Systematic review and meta-analysis of the risk of bowel ischemia after ruptured abdominal aortic aneurysm repair

Jalalzadeh, Hamid; Leeuwen, Carlijn F. van; Indrakusuma, Reza; Balm, Ron; Koelemay, M.J.W.

doi:10.1016/j.jvs.2018.05.018

Cited by 9 publications

(3 citation statements)

References 106 publications

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“…Recent meta-analyses have demonstrated a higher prevalence of CI after OSR compared with EVAR, both after elective and ruptured AAA repair. 20,21 Contrary to the other studies, the present study did not highlight a significant difference in CI prevalence after EVAR compared with OSR (4.5% vs. 7.0%). The most likely reason for this was the low absolute rate of CI, particularly in the EVAR group (n ¼ 3).…”

Section: Discussioncontrasting

confidence: 99%

The Value of Sigmoidoscopy to Detect Colonic Ischaemia After Ruptured Abdominal Aortic Aneurysm Repair

Jalalzadeh

Schaik

Duin

et al. 2019

European Journal of Vascular and Endovascular Surgery

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WHAT THIS PAPER ADDS This study determined the value of sigmoidoscopy to detect colonic ischaemia (CI) after repair of ruptured abdominal aortic aneurysm (RAAA). It demonstrates that sigmoidoscopy is mainly valuable in patients with a moderate clinical suspicion of CI. The probability of identifying a patient with transmural ischaemia increases from approximately 22% to 73% when moderate to severe CI is detected at sigmoidoscopy. Moreover, sigmoidoscopy is effective in ruling out the presence of CI. Objectives: Diagnosing colonic ischaemia (CI) after ruptured abdominal aortic aneurysm (RAAA) repair is challenging. This study determined the diagnostic value of sigmoidoscopy in patients suspected of CI after RAAA repair. Methods: This was a retrospective multicentre cohort study. Patients who underwent RAAA repair in three hospitals in Amsterdam, the Netherlands, between 2004 and 2011 (AJAX cohort) were included. Sigmoidoscopies were carried out based on clinical judgment. Endoscopy results were classified as "no ischaemia," "mild CI," or "moderate to severe CI." The surgical diagnosis was classified as "transmural" or "no transmural" CI. The value of sigmoidoscopy was assessed with calculation of positive and negative predictive values (PPV, NPV) with 95% CI for transmural CI. Logistic regression analysis was used to express the association of risk factors with CI as adjusted OR. Results: Transmural CI was diagnosed in 23 of 351 patients (6.6%). Thirteen of sixteen patients (81%) who underwent direct laparotomy for high suspicion of CI indeed had transmural CI. Forty-six patients (13%) underwent sigmoidoscopy. The prevalence of transmural CI was 22% (10/46; 95% CI 12e36%) in these patients. The PPV for transmural CI of "moderate to severe CI" on sigmoidoscopy was 73% (8/11; 95% CI 43e 90%). The PPV of "mild CI" on sigmoidoscopy was 11% (2/19; 95% CI 2.9e31%). The NPV of "no ischaemia" on sigmoidoscopy was 100% (95% CI 78e100%). Cardiac comorbidity (OR 3.1, 95% CI 1.19e7.97), low first haemoglobin (OR 0.6, 95% CI 0.47e0.87), and high vasopressor administration (OR 9.4, 95% CI 1.99e44.46) were independently associated with CI. Conclusions: Sigmoidoscopy increases the likelihood of correctly identifying the presence or absence of transmural CI, especially in patients with a moderate clinical suspicion for CI after RAAA repair.

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Section: Discussioncontrasting

confidence: 99%

The Value of Sigmoidoscopy to Detect Colonic Ischaemia After Ruptured Abdominal Aortic Aneurysm Repair

Jalalzadeh

Schaik

Duin

et al. 2019

European Journal of Vascular and Endovascular Surgery

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“…Although the PAF of bowel ischaemia was lower than that of arterial occlusion after secondary interventions, it showed the highest clinical impact on two of the three outcomes in the present study. The origin of postoperative bowel ischaemia is multifactorial, but patient factors (age, female gender, hypertension) as well as longer operating time, and increased blood loss are proven risk factors 20 , 24 , 25 . Surgical quality-improvement programmes should prioritize the prevention of these risk factors.…”

Section: Discussionmentioning

confidence: 99%

Short-term outcomes of open surgical abdominal aortic aneurysm repair from the Dutch Surgical Aneurysm Audit

Geraedts

Alberga²,

Koelemay

et al. 2021

BJS Open

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Background The sharp decrease in open surgical repair (OSR) for abdominal aortic aneurysm (AAA) has raised concerns about contemporary postoperative outcomes. The study was designed to analyse the impact of complications on clinical outcomes within 30 days following OSR. Methods Patients who underwent OSR for intact AAA registered prospectively between 2016 and 2019 in the Dutch Surgical Aneurysm Audit were included. Complications and outcomes (death, secondary interventions, prolonged hospitalization) were evaluated. The adjusted relative risk (aRr) and 95 per cent confidence intervals were computed using Poisson regression. Subsequently, the population-attributable fraction (PAF) was calculated. The PAF reflects the expected percentage reduction of an outcome if a complication were to be completely prevented. Results A total of 1657 patients were analysed. Bowel ischaemia and renal complications had the largest impact on death (aRr 12·44 (95 per cent c.i. 7·95 to 19·84) at PAF 20 (95 per cent c.i. 8·4 to 31·5) per cent and aRr 5·07 (95 per cent c.i. 3·18 to 8.07) at PAF 14 (95 per cent c.i. 0·7 to 27·0) per cent, respectively). Arterial occlusion had the greatest impact on secondary interventions (aRr 11·28 (95 per cent c.i. 8·90 to 14·30) at PAF 21 (95 per cent c.i. 14·7 to 28·1) per cent), and pneumonia (aRr 2·52 (95 per cent c.i. 2·04 to 3·10) at PAF 13 (95 per cent c.i. 8·3 to 17·8) per cent) on prolonged hospitalization. Small effects were observed on outcomes for other complications. Conclusion The greatest clinical impact following OSR can be made by focusing on measures to reduce the occurrence of bowel ischaemia, arterial occlusion and pneumonia.

