Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 145-149

Inferior Mesenteric Artery Revascularizatıon during Abdominal Aortic Surgery


1 Department of Cardiovascular Surgery, Lokman Hekim Hospital, Ankara, Turkey
2 Department of Anesthesiology, Lokman Hekim Hospital, Ankara, Turkey
3 General Surgery, A-Life Hospital, Lokman Hekim Hospital, Ankara, Turkey

Date of Submission01-Dec-2019
Date of Decision11-Dec-2019
Date of Acceptance19-Dec-2019
Date of Web Publication17-Jun-2020

Correspondence Address:
Dr. Erkan Kuralay
Department of Cardiovascular Surgery, Lokman Hekim Hospital, Ankara
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_102_19

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  Abstract 


Introduction: The incidence of ischemic colitis development after elective abdominal aorta surgery is 2%. However, it may rise to 32% in ruptured aneurysm operations. Inferior mesenteric artery (IMA) revascularization reduces the incidence of ischemic colitis. Materials and Methods: Our study included 87 patients who underwent abdominal aorta aneurysm surgery. IMA revascularization was applied in 32 patients. Four techniques are used for IMA revascularization. Carrel button technique is used in seven patients; direct IMA anastomosis to the main body of aortic graft is performed in 15 patients. IMA anastomosis is performed to the left limb of aortic graft in seven patients. IMA is extended by Dacron graft in six patients and saphenous vein is used for extension only one patient. Results: Colonic mucosal ischemia was observed in two patients with IMA revascularization, whereas in five patients without IMA revascularization. The clinical picture of ischemic colitis was evident in two patients without IMA revascularization. Average gaseous and stool output time after surgery were significantly earlier in patients with IMA revascularization. The average gaseous output time is 17 h with IMA revascularization, whereas 28 h in patients without IMA revascularization after surgery (P = 0.001). The average stool output time is 38 h after surgery in IMA revascularization but 55 h patients without IMA revascularization (P = 0.001). Conclusion: IMA revascularization is a considerably effective procedure for the prevention of ischemic colitis. Despite the low incidence, ischemic colitis carries high morbidity and mortality risk. IMA revascularization should be considered in the presence of the risk of the development of ischemic colitis.

Keywords: Abdominal aorta aneurysm, inferior mesenteric artery revascularization, ischemic colitis


How to cite this article:
Sahin MA, Temiz E, Külah B, Kuralay E. Inferior Mesenteric Artery Revascularizatıon during Abdominal Aortic Surgery. Indian J Vasc Endovasc Surg 2020;7:145-9

How to cite this URL:
Sahin MA, Temiz E, Külah B, Kuralay E. Inferior Mesenteric Artery Revascularizatıon during Abdominal Aortic Surgery. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Aug 12];7:145-9. Available from: http://www.indjvascsurg.org/text.asp?2020/7/2/145/286900




  Introductıon Top


Although the risk of development of ischemic colitis after elective abdominal aortic aneurysm surgery is low, this risk considerably increases (32%) after ruptured abdominal aorta surgery (32%).[1] The mortality rate due to colon infarction after aortic surgery is 80%–100%.[2] İschemic changes in the colonic mucosa were observed in 7%–35% of colonoscopic examinations in the follow-up.[3] Ischemic colitis due to abdominal aortic aneurysm surgery results from factors such as the coexistence of ruptured aneurysm, prolonged cross-clamping time, postoperative hypotension, excessive blood transfusion, ligation of hypogastric vessels, and ligation of the inferior mesenteric artery (IMA).[4] Routine IMA reimplantation has been suggested during abdominal aortic aneurysm surgery because it has been shown that the risk of development of all forms of ischemic colitis can be reduced using this technique.[5],[6] We performed a variety of surgical techniques for revascularization of IMA an addition to the reimplantation technique in our clinic for avoiding from colonic ischemia. Our prospective study aimed to compare the results of IMA reimplantation with the results of revascularization after IMA ligation.[7],[8],[9],[10]


  Materıals and Methods Top


Our study was conducted between June 1996 and August 2019 and included a total of 87 patients who underwent elective abdominal aortic surgery. IMA revascularization had not been added to abdominal aortic aneurysm procedures between 1996 and 2010 years. After we realized the importance of IMA revascularization, we routinely performed in addition to abdominal aortic aneurysm surgery for avoiding ischemic colitis.

