Colonic ischemia in EVAR and open repair

1. COLONIC ISCHEMIA IN EVAR & OPEN
REPAIR AAA
(RUPTURE AND ELECTIVE SX)
F1 Parach Sirisriro
12 March 2018

2. OUTLINE
Definition and Anatomy reviews
Pathogenesis
Incidence and risk factor
Diagnosis and investigation
Treatment outcome and prognosis
Summary

3. REFERENCE

4. REFERENCE
• Colon ischemia following abdominal aortic aneurysm repair in the era of endovascular
abdominal aortic repair : Journal of Vascular Surgery Volume 47, Issue 2 , January 2008,
Pages 258-263
• Risk factors and outcomes of postoperative ischemic colitis in contemporary open and
endovascular abdominal aortic aneurysm repair : Journal of Vascular Surgery Volume 63,
Issue 4, April 2016, Pages 866-872
• Incidence of and risk factors for bowel ischemia after abdominal aortic aneurysm repair :
Journal of Vascular Surgery Volume 64, Issue 5, November 2016, Pages 1384-1391
• Care of Patients with an Abdominal Aortic Aneurysm : 2018 Practice Guidelines from the
Society for Vascular Surgery

5. REFERENCE
• Koruda, M. J. (2012). " Colonic bleeding and ischemia." , Shackelford's Surgery of the
Alimentary Tract , Chapter 152: 1856-1877.
• Huguier, M., et al. (2006). "Ischemic colitis." Am J Surg 192(5): 679-684.
• Perry, R. J. T., et al. (2008). "Colonic ischemia complicating open vs endovascular abdominal
aortic aneurysm repair." Journal of vascular surgery 48(2): 272-277.
• Cronenwett, J. L. and K. W. Johnston (2014). “Abdominal aortic aneurysm” ,Rutherford's
Vascular Surgery 8th edition , Chapter 131-133

6. COLONIC
ISCHEMIA
• Refers to
inflammation of the
colon secondary to
vascular insufficiency
and ischaemia.
• . The severity and
consequences
of the disease are
highly variable.
Koruda, M. J. (2002). "Shackelford's Surgery of the Alimentary Tract." Gastroenterology 123(3): 951-952.

7. ANATOMY REVIEW
Koruda, M. J. (2012). " Colonic bleeding and ischemia." , Shackelford's Surgery of the Alimentary Tract , Chapter 152: 1856-1877.

8. ANATOMY REVIEW
Koruda, M. J. (2012). " Colonic bleeding and ischemia." , Shackelford's Surgery of the Alimentary Tract , Chapter 152: 1856-1877.

9. COLLATERAL CIRCULATION
Koruda, M. J. (2012). " Colonic bleeding and ischemia." , Shackelford's Surgery of the Alimentary Tract , Chapter 152: 1856-1877.
IMA
occluded

10. COLLATERAL CIRCULATION
Koruda, M. J. (2012). " Colonic bleeding and ischemia." , Shackelford's Surgery of the Alimentary Tract , Chapter 152: 1856-1877.
SMA
occluded

11. COLLATERAL CIRCULATION
Koruda, M. J. (2012). " Colonic bleeding and ischemia." , Shackelford's Surgery of the Alimentary Tract , Chapter 152: 1856-1877.
IMA and IIA
occluded

12. Colonic ischemia (esp Sigmoid
colon) following AAA repair is a rare
but devastating complication
This may result from
1. Nonocclusive ischemia due to shock
or vasopressive drugs,
2. Occlusive ischemia
embolization
occlusion or ligation of the IMA or
IIAs
PATHOGENESIS
Cronenwett, J. L. and K. W. Johnston (2014).””Abdominal aortic aneurysm” Rutherford's Vascular Surgery 8th edition , Chapter 131-133

13. INCIDENCE AND RISK FACTOR
Open repair EVAR
Incidence in elective 0.2% to 6% 1.7%
Incidence in RAAA 38% 23%
Risk factor - Ligation of the IMA
- Failure to revascularize the hypogastric arteries
- Preexisting iliofemoral occlusive disease
- SMA stenosis
- Atheroembolism
- Retractor injury
- Previous colonic resection
Cronenwett, J. L. and K. W. Johnston (2014).””Abdominal aortic aneurysm” Rutherford's Vascular Surgery 8th edition , Chapter 131-133

14. Colon ischemia following abdominal aortic
aneurysm repair in the era of endovascular
abdominal aortic repair
Jean-Pierre Becquemin, MD, Marek Majewski, MD, Nicoletta Fermani, MD, Jean Marzelle, MD,
Pascal Desgrandes, MD, Eric Allaire, MD, and Françoise Roudot-Thoraval, MD, Creteil, Paris

