in preoperative comorbidities between the two groups. IMA-R was associated with increased mean operative time (319.7 6 117.8 minutes vs 242.4 6 109.3 minutes; P < .001). Examination of 30-day outcomes revealed patients with IMA-R had a higher rate of return to the operating room (20.0% vs 7.2%; P ¼ .006), a higher rate of wound complications (17.1% vs 3.0%; P ¼ .001), and a higher incidence of ischemic colitis (8.6% vs 2.4%; P ¼ .027). There were no significant differences in mortality, pulmonary complications, or renal complications between the two groups. In multivariable analysis, IMA-R was a significant predictor of ischemic colitis and wound complications.Conclusions: These data suggest that IMA-R is not associated with protection from ischemic colitis after open AAA repair. The role of IMA-R remains to be identified.

Outcome analysis and risk factors for postoperative colonic ischaemia after aortic surgery

“…In the current guidelines of the Society for Vascular Surgery, the preservation of blood flow to at least one hypogastric artery in the course of open surgery is recommended [19]. Nevertheless, neither the re-implantation of the inferior mesenteric artery [20] nor the preservation of pelvic perfusion with iliac branch devices [2] decreased ischaemic colitis. At the same time, the presence of atherosclerosis was postulated to be complicated for the pelvic circulation in case of interruption of hypogastric arteries [21], probably due to the loss of collateral blood supply through the hypogastric vessels brunches.…”

Pelvic radiation therapy as a potential risk factor for ischemic colitis complicating abdominal aortic reconstruction

“…These strategies remain controversial. Moreover, Lee et al 4 concluded that IMA reimplantation does not protect against CI. However, the study design has been criticized (and addressed by the authors).…”

Aneurysms and dissections - What is new in the literature of 2019/2020 - a European Society of Vascular Medicine annual review

“…Regular surveillance is still needed due to aortic dilatation after its treatment [275]. Whereas bilateral occlusion of the hypogastric artery may lead to ischaemic colitis, inferior mesenteric artery replantation does not decrease the risk of ischemic colitis after open infrarenal AAA repair [276].…”