Thirty-three patients were female and 54 were male. The mean age was 68 ± 8 in males and 71 ± 6 in males. Fifty patients were diabetic. Of the 87 patients, 73 were hypertensive, and the majority (80) had a history of smoking. Coronary artery disease was present in 30 patients, coronary bypass surgery was performed in 19 patients and percutaneous coronary intervention (balloon, stent) was performed in nine patients. In aortic surgery, aorto bi-iliac graft interposition technique (50 patients) was performed. In 25 patients, bi-femoral graft interposition was applied to the aorta and tubular graft interposition techniques were applied in 12 patients. IMA revascularization was performed with four different techniques. In seven patients, IMA orifice was prepared as a button and anastomosed as end-to-side with 5-0 prolene to the graft body [Figure 1]. Three of these patients underwent local endarterectomy to the IMA orifice. In 15 patients, IMA was anastomosed as end-to-side with 6-0 prolene to the body of the graft [Figure 2] and [Figure 3]a. IMA artery was shortened until an appropriate location was found in the anastomosis. In seven patients, IMA was anastomosed to the left leg of the main graft [Figure 4]. IMA grafts were not grown in two patients and the IMA was extended with 6 no Dacron grafts (anastomosis was performed at the distal end) and the Dacron graft was anastomosed end to the main graft. Because the IMA diameter was small in one patient, an extension was performed with a saphenous vein. The proximal of the saphenous vein was anastomosed to the main body of the graft. Patients were divided into two groups according to whether IMA reimplantation/revascularization was performed or not. IMA revascularization was performed in the first group (informed consent was obtained from all these patients) and not performed in the second group. Statistical comparisons were done by using SPSS 15.0 IBM SPSS statistics for Windows (Armonk, New York, USA) package program. Chi-square, Fischer's exact test, and student's t-test were used for comparison of mean values. P < 0.05 was accepted as statistically significant. The demographic characteristics of the patients were detailed in [Table 1].
Figure 1: Inferior mesenteric artery was prepared as botton and anastomosed end-to-side of the main body of the graft. Three patients underwent endarterectomy to the inferior mesenteric artery orifice before the procedure

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Figure 2: (a) Inferior mesenteric artery was anastomosed end-to-side to the main body of the graft after release. (b) Computed tomography angiography performed at the postoperative 3 months of the patient showed Inferior mesenteric artery

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Figure 3: Inferior mesenteric artery was anastomosed to the main body of graft by end-to-side fashion. (a) Inferior mesenteric artery directly anastomosed to maın body of aortıc graft. (b) Six mounts later computed tomography scan showed patient inferior mesenteric artery (arrow indicated patient inferior mesenteric artery)

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Figure 4: Inferior mesenteric artery was anastomosed to the left arm of the graft. Inferior mesenteric artery still patient in 3 months later computed tomography angiogram

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Table 1: Patients demographie revascularization techniques and results

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  Results Top


Transmural colonic ischemia was developed in two patients without IMA revascularization. Transmural colonic ischemia was not developed in patients with IMA revascularization (P = 0.034). Mucosal (nontransmural) colonic ischemia was developed in five patients without IMA revascularization but two patients with IMA revascularization (P = 0.044). Mortality was noted in one patient on the 4th postoperative day due to massive pulmonary embolism in patients with IMA revascularization. Three of the patients without revascularization surgery died (P = 0.023). Deaths were due to severe colonic ischemia in two patients without IMA revascularization. Both of the patients had poor performance status. Distal colectomy with proximal part of the rectum was removed en bloc and colostomy had been applied in these patients. One patient died from sepsis on the 25th of postoperative day and one patient died on the first postoperative day. Preoperative coronary angiography revealed a 50% stenosis in the middle segment of the left anterior descending branch, and medical treatment was prescribed. Two of the patients undergoing IMA revascularization suffered from bloody diarrhea and abdominal pain on the 3rd postoperative day. The presence of mucosal ischemia was detected in the colonoscopic examination. Clinical signs of colonic ischemia were alleviated with palliative management. Similar mucosal ischemic findings were detected in five patients without IMA revascularization. Strikingly, gas and stool discharge had occurred earlier in patients with IMA revascularization. Postoperatively, gas discharge was observed at the 17th hour in patients who underwent IMA revascularization. Postoperative gas discharge time was on average 28 h in the patients without IMA revascularization (P = 0.001). Postoperative stool discharge was noted at 38th h in patients who underwent IMA revascularization. Whereas this time was 55 h in patients without IMA revascularization (P = 0.001).