15. Colon ischemia following abdominal aortic
aneurysm repair in the era of endovascular
abdominal aortic repair
Jean-Pierre Becquemin, MD, Marek Majewski, MD, Nicoletta Fermani, MD, Jean Marzelle, MD,
Pascal Desgrandes, MD, Eric Allaire, MD, and Françoise Roudot-Thoraval, MD, Creteil, Paris
- Rupture
- Duration of operation
more than 4 hours
- Creatinin > 200 mol/l
were independent factors
of Colonic ischemia

16. Risk factors and outcomes of postoperative ischemic colitis in contemporary
open and endovascular abdominal aortic aneurysm repair :
Zhobin Moghadamyeghaneh, MD,a Michael D. Sgroi, MD,a Samuel L. Chen, MD,a
Nii-Kabu Kabutey, MD,a Michael J. Stamos, MD,b and Roy M. Fujitani, MD,a Orange, Calif
Risk factors and outcomes of postoperative ischemic colitis in contemporary
open and endovascular abdominal aortic aneurysm repair :
Zhobin Moghadamyeghaneh, MD,a Michael D. Sgroi, MD,a Samuel L. Chen, MD,a
Nii-Kabu Kabutey, MD,a Michael J. Stamos, MD,b and Roy M. Fujitani, MD,a Orange, Calif

17. Risk factors and outcomes of postoperative ischemic colitis in contemporary
open and endovascular abdominal aortic aneurysm repair :
Zhobin Moghadamyeghaneh, MD,a Michael D. Sgroi, MD,a Samuel L. Chen, MD,a
Nii-Kabu Kabutey, MD,a Michael J. Stamos, MD,b and Roy M. Fujitani, MD,a Orange, Calif

18. RAAA WITH ISCHEMIC COMPLICATION IN OSR
• In a prospective analysis of RAAA
• 24 hours postoperatively
26% incidence of grades I and II ischemia was detected
with colonoscopy,
10% having grade III changes.
• 48 hours postoperatively
11% of grade I or grade II  to grade III.
grade III changes were found at surgery to have extensive
sigmoid and frequently rectal necrosis
with surgical management  mortality rate of 55%
Becquemin JP, et al: Colon ischemia following abdominal aortic aneurysm repair in the era of endovascular abdominal aortic repair. J Vasc Surg
2008; 47: pp. 258-263

19. RAAA WITH ISCHEMIC COMPLICATION IN OSR
4% with tube grafts 2.7% with aortoiliac grafts 22% with
aortobifemoralBecquemin JP, et al: Colon ischemia following abdominal aortic aneurysm repair in the era of endovascular abdominal aortic repair. J Vasc Surg
2008; 47: pp. 258-263

20. INDICATION FOR IMA PRESERVATION
By imaging preoperative CTA
• Significant SMA disease
• Bilateral hypogastric artery occlusions
• A large IMA, or prior colectomy
Intra-op finding IMA management
• brisk back-bleeding from the IMA  be safely ligated
• sluggish or no back-bleeding from an IMA  to be patent, or
evidence of colonic ischemia, argues for revascularization.
Cronenwett, J. L. and K. W. Johnston (2014).””Abdominal aortic aneurysm” Rutherford's Vascular Surgery 8th edition , Chapter 131-133

21. REIMPLANTATION OF
THE IMA
a small cuff of surrounding
aorta or in an end-to-end
fashion from a sidearm
attached to the body of
the graft.
Cronenwett, J. L. and K. W. Johnston (2014).””Abdominal aortic aneurysm” Rutherford's Vascular Surgery 8th edition , Chapter 131-133

23. Care of Patients with an Abdominal Aortic Aneurysm : 2018 Practice Guidelines from the Society for Vascular Surgery

24. Care of Patients with an Abdominal Aortic Aneurysm : 2018 Practice Guidelines from the Society for Vascular Surgery

25. DIAGNOSIS AND INVESTIGATION

26. CLINICAL PRESENTATION
• Abdominal pain (78%)
• lower digestive bleeding (62%)
• diarrhea(38%)
• Fever higher than 38°C (34%)
Huguier, M., et al. (2006). "Ischemic colitis." Am J Surg 192(5): 679-684.

27. PHYSICAL EXAMINATION AND
LABORATORY
• Abdominal tenderness (21%)
• The white blood cell count was more than
15,000/mm3 (27%)
• The serum bicarbonate level was less than
24 mmol/L (36%)
Huguier, M., et al. (2006). "Ischemic colitis." Am J Surg 192(5): 679-684.

28. PLAIN RADIOGRAPHY(THUMBPRINTING SIGN
Huguier, M., et al. (2006). "Ischemic colitis." Am J Surg 192(5): 679-684.

29. CT IN SEVERE CASES
Huguier, M., et al. (2006). "Ischemic colitis." Am J Surg 192(5): 679-684.

30. COLONOSCOPY IN THE DIAGNOSIS
• Early colonoscopy (within 48 h of presentation)
should be performed in suspected CI cases to confirm the diagnosis
• The endoscopic procedure should be stopped at the
distal-most extent of the disease
• Contraindicated: acute peritonitis, gangrene, pneumatosis
intestinalis
Huguier, M., et al. (2006). "Ischemic colitis." Am J Surg 192(5): 679-684.

