HHS Public Access Author manuscript Author Manuscript
J Vasc Surg. Author manuscript; available in PMC 2017 November 01. Published in final edited form as: J Vasc Surg. 2016 November ; 64(5): 1384–1391. doi:10.1016/j.jvs.2016.05.045.
Incidence of and Risk Factors for Bowel Ischemia following Abdominal Aortic Aneurysm Repair Klaas H.J. Ultee, BSc1,2, Sara L. Zettervall, MD MPH1, Peter A. Soden, MD1, Jeremy Darling, BA1, Daniel J. Bertges, MD3, Hence J.M. Verhagen, MD PhD2, and Marc L. Schermerhorn, MD1 on behalf of the Vascular Study Group of New England
Author Manuscript
1Department
of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA 2Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands 3Department of Surgery, Division of Vascular Surgery, University of Vermont Medical Center, Burlington, VT, USA
Abstract Introduction—Bowel ischemia is a rare but devastating complication following abdominal aortic aneurysm (AAA) repair. Its rarity has prohibited extensive risk factor analysis, particularly since the widespread adoption of endovascular repair (EVAR). Therefore, the purpose of this study was to assess the incidence of postoperative bowel ischemia following AAA repair in the endovascular era, and identify risk factors for its occurrence.
Author Manuscript
Methods—All patients undergoing AAA repair, either intact or ruptured, in the Vascular Study Group of New England between January 2003 and November 2014 were included. We compared patients with postoperative bowel ischemia to those without, and stratified by indication (intact and ruptured) and treatment approach (open repair and EVAR). Criteria for diagnosis were endoscopic or clinical evidence of ischemia, including bloody stools in patients who died before diagnostic procedures were performed. Independent predictors of postoperative bowel ischemia were established using multivariable logistic regression analysis.
Author Manuscript
Results—A total of 7312 patients were included, with 6668 intact (67.0% EVAR), and 644 ruptured AAA repairs (31.5% EVAR). 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), followed by open repair (OR:2.9, 95%CI:1.8 – 4.7). Additional predictive patient factors were advanced age (OR:1.4 per 10 years, 95%CI:1.1 – 1.7), female gender (OR:1.6, 95%CI:1.1 – 2.2), hypertension (OR:1.8, 95%CI:1.1 – 3.0), heart failure (OR:1.8, 95%CI:1.2 – 2.8), and current smoking (OR:1.5, 95%CI:1.1 – 2.1). Other risk factors
Corresponding Author / Reprints: Marc L. Schermerhorn, 110 Francis St. Suite 5B, Boston, MA 02215; Phone: 617-632-9971; [email protected]. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Will be presented at the 2016 SCVS Annual Symposium (March 12-16, Las Vegas, NV)
Ultee et al.
Page 2
Author Manuscript
included unilateral interruption of the hypogastric artery (OR:1.7, 95%CI:1.0 – 2.8), prolonged operative time (OR:1.2 per 60 min. increase, 95%CI:1.1 – 1.3), blood loss >1L (OR:2.0, 95%CI: 1.3 – 3.0), and a distal anastomosis to the femoral artery (OR:1.7, 95%CI:1.1 – 2.7). Bowel ischemia patients had a significantly higher perioperative mortality after both intact (open repair: 20.5% vs. 1.9%, P.99
.40
>.99
-
P-value
Ultee et al. Page 15
Author Manuscript
Author Manuscript
J Vasc Surg. Author manuscript; available in PMC 2017 November 01.
Author Manuscript
J Vasc Surg. Author manuscript; available in PMC 2017 November 01. 11 (14) 12 (15) 38 (49) 21 (34) 37 (47) 56 (72) 70 (90)
MI – N (%)
CHF – N (%)
Respiratory complication -N (%)
>3 transfusions – N (%)
Return to OR – N (%)
Prolonged length of stay – N (%)α
Prolonged ICU stay – N (%)β
Open repair
41 (48) 51 (65) 16 (20) 22 (26)
30-day Mortality – N (%)
Renal deterioration – N (%)
Dialysis – N (%)
Leg Ischemia – N (%)
Yes N=85
16 (4.5)
21 (5.9)
99 (28.0)
91 (25.6)
No N=356
J Vasc Surg. Author manuscript; available in PMC 2017 November 01. Published in final edited form as: J Vasc Surg. 2016 November ; 64(5): 1384–1391. doi:10.1016/j.jvs.2016.05.045.
