Department of Surgery, George Washington University, Washington, D.C..
Department of Surgery, George Washington University, Washington, D.C.
J Vasc Surg. 2020 Mar;71(3):815-823. doi: 10.1016/j.jvs.2019.05.042. Epub 2019 Aug 27.
Ischemic colitis is a rare but devastating complication of endovascular repair of infrarenal abdominal aortic aneurysms. Although it is rare (0.9%) in standard endovascular aneurysm repair (EVAR), the incidence increases to 2% to 3% in EVAR with hypogastric artery embolization (HAE). This study investigated whether preservation of pelvic perfusion with iliac branch devices (IBDs) decreases the incidence of ischemic colitis.
We used the targeted EVAR module in the American College of Surgeons National Surgical Quality Improvement Program database to identify patients undergoing EVAR of infrarenal abdominal aortic aneurysm from 2012 to 2017. The cohort was further stratified into average-risk and high-risk groups. Average-risk patients were those who underwent elective repair for sizes of the aneurysms, whereas high-risk patients were repaired emergently for indications other than asymptomatic aneurysms. Within these groups, we examined the 30-day outcomes of standard EVARs, EVAR with HAE, and EVAR with IBDs. The primary outcome was the incidence of ischemic colitis. Secondary outcomes included mortality, major organ dysfunction, thromboembolism, length of stay, and return to the operating room. The χ test, Fisher exact test, Kruskal-Wallis test, and multivariate regression models were used for data analysis.
There were 11,137 patients who had infrarenal EVAR identified. We designated this the all-risk cohort, which included 9263 EVAR, 531 EVAR-HAE, and 1343 EVAR-IBD procedures. These were further stratified into 9016 cases with average-risk patients and 2121 cases with high-risk patients. In the average-risk group, 7482 had EVAR, 411 had EVAR-HAE, and 1123 had EVAR-IBD. In the high-risk group, 1781 had EVAR, 120 had EVAR-HAE, and 220 had EVAR-IBD. There was no significant difference in 30-day outcomes (including ischemic colitis) between EVAR, EVAR-HAE, and EVAR-IBD in the all-risk and high-risk groups. In the average-risk cohort, EVAR-HAE was associated with a higher mortality rate than EVAR (2.2% vs 1.0%; adjusted odds ratio, 2.58; P = .01). Although EVAR-IBD was not superior to EVAR-HAE in 30-day mortality, major organ dysfunction, or ischemic colitis in this average-risk cohort, EVAR-IBD exhibited a trend toward lower mortality compared with EVAR-HAE in this cohort, but it was not statistically significant (1.0% vs 2.2%; adjusted odds ratio, 0.42; P = .07).
Ischemic colitis is a rare complication of EVAR. HAE does not appear to increase the risk of ischemic colitis, and preservation of pelvic perfusion with IBDs does not decrease its incidence. Although HAE is associated with significantly higher mortality than standard EVAR in average-risk patients, the preservation of pelvic perfusion with IBDs does not appear to improve mortality over HAE.
缺血性结肠炎是腹主动脉瘤腔内修复术的罕见但严重的并发症。虽然在标准的腹主动脉瘤腔内修复术（EVAR）中发病率较低（0.9%），但在伴有髂动脉栓塞（HAE）的 EVAR 中发病率增加至 2%至 3%。本研究旨在探讨使用髂分支装置（IBD）保留盆腔灌注是否会降低缺血性结肠炎的发生率。
我们使用美国外科医师学会国家手术质量改进计划数据库中的靶向 EVAR 模块，确定了 2012 年至 2017 年间接受腹主动脉瘤腔内修复术的患者。该队列进一步分为低危组和高危组。低危组患者为择期修复动脉瘤大小，高危组患者为因除无症状动脉瘤以外的指征而行紧急修复。在这些组中，我们检查了标准 EVAR、EVAR-HAE 和 EVAR-IBD 的 30 天结果。主要结局是缺血性结肠炎的发生率。次要结局包括死亡率、主要器官功能障碍、血栓栓塞、住院时间和返回手术室。使用 χ 检验、Fisher 确切检验、Kruskal-Wallis 检验和多变量回归模型进行数据分析。
共确定了 11137 例接受腹主动脉瘤腔内修复术的患者。我们将其指定为全风险队列，其中包括 9263 例 EVAR、531 例 EVAR-HAE 和 1343 例 EVAR-IBD 手术。这些进一步分为低危患者 9016 例和高危患者 2121 例。在低危组中，7482 例接受 EVAR，411 例接受 EVAR-HAE，1123 例接受 EVAR-IBD。在高危组中，1781 例接受 EVAR，120 例接受 EVAR-HAE，220 例接受 EVAR-IBD。在全风险组和高危组中，EVAR、EVAR-HAE 和 EVAR-IBD 之间的 30 天结局（包括缺血性结肠炎）无显著差异。在低危组中，EVAR-HAE 的死亡率高于 EVAR（2.2%比 1.0%；调整后的优势比，2.58；P=0.01）。虽然在低危队列中，EVAR-IBD 在 30 天死亡率、主要器官功能障碍或缺血性结肠炎方面并不优于 EVAR-HAE，但与 EVAR-HAE 相比，EVAR-IBD 表现出降低死亡率的趋势，但无统计学意义（1.0%比 2.2%；调整后的优势比，0.42；P=0.07）。
缺血性结肠炎是 EVAR 的一种罕见并发症。HAE 似乎不会增加缺血性结肠炎的风险，使用 IBD 保留盆腔灌注并不会降低其发生率。虽然在低危患者中，HAE 与标准 EVAR 相比死亡率显著升高，但使用 IBD 保留盆腔灌注似乎并未改善 HAE 的死亡率。
