Jayaraj Arjun, DeMartino Randall R, Bower Thomas C, Oderich Gustavo S, Gloviczki Peter, Kalra Manju, Duncan Audra A, Fleming Mark D
Mayo Clinic, Rochester, MN.
Mayo Clinic, Rochester, MN.
Ann Vasc Surg. 2020 Jul;66:65-69. doi: 10.1016/j.avsg.2019.12.035. Epub 2020 Jan 14.
The role of inferior mesenteric artery (IMA) reimplantation during open aortic reconstruction is debated. We assessed outcomes after inferior mesenteric artery reimplantation (IMAR) for aortic aneurysmal disease to help shed light on this question.
A single-center retrospective review of all IMARs performed during open aortic surgery over a 10-year period between 2000 and 2009 was carried out. The primary outcome was patency, while secondary outcomes included colonic ischemia and overall survival. Analysis was performed using Cox models and Kaplan-Meier estimates.
Of 840 patients who underwent elective abdominal aortic aneurysm (AAA) reconstructions during this period, 70 underwent IMAR. Indications for IMAR included intraoperative colonic ischemia (n = 24), poor back bleeding (n = 52), large IMA (n = 5), internal iliac disease (n = 5), and prior colon surgery (n = 1). Follow-up imaging studies were available in 35 of 70 patients (computed tomography in 30 [86%] and duplex in 5 [14%]). Patency was confirmed in 32 of 35 patients (91%) over a median follow-up of 98 months. Both losses in patency were at 4 months and did not require an operation. One patient underwent left colon resection on postoperative day 9 because of ischemia. (Patency could not be confirmed.) No statistically significant predictor of patency was noted. Incidence of colonic ischemia was 1.4% in patients undergoing IMAR. The overall mortality was 51% in patients undergoing IMAR over the median follow-up period. The overall 10-year survival was 30% in patients undergoing IMAR for aortic aneurysmal disease. The nature of aneurysm (juxtarenal or higher juxta renal abdominal aortic aneurysm [JRAAA]) was associated with mortality, with a hazard ratio of 1.8 (P = 0.08) approaching significance. Ten-year survival was worse if IMAR was performed for intraoperative colonic ischemia (26% vs 34%) or in JRAAA (19.0% vs 38%; P = 0.03). Age per year at the time of repair was the only statistically significant predictor of survival (P < 0.001).
IMAR for AAA remains necessary for select patients. Reimplantation is associated with excellent long-term patency and low risk of colonic ischemia.
在开放性主动脉重建术中，肠系膜下动脉（IMA）再植术的作用存在争议。我们评估了肠系膜下动脉再植术（IMAR）治疗主动脉瘤疾病后的结局，以助于阐明这一问题。
对2000年至2009年这10年间在开放性主动脉手术中进行的所有IMAR进行单中心回顾性研究。主要结局是通畅率，次要结局包括结肠缺血和总生存率。使用Cox模型和Kaplan-Meier估计进行分析。
在此期间接受择期腹主动脉瘤（AAA）重建的840例患者中，70例接受了IMAR。IMAR的指征包括术中结肠缺血（n = 24）、回血不佳（n = 52）、IMA粗大（n = 5）、髂内疾病（n = 5）和既往结肠手术史（n = 1）。70例患者中有35例（86%为计算机断层扫描，14%为双功超声）有随访影像学检查结果。35例患者中有32例（91%）在中位随访98个月时通畅率得到证实。两次通畅率丧失均发生在4个月时，且无需手术。1例患者术后第9天因缺血行左半结肠切除术。（通畅率无法证实。）未发现通畅率的统计学显著预测因素。接受IMAR的患者结肠缺血发生率为1.4%。在中位随访期内，接受IMAR的患者总死亡率为51%。因主动脉瘤疾病接受IMAR的患者10年总生存率为30%。动脉瘤的性质（肾旁或更高位置的肾旁腹主动脉瘤[JRAAA]）与死亡率相关，风险比为1.8（P = 0.08），接近显著水平。如果因术中结肠缺血进行IMAR（26%对34%）或在JRAAA中进行IMAR（19.0%对38%；P = 0.03），10年生存率更差。修复时每年的年龄是唯一具有统计学显著意义的生存预测因素（P < 0.001）。
对于特定患者，AAA的IMAR仍然是必要的。再植术与良好的长期通畅率和低结肠缺血风险相关。
