Colonic Ischemia after Standard Endovascular Abdominal Aortic Aneurysm Repair, a Rare but Dangerous Complication

Colonic ischemia (CI) after abdominal aortic aneurysm repair, although rare, is associated with severe prognosis. Endovascular aneurysm repair (EVAR) is becoming the standard of practice in most vascular centers, and it also may reduce CI incidence in comparison with conventional open repair. We report 2 cases of fatal CI after 636 standard EVAR procedures performed at our institution, from January 1998 to December 2017. Both patients were electively treated by highly skilled operators. In one patient, presenting early CI, EVAR procedure was complicated by intraoperative common iliac artery rupture. The other one, presenting CI in seventh postoperative day, had a history of previous left hemicolectomy. In both patients, CI with leakage of fecal material in the abdominal cavity was confirmed by surgical exploration. Only few cases of CI after EVAR have been reported in literature, and the etiology of this complication remains uncertain. While saving the inferior mesenteric artery is almost impossible during standard EVAR, the preservation of hypogastric arteries could play an important role, especially after colonic surgery, but other factors should also be considered. Our preliminary, although limited experience, seems to suggest that in CI developing, intraoperative persistent hypotension and hypogastric branches distal embolization have both a role that should be better addressed.