Impact of Previous Open Abdominal Surgery on Open Abdominal Aortic Repair: A Study from the NSQIP Database.

BACKGROUND: While endovascular aneurysm repair has become a first-line strategy in many centers, open surgical repair (OSR) of abdominal aortic aneurysms (AAAs) is still the best option for certain patients. A significant number of patients who are offered OSR for AAA have been previously submitted to other open abdominal surgeries (PAS). It is unclear, however, how this may impact their outcomes. The purpose of this study was to determine if there is an association between PAS and outcomes of OSR of AAA. METHODS: This is a retrospective cohort study based on clinical data from the American College of Surgeons National Surgical Quality Improvement Program database, including all patients undergoing elective OSR for AAA between 2011 and 2017. Excluded were patients with missing data on prior abdominal surgery, supramesenteric clamping, or urgent repairs. Patients with prior abdominal surgery (PAS) and patients without prior abdominal surgeries (nonPAS) were compared. The primary outcome was 30-day postoperative mortality. Secondary outcomes were operating time, ischemic colitis, postoperative complications, and lengths of hospital stay. RESULTS: Of the 2034 patients included, 27% had previous open abdominal surgery and 73% did not. Overall, the median age was 71(interquartile range 65-76), 72% of patients were male, 44% were smokers, and the average body mass index was 27 kg/m2. Univariate analysis showed no difference in postoperative 30-day mortality (4.0% PAS vs. 4.1% nonPAS, P = 0.91) or overall postoperative complication rates (33% PAS vs. 29% nonPAS, P = 0.07). Previous open abdominal surgery was significantly associated with longer operating times (P = 0.032) and an almost doubled rate of ischemic colitis (4.7% PAS vs. 2.6% nonPAS, P = 0.02). Postoperative intensive care unit and hospitalization were also significantly longer in patients with prior abdominal surgery (P = 0.005 and P = 0.014, respectively). Finally, there were significantly less patients discharged home, as opposed to institutionalized care (75.7% PAS down from 82.4% nonPAS, P = 0.001). Despite these initial univariate analysis results, on multivariate analysis, PAS actually did not prove to be a statistically significant independent risk factor for 30-day mortality, ischemic colitis, or longer operating times. CONCLUSIONS: This study suggests that patients who have undergone PAS may have some disadvantages in OSR of AAA. However, these negative trends do not go so far as to statistically significantly identify PAS as an independent risk factor for 30-day mortality, ischemic colitis, or longer operating times. As such, we suggest that a history of previous open abdominal surgery, in and of its own, should not exclude patients from consideration for open aortic abdominal aneurysm repair.

[A case of COVID-19 associated ischemic colitis].

Ischemic colitis is a disease in which local tissue in the intestinal wall dies to varying degrees due to insufficient blood supply to the colon. Risk factors include cardiovascular disease, diabetes, chronic kidney disease, chronic obstructive pulmonary disease, etc. Typical clinical manifestations of the disease are abdominal pain and hematochezia. The most common locations are the watershed areas of splenic flexure and rectosigmoid junction. The lesions are segmental and clearly demarcated from normal mucosa under endoscopy. The digestive tract is a common extra-pulmonary organ affected by the novel coronavirus, which can be directly damaged by the virus or indirectly caused by virus-mediated inflammation and hypercoagulability. The corona virus disease 2019 (COVID-19) associated intestinal injury can be characterized by malabsorption, malnutrition, intestinal flora shift, etc. CT can show intestinal ischemia, intestinal wall thickening, intestinal wall cystoid gas, intestinal obstruction, ascites, intussusception and other signs. In this study, we reported a case of ischemic colitis in a moderate COVID-19 patient. The affected area was atypical and the endoscope showed diffuse lesions from the cecum to the rectosigmoid junction. No signs of intestinal ischemia were found on imaging and clear thrombosis in small interstitial vessels was found in pathological tissue. Combined with the fact that the patient had no special risk factors in his past history, the laboratory tests indicated elevated ferritin and D-dimer, while the autoantibodies and fecal etiology results were negative, we speculated that the hypercoagulability caused by novel coronavirus infection was involved in the occurrence and development of the disease in this patient. After prolonged infusion support and prophylactic anti-infection therapy, the patient slowly resumed diet and eventually went into remission. Finally, we hoped to attract clinical attention with the help of this case of moderate COVID-19 complicated with ischemic colitis which had a wide range of lesions and a slow reco-very. For patients with abdominal pain and blood in the stool after being diagnosed as COVID-19, even if they are not severe COVID-19, they should be alert to the possibility of ischemic colitis, so as not to be mistaken for gastrointestinal reactions related to COVID-19.