The patency rate of IMA revascularization was also investigated in our study. Computerized CT angiography was not carried out in asymptomatic patients due to insurance laws. Patency of IMA was found as intact in three patients with atypical symptoms in CT angiographic evaluation [Figure 2] and [Figure 3]b. The patency of IMA was investigated using Doppler ultrasound on postoperative 3rd and 6th months in other patients. The patency of IMA was found intact in these patients. A total of 32 patients underwent IMA revascularization. Seven of these patients had no flow in the IMA. Saphenous and Dacron grafts were used 3 of these patients. IMA anastomosis was performed on the left iliac crest in four patients had no flow in IMA.


  Dıscussıon Top


Ischemic colitis may occur after the reconstruction of the abdominal aorta and carries very high mortality risk. Mortality risk rises to 80%–100% in the presence of transmural ischemic colitis.[1],[2] IMA revascularization plays a critical role to avoid ischemic colitis.[5] According to knowledge in the literature, ischemic colitis more frequently occurs in conditions such as the presence of the patent IMA,[6] ruptured abdominal aorta, IMA mean stump pressure is below 40 mmHg after aortic reconstruction and presence of the stenosis of the superior mesenteric artery (SMA). Seeger et al.[5] reported that ischemic colitis had never developed in the patients who underwent IMA revascularization regardless of IMA stump pressure during abdominal aorta surgery. Our study showed that ischemic colitis developed in 2.7% of patients undergoing IMA ligation. Alpagut et al.[11] performed IMA ligation in 15 of 25 patients with patent IMA and reported transient ischemic colitis and diarrhea in 10 of these patients. Reoperation was required in two patients who suffered from severe gastric dilatation and anemia. Ischemic colitis results from abdominal aortic surgery are mainly due to the lack of IMA revascularization and lack of adequate collateral flow between SMA and hypogastric arteries. However, a variety of mechanisms may lead to ischemia in colonic mucosa. It is well known that the sensitivity of mesenteric circulation to angiotensin is higher than that of systemic circulation and pharmacologic interventions may lead to a decrease in the blood flow.[9],[10]

Clinical spectrum of ischemic colitis findings varies from subclinical changes to severe evident ischemic changes such as intestinal necrosis, perforation, peritonitis, and death.[12] Diarrhea is the most important presenting symptom and may be bloody or juicy brown form.[13]

Clinical symptoms of ischemic colitis may be subtle, and ischemic changes may not be visible. Thus further techniques such as Doppler ultrasound, fluorescent injection and intramural PH monitoring of sigmoid colon are required to identify the adequacy of mesenteric blood flow. Early diagnosis of ischemic changes in the colonic mucosa is extremely important, and colonoscopic examinations are required after aortic aneurysm surgery. Decompression of colon and maintaining fluid-electrolyte balance is required in these group patients. Delayed IMA revascularization procedures performed after the development of evident ischemic changes have no any healing effects on severe clinic picture. Timely performed IMA revascularization interventions may be beneficial in the presence of only mucosal and nontransmural ischemic changes detected by colonoscopy. However, there is a little information about this subject in the literature.

We think that IMA revascularization term should be used instead of IMA reimplantation. Our surgical strategy is based on revascularization of all IMA should be performed regardless of preoperatively patent or not. We used grafting techniques in all cases and added endarterectomy in the presence of IMA orifice stenosis. When we could not find the proximal lumen of the IMA, we continued the dissection until a suitable lumen for anastomosis and remained relatively short part of IMA anastomosed to the left leg of the main graft. Only if the remaining part of IMA could not reach any part of the main graft, Dacron or saphenous graft was used to extend the remaining IMA for anastomosis.

Most of the extended grafts prepared using Dacron or saphenous vein were completely obstructed in the long-time period. However, any colonic ischemia finding was not observed in the early and late postoperative period.

Ozen et al.[6] reported that earlier gaseous and stool discharge occurred in the presence of the IMA revascularization. Our results were consistent with this finding.

