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Inferior Mesenteric Artery Replantation Does Not Prevent Ischemic Colitis After Open Infra-renal Abdominal Aortic Aneurysm Repair - An Analysis of the ACS-NSQIP Targeted Database
Kyongjune B. Lee, MD, Jinny Lu, MD, Richard Amdur, PhD, Anton Sidawy, MD, Robyn Macsata, MD, Bao-Ngoc Nguyen, MD.
The George Washington University Hospital, Washington, DC, USA.

OBJECTIVES:
Ischemic colitis remains a significant complication after open infra-renal abdominal aortic aneurysm (AAA) repair with a nationwide reported rate of 6%. Inferior mesenteric artery (IMA) replantation is performed at the discretion of surgeons despite the lack of clear evidence to support this practice. This study, using the American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) database, re-examines whether IMA replantation reduces ischemic colitis.
METHODS:
Patients who underwent open infra-renal AAA repair were identified in the multicenter ACS-NSQIP Targeted AAA database during 2012-2015. Emergent cases and those that required supra-renal clamping were excluded. The remaining elective cases were divided into two groups: those with IMA replantation and those with IMA ligation. A multivariate logistic regression model was used for data analysis.
RESULTS:
We identified 2397 patients who underwent AAA repair between 2012-2015, of which 135 patients (5.6%) had ischemic colitis. After excluding emergent, supra-renal-clamp, chronically occluded, or “unknown” status of the IMA, a total of 572 remaining cases were analyzed: 505 cases with IMA ligation vs. 67 cases with IMA replantation. No significant difference in demographics and pre-operative comorbidities was found between the two groups. IMA replantation was associated with increased operative time (operative time > 7 hours: 16% vs. 7%, p = 0.004; mean operative time: 5.3 ± 2.3 vs. 4.0 ± 1.7 hours, p = <0.0001), higher rate of return to the operating room (18% vs. 10%, p = 0.048) and higher incidence of ischemic colitis (12% vs. 5%, p = 0.044). There were no significant differences in 30-day mortality, cardiac, pulmonary, renal dysfunction, or composite outcome between the two groups.
CONCLUSIONS:
IMA replantation results in longer operative time and higher risk of return to the operating room without the benefit of reducing ischemic colitis.

Table 1: 30-day Outcomes of IMA replantation vs. IMA ligation
Replanted IMALigated IMAp
(n=67)(n=505)
Mean operative time (hrs)5.3 ± 2.34.0 ±1.7<0.0001
Operative time > 7 hours11 (16%)33 (7%)0.004
Return to operating room12 (18%)50 (10%)0.048
Mortality5 (7%)20 (4%)0.200
Ischemic colitis8 (12%)25 (5%)0.044
Cardiac events4 (6%)23 (5%)0.540
Pulmonary complications11 (16%)78 (15%)0.840
Acute kidney injury or renal failure5 (7%)27 (5%)0.480
Wound complications*6 (9%)19 (4%)0.060
Composite outcome**23 (34%)128 (25%)0.120
*Wound complications: surgical site infection, deep wound infection, organ space infection or wound dehiscence.
**Composite outcome: combined incidence of mortality, ischemic colitis, cardiac, pulmonary, renal, wound complications.,


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