31. SEVERITY AND GRADING
Severity Desscription Figure
Grade I patchy mucosal necrosis
Grade II to mucosal and muscularis
involvement
Gr II
Gr I
Huguier, M., et al. (2006). "Ischemic colitis." Am J Surg 192(5): 679-684.

32. SEVERITY AND GRADING
Severity Desscription Figure
Grade III transmural necrosis,
gangrene, and perforation
Huguier, M., et al. (2006). "Ischemic colitis." Am J Surg 192(5): 679-684.

33. RESULT
Koruda, M. J. (2002). "Shackelford's Surgery of the Alimentary Tract." Gastroenterology 123(3): 951-952.

34. TREATMENT AND OUTCOMES

35. Perry, R. J. T., et al. (2008). "Colonic ischemia complicating open vs endovascular abdominal aortic aneurysm repair." Journal of vascular surgery 48(2):
277.
Colonic ischemia complicating open vs
endovascular abdominal aortic aneurysm repair
Robert Jason T. Perry, MD, Matthew J. Martin, MD, Matthew J. Eckert, MD, Vance Y. Sohn, MD, and
Scott R. Steele, MD, Tacoma, Wash

36. Perry, R. J. T., et al. (2008). "Colonic ischemia complicating open vs endovascular abdominal aortic aneurysm repair." Journal of vascular surgery 48(2):
277.
Colonic ischemia complicating open vs
endovascular abdominal aortic aneurysm repair
Robert Jason T. Perry, MD, Matthew J. Martin, MD, Matthew J. Eckert, MD, Vance Y. Sohn, MD, and
Scott R. Steele, MD, Tacoma, Wash

37. PROGNOSIS
• 1941 patients who developed CI
• 692 (35.7%) underwent colectomy
• 370 (53.5%) died.
Event after diagnosis colonic ischemia rAAA Open repair EVAR
Colectomy 41% 31% 27%
Mortality after colectomy 48% 51% 73%
Survival after non operative management 60% 78% 84%
Perry, R. J. T., et al. (2008). "Colonic ischemia complicating open vs endovascular abdominal aortic aneurysm repair." Journal of vascular surgery 48(2):
277.

38. MANAGEMENT
• early and aggressive therapy
• aggressively resuscitated
• broad-spectrum intravenous antibiotics
(targeting intestinal flora)
• **if clinical deterioration abdominal exploration
is indicated
Cronenwett, J. L. and K. W. Johnston (2014).””Abdominal aortic aneurysm” Rutherford's Vascular Surgery 8th edition , Chapter 131-133

39. • patients should be placed on bowel rest (retain NG
tube)
• Close monitor : fever, leukocytosis, peritoneal
irritation, protracted diarrhea, or gastrointestinal
bleeding
• parenteral nutrition
MANAGEMENT
Cronenwett, J. L. and K. W. Johnston (2014).””Abdominal aortic aneurysm” Rutherford's Vascular Surgery 8th edition , Chapter 131-133

40. GRADE I OR II WITHOUT EVIDENCE OF
SYSTEMIC DERANGEMENT
• managed expectantly
• strict surveillance based on clinical evaluation
• repeated colonoscopy is mandatory
Cronenwett, J. L. and K. W. Johnston (2014).””Abdominal aortic aneurysm” Rutherford's Vascular Surgery 8th edition , Chapter 131-133

41. GRADE III AND EVIDENCE OF ORGAN
FAILURE
• require emergent exploratory laparotomy and bowel
resection and diverting colostomy
• extent of ischemia may be difficult to determine in case of
doubt, an exploratory laparotomy or laparoscopy may be
the best way to make the diagnosis.
• A negative exploration is preferable to a missed full-
thickness diagnosis and perforation
Cronenwett, J. L. and K. W. Johnston (2014).””Abdominal aortic aneurysm” Rutherford's Vascular Surgery 8th edition , Chapter 131-133

42. SURGICAL MANAGEMENT
• Primary anastomosis is usually not
performed
- A colostomy is formed with the
proximal colonic loop , the distal loop is
either
exteriorized as a mucous fistula or
closed to form a Hartman pouch.
- Despite resection, the mortality rates
exceed 50% in those with infarcted
bowel
Cronenwett, J. L. and K. W. Johnston (2014).””Abdominal aortic aneurysm” Rutherford's Vascular Surgery 8th edition , Chapter 131-133

43. ALGORITHM MANAGEMENT

44. POST OPERATIVE TREATMENT
ALGORITHM
Sign and
symptoms

45. THANK YOU