Incidence of and Risk Factors for Bowel Ischemia following Abdominal Aortic Aneurysm Repair Klaas H.J. Ultee, BSc1,2, Sara L. Zettervall, MD MPH1, Peter A. Soden, MD1, Jeremy Darling, BA1, Daniel J. Bertges, MD3, Hence J.M. Verhagen, MD PhD2, and Marc L. Schermerhorn, MD1 on behalf of the Vascular Study Group of New England
Author Manuscript
1Department
of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA 2Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands 3Department of Surgery, Division of Vascular Surgery, University of Vermont Medical Center, Burlington, VT, USA
Abstract Introduction—Bowel ischemia is a rare but devastating complication following abdominal aortic aneurysm (AAA) repair. Its rarity has prohibited extensive risk factor analysis, particularly since the widespread adoption of endovascular repair (EVAR). Therefore, the purpose of this study was to assess the incidence of postoperative bowel ischemia following AAA repair in the endovascular era, and identify risk factors for its occurrence.
Author Manuscript
Methods—All patients undergoing AAA repair, either intact or ruptured, in the Vascular Study Group of New England between January 2003 and November 2014 were included. We compared patients with postoperative bowel ischemia to those without, and stratified by indication (intact and ruptured) and treatment approach (open repair and EVAR). Criteria for diagnosis were endoscopic or clinical evidence of ischemia, including bloody stools in patients who died before diagnostic procedures were performed. Independent predictors of postoperative bowel ischemia were established using multivariable logistic regression analysis.
Author Manuscript
Results—A total of 7312 patients were included, with 6668 intact (67.0% EVAR), and 644 ruptured AAA repairs (31.5% EVAR). 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), followed by open repair (OR:2.9, 95%CI:1.8 – 4.7). Additional predictive patient factors were advanced age (OR:1.4 per 10 years, 95%CI:1.1 – 1.7), female gender (OR:1.6, 95%CI:1.1 – 2.2), hypertension (OR:1.8, 95%CI:1.1 – 3.0), heart failure (OR:1.8, 95%CI:1.2 – 2.8), and current smoking (OR:1.5, 95%CI:1.1 – 2.1). Other risk factors
Corresponding Author / Reprints: Marc L. Schermerhorn, 110 Francis St. Suite 5B, Boston, MA 02215; Phone: 617-632-9971; [email protected]. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Will be presented at the 2016 SCVS Annual Symposium (March 12-16, Las Vegas, NV)
Ultee et al.
Page 2
Author Manuscript
included unilateral interruption of the hypogastric artery (OR:1.7, 95%CI:1.0 – 2.8), prolonged operative time (OR:1.2 per 60 min. increase, 95%CI:1.1 – 1.3), blood loss >1L (OR:2.0, 95%CI: 1.3 – 3.0), and a distal anastomosis to the femoral artery (OR:1.7, 95%CI:1.1 – 2.7). Bowel ischemia patients had a significantly higher perioperative mortality after both intact (open repair: 20.5% vs. 1.9%, P.99
.40
>.99
-
P-value
Ultee et al. Page 15
Author Manuscript
Author Manuscript
J Vasc Surg. Author manuscript; available in PMC 2017 November 01.
Author Manuscript
J Vasc Surg. Author manuscript; available in PMC 2017 November 01. 11 (14) 12 (15) 38 (49) 21 (34) 37 (47) 56 (72) 70 (90)
MI – N (%)
CHF – N (%)
Respiratory complication -N (%)
>3 transfusions – N (%)
Return to OR – N (%)
Prolonged length of stay – N (%)α
Prolonged ICU stay – N (%)β
Open repair
41 (48) 51 (65) 16 (20) 22 (26)
30-day Mortality – N (%)
Renal deterioration – N (%)
Dialysis – N (%)
Leg Ischemia – N (%)
Yes N=85
16 (4.5)
21 (5.9)
99 (28.0)
91 (25.6)
No N=356