Arterial embolization during percutaneous vertebroplasty resulting in bilateral renal infarcts and ischemic colitis.

This case report documents an arterial embolic event that occurred during vertebroplasty for a pathological compression fracture of T12 in a 54-year-old female with known metastatic breast carcinoma. A CT angiogram performed after the procedure demonstrated cement migration into the aorta, both kidneys, and the inferior mesenteric artery and its branches, with ischemic colitis involving the descending colon and sigmoid colon. A CT scan 4 months post-procedure demonstrated resolution of the colitis. Neovascularity and cortical destruction in malignant bone lesions are thought to contribute to arterial cement leak.

The Effect of Hypogastric Artery Revascularization on Ischemic Colitis in Endovascular Aneurysm Repair.

BACKGROUND: The objective of the study was to examine the effect of hypogastric revascularization maneuvers on the rate of postoperative ischemic colitis among patients undergoing endovascular aortoiliac aneurysm repair. METHODS: Using the 2011-2018 Endovascular Aneurysm Repair Procedure-Targeted American College of Surgeons National Surgical Quality Improvement Program Participant Use Files, we analyzed patients undergoing elective endovascular infrarenal aortoiliac aneurysm repairs. Using multivariable modeling techniques, a cohort of patients at high risk for postoperative ischemic colitis was identified. The outcomes of this group were then compared using Pearson's chi-square testing in accordance with whether or not they underwent hypogastric revascularization. RESULTS: Of 4753 patients undergoing endovascular aortoiliac aneurysm repair in the National Surgical Quality Improvement Program cohort, 1161 had concomitant hypogastric revascularization procedures. High-risk predictors of ischemic colitis included chronic obstructive pulmonary disease and concurrent renal artery or external iliac artery stenting. There was not a significant association between pelvic revascularization and postoperative ischemic colitis [1.0% with versus 0.5% without pelvic revascularization; adjusted odds ratio of ischemic colitis with revascularization 2.07 (0.96, 4.46); P = 0.06] after adjustment for patient- and procedure-related factors. In a subgroup analysis of patients with a distal aneurysm extent beyond the common iliac artery, the incidence of ischemic colitis was significantly lower in patients without pelvic revascularization (0.1% versus 1.6%, P = 0.004). CONCLUSIONS: Our analysis of patients undergoing elective endovascular repair of infrarenal aortoiliac aneurysmal disease did not find a reduced incidence of postoperative ischemic colitis in patients who received a concomitant pelvic revascularization procedure, suggesting instead that such procedural adjuncts may actually increase risk for this complication.

[Ischemic Colitis after Closure of Temporary Ileostomy for Low Anterior Resection of Rectal Cancer in a Dialysis Patient-A Case Report].

