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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.

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.
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.
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.
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
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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