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“…13 Changes in systemic circulation during open aortic surgery and temporary or permanent occlusion of the inferior mesenteric artery (IMA) may cause an imbalance in this equilibrium, leading to sigmoid ischaemia in up to 5% of patients undergoing elective JAA repair, 1e3,5e 7,9e17 compared with more than 10% of the patients undergoing repair for ruptured abdominal aneurysms. 16,18 Post-operative renal failure may have a deleterious effect on remote organs. During AKI, tubular and epithelial cell necrosis occurs thereby reducing renal elimination of asymmetrical dimethylarginine (ADMA) and production of arginine (an endogenous inhibitor of nitric oxide (NO) synthase and a NO precursor respectively).…”

Section: Introductionmentioning

confidence: 99%

Cold Renal Perfusion During Simulation of Juxtarenal Aortic Aneurysm Repair Reduces Systemic Oxidative Stress and Sigmoid Damage in Rats

Schaik

Jongkind

Lindhout

et al. 2019

European Journal of Vascular and Endovascular Surgery

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WHAT THIS PAPER ADDS Complications of juxtarenal aortic aneurysm repair include renal ischaemia reperfusion injury and post-operative colonic ischaemia. Renal ischaemia reperfusion injury results in the production of reactive oxygen species during oxidative stress. In the present study renal cooling preserved renal function. Above all, renal cooling was able to reduce the detrimental remote effects on sigmoid integrity of renal ischaemia reperfusion caused by suprarenal clamping; by preserving microcirculatory flow, attenuating circulating leukocyte ROS production, and decreasing leukocyte infiltration in the sigmoid. Objectives: Juxtarenal aortic surgery induces renal ischaemia reperfusion, which contributes to systemic inflammatory tissue injury and remote organ damage. Renal cooling during suprarenal cross clamping has been shown to reduce renal damage. It is hypothesised that renal cooling during suprarenal cross clamping also has systemic effects and could decrease damage to other organs, like the sigmoid colon. Methods: Open juxtarenal aortic aneurysm repair was simulated in 28 male Wistar rats with suprarenal cross clamping for 45 min, followed by 20 min of infrarenal aortic clamping. Four groups were created: sham, no, warm (37 C saline), and cold (4 C saline) renal perfusion during suprarenal cross clamping. Primary outcomes were renal damage and sigmoid damage. To assess renal damage, procedure completion serum creatinine rises were measured. Peri-operative microcirculatory flow ratios were determined in the sigmoid using laser Doppler flux. Semi-quantitative immunofluorescence microscopy was used to measure alterations in systemic inflammation parameters, including reactive oxygen species (ROS) production in circulating leukocytes and leukocyte infiltration in the sigmoid. Sigmoid damage was assessed using digestive enzyme (intestinal fatty acid binding protein-I-FABP) leakage, a marker of intestinal integrity. Results: Suprarenal cross clamping caused deterioration of all systemic parameters. Only cold renal perfusion protected against serum creatinine rise: 0.45 mg/dL without renal perfusion, 0.33 mg/dL, and 0.14 mg/dL (p ¼ .009) with warm and cold perfusion, respectively. Microcirculation in the sigmoid was attenuated with warm (p ¼ .002) and cold renal perfusion (p ¼ .002). A smaller increase of ROS production (p ¼ .034) was seen only after cold perfusion, while leukocyte infiltration in the sigmoid colon decreased after warm (p ¼ .006) and cold perfusion (p ¼ .018). Finally, digestive enzyme leakage increased more without (1.5AU) than with warm (1.3AU; p ¼ .007) and cold renal perfusion (1.2AU; p ¼ .002). Conclusions: Renal ischaemia/reperfusion injury after suprarenal cross clamping decreased microcirculatory flow, increased systemic ROS production, leukocyte infiltration, and I-FABP leakage in the sigmoid colon. Cold renal perfusion was superior to warm perfusion and reduced renal damage and had beneficial systemic effects, reducing sigmoid damage in this experimental study.

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Systematic review and meta-analysis of the risk of bowel ischemia after ruptured abdominal aortic aneurysm repair

Abstract: The prevalence of clinically relevant BI after RAAA repair is approximately 10%. Approximately 5% of patients undergoing RAAA repair suffer from severe consequences of BI. BI is less prevalent after EVAR than after OR.

Cited by 9 publications

References 106 publications

The Value of Sigmoidoscopy to Detect Colonic Ischaemia After Ruptured Abdominal Aortic Aneurysm Repair

The Value of Sigmoidoscopy to Detect Colonic Ischaemia After Ruptured Abdominal Aortic Aneurysm Repair

Short-term outcomes of open surgical abdominal aortic aneurysm repair from the Dutch Surgical Aneurysm Audit

Cold Renal Perfusion During Simulation of Juxtarenal Aortic Aneurysm Repair Reduces Systemic Oxidative Stress and Sigmoid Damage in Rats

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