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Incidence of and Risk Factors for Bowel Ischemia following Abdominal Aortic Aneurysm Repair
Klaas H. Ultee1, Sara L. Zettervall, MD, MPH1, Peter A. Soden, MD1, Daniel J. Bertges, MD2, Jeffrey J. Siracuse, MD2, Hence J. Verhagen, MD, PhD3, Marc L. Schermerhorn, MD1.
1Beth Israel Deaconess Medical Center, Boston, MA, USA, 2University of Vermont Medical Center, Burlington, VT, USA, 3Erasmus Medical Center, Rotterdam, Netherlands.
OBJECTIVES:
Bowel ischemia is a rare but devastating complication following abdominal aortic aneurysm (AAA) repair. The purpose of this study is to assess the incidence of postoperative bowel ischemia following AAA repair in the endovascular era, and identify risk factors for its occurrence.
METHODS:
Patients undergoing AAA repair, either intact or ruptured, in the Vascular Study Group of New England between January 2003 and November 2014 were included. Stratified by indication (intact and ruptured) and treatment approach (open repair and EVAR), patients with postoperative bowel ischemia were compared to those without. Independent predictors of postoperative bowel ischemia were established using multivariable logistic regression analysis.
RESULTS:
A total of 7312 patients were included, with 4675 (63.9%) undergoing EVAR and 2637 (36.1%) undergoing open repair. The incidence of bowel ischemia following intact repair was 1.6% (open repair: 3.6%, EVAR: 0.6%), and 15.2% following ruptured repair (open repair: 19.3%, EVAR: 6.4%). Ruptured AAA was the most important determinant of postoperative bowel ischemia (OR: 6.4, 95% CI: 4.5 - 9.0). Open repair was also associated with a higher risk of bowel ischemia compared to EVAR (2.9, 1.8 - 4.7). Additional predictive patient factors were advanced age (1.4 per 10 years, 1.1 - 1.7), female gender (1.6 95: CI: 1.1 - 2.2), hypertension (1.8, 1.1 - 3.0), heart failure (1.8, 1.2 - 2.8), and current smoking (1.5, 1.1 - 2.1). Other risk factors included interruption of the hypogastric artery (1.7, 1.0 - 2.8), prolonged operative time (1.2 per 60 min. increase, 1.1 - 1.3), blood loss >1L (2.0, 1.3 - 3.0), and a distal anastomosis to the femoral artery (1.7, 1.1 - 2.7). Bowel ischemia patients had a significantly higher perioperative mortality after both intact (open repair: 20.5% vs. 1.9%, P<.001; EVAR: 34.6% vs. 0.9%, P<.001), as well ruptured AAA repair (open repair: 48.2% vs. 25.6%, P<.001; EVAR: 30.8% vs. 21.1%, P<.001).
CONCLUSIONS:
This study underlines that although bowel ischemia following AAA repair is rare, the associated outcome is very poor. The cause of postoperative bowel ischemia is multifactorial in nature, and can be attributed to both patient factors, and operative characteristics. Knowledge of these risk factors may provide important information for perioperative planning in an effort to decrease the incidence of bowel ischemia and its associated morbidity and mortality.
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