There was no comparable study tackled with IMA revascularization study in the literature. Few studies focused on IMA revascularization has been reported in vascular surgery in the literature. There was only one comparable study conducted by Ozen et al.[6] had been published in a national Turkısh vascular surgery journal. Our results were comparable and consistent with their results. Severe transmural colonic ischemia was not frequently encountered finding in small size case reports published in literature. However, all authors are favor in IMA revascularization procedure. A comparison could not be done due to the lack of the results of a comparative study.

Adequate and effective IMA revascularization procedure may be protective against the development of colonic ischemia. Although Ischemic colitis occurs rarely carries high morbidity and mortality risk. Routine IMA revascularization should be performed in the presence of the risk of the development of colonic ischemia after abdominal aortic aneurysm surgery. A variety of extension techniques should be considered for a safety anastomosis in the presence of the inadequate length of IMA.


  Conclusion Top


Routine IMA revascularization should be performed during abdominal aortic aneurysm surgery to avoid colonic ischemia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bandyk DF, Florence MG, Johansen KH. Colon ischemia accompanying ruptured abdominal aortic aneurysm. J Surg Res 1981;30:297-303.  Back to cited text no. 1
    
2.
Kim MW, Hundahl SA, Dang CR, McNamara JJ, Straehley CJ, Whelan TJ Jr. Ischemic colitis after aortic aneurysmectomy. Am J Surg 1983;145:392-4.  Back to cited text no. 2
    
3.
Hagihara PF, Ernst CB, Griffen WO Jr. Incidence of ischemic colitis following abdominal aortic reconstruction. Surg Gynecol Obstet 1979;149:571-3.  Back to cited text no. 3
    
4.
Senekowitsch C, Assadian A, Assadian O, Hartleb H, Ptakovsky H, Hagmüller GW. Replanting the inferior mesentery artery during infrarenal aortic aneurysm repair: İnfluence on postoperative colon ischemia. J Vasc Surg 2006;43:689-94.  Back to cited text no. 4
    
5.
Seeger JM, Coe DA, Kaelin LD, Flynn TC. Routine reimplantation of patent inferior mesenteric arteries limits colon infarction after aortic reconstruction. J Vasc Surg 1992;15:635-41.  Back to cited text no. 5
    
6.
Özen Y, Güler A, Uçak A, Yilmaz AT. Relationship of the risk of colonic ischemia after abdominal aortic aneurysm and inferior mesenteric artery reimplantation. Kosuyolu Kalp Derg 2012;15:17-21.  Back to cited text no. 6
    
7.
Bandyk DF, Florance MG, Johansen KH. Colon ischemia accompanying ruptured abdominal aortic aneurysm. J surg Res 1981;30:297-9.  Back to cited text no. 7
    
8.
Bernsteın WC, Bernsteın EF. Ischemic ulcerative colitis following inferior mesenteric arterial ligation. Dis Colon Rectum 1963;6:54-61.  Back to cited text no. 8
    
9.
Bailey RW, Bulkley GB, Hamilton SR, Morris JB, Smith GW. Pathogenesis of nonocclusive ischemic colitis. Ann Surg 1986;203:590-9.  Back to cited text no. 9
    
10.
Lopez JA, Harrison DG, Armstrong ML, Heistad DD. The hemodynamic consequences of the changes in the artery wall during atherogenesis. In: Glagov S, Newman WP 3rd, Schaffer SA, editors. Pathobiology of Human Atherosclerotic Plaque. New York: Springer-Verlag; 1990. p. 481-96.  Back to cited text no. 10
    
11.
Alpagut U, Kalko Y, Dayioglu E. Gastrointestinal complications after transperitoneal abdominal aortic surgery. Asian Cardiovasc Thorac Ann 2003;11:3-6.  Back to cited text no. 11
    
12.
Rutherford RB. Vascular Surgery. 4th ed., Vol. 2. Philadelphia: WB Saunders; 1995. p. 1312-20.  Back to cited text no. 12
    
13.
Schroeder T, Christoffersen JK, Andersen J, Bille S, Gravgaard E, Kimose HH, et al. Ischemic colitis complicating reconstruction of the abdominal aorta. Surg Gynecol Obstet 1985;160:299-303.  Back to cited text no. 13
    


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