Dialysis patients are at increased risk of ischemic colitis and are likely to develop irreversible ischemic colitis. We report a rare case of ischemic colitis after the closure of a temporary ileostomy for low anterior resection(LAR)of rectal cancer in a dialysis patient. A 77-year-old man undergoing maintenance dialysis was diagnosed as having colorectal cancer with a type 2 tumor at the anastomosis site of high anterior resection performed for sigmoid colon cancer 14 years ago. After undergoing excision which included the anastomosis site of the previous operation, LAR with anastomosis in the transverse colon and rectum and temporary ileostomy were performed. Seven months later, closure of the temporary ileostomy was performed, which resulted in ileus and septic shock. Computed tomography(CT)revealed inflammation in the colon on the oral side of the anastomosis, which was diagnosed as ischemic colitis. Ischemic colitis did not improve with conservative treatment, and fever reoccurred at each maintenance dialysis session. Therefore, ileostomy was performed again, but multiple organ failure due to disseminated intravascular coagulopathy(DIC)progressed and he died. It is considered that Hartmann's operation should be selected for dialysis patients with serious underlying diseases, and if ischemic colitis is observed after closure of the stoma temporary colostomy in such patients, the lesion site of ischemic colitis should be excised promptly and colostomy should be performed again.

[A case of circumferential rectal wall thickening caused by prostate cancer invasion concomitant with ischemic colitis].

A man in his 70s presented to Kyojinkai Komatsu Hospital with lower left abdominal pain and hematochezia after repeated use of laxatives. Computed tomography (CT) revealed continuous bowel wall thickening from the descending colon to the rectum. The symptoms and CT findings were consistent with ischemic colitis. The patient's condition improved with conservative treatment. However, the patient was reexamined 3 months later because complaints of constipation and voiding difficulty continued. Colonoscopic findings revealed rectal stenosis and reddish edematous mucosa with nodular alterations. Although CT showed that the abnormality in the descending and sigmoid colon had resolved, the wall thickening and annular stricture of the rectum persisted. The prostate was irregularly enlarged, encircling and compressing the rectum. Rectal biopsy results did not reveal malignancy. However, moderately to poorly differentiated adenocarcinoma was detected by prostate biopsy. Consequently, the patient was diagnosed with prostate cancer with rectal involvement. The rectal wall thickening and the symptoms improved following hormone therapy. Thus, concomitant prostate cancer invasion should be considered when CT reveals continuous colon wall thickening up to the rectum in a patient suspected of ischemic colitis.

Preservation of pelvic perfusion with iliac branch devices does not decrease ischemic colitis compared with hypogastric embolization in endovascular abdominal aortic aneurysm repair.

OBJECTIVE: 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. METHODS: 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 χ2 test, Fisher exact test, Kruskal-Wallis test, and multivariate regression models were used for data analysis. RESULTS: 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). CONCLUSIONS: 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.

Chimney Technique to Preserve Visceral Flow in a Coral Reef Aorta.

The coral reef aorta (CRA) is a rare phenomenon of extreme calcification in the juxtarenal and suprarenal aorta. Open revascularization has an overall in-hospital mortality rate of 13%. We present a patient with a suprarenal CRA with colon ischemia. She has an extensive past medical history of percutaneous transluminal angioplasty and stenting of the celiac trunk (CT) and superior mesenteric artery (SMA). The computed tomography angiography showed a CRA of the suprarenal aorta with occlusion of the CT stent and near occlusion of the SMA stent. Our case illustrates that the CRA in the suprarenal part of the aorta can be treated well by chimney graft procedure, although owing to lack of long-term follow-up, it might be reserved for high-risk candidates for (thoraco)abdominal aortic surgery.

The sigmoidea ima artery: A player in colonic ischemia?

INTRODUCTION: The sigmoidea ima artery is defined as the lowest sigmoid artery, which forms the distal end of the marginal artery by linking with the superior rectal artery. It supplies the rectosigmoid junction, which is a critical area for ischemia. The aim of the present study was to delineate the area supplied by the inferior mesenteric artery with special consideration of the sigmoidea ima artery. MATERIALS AND METHODS: The inferior mesenteric artery was dissected from its origin to the bifurcation of the superior rectal artery in 30 cadavers (15 male, 15 female). Vessel length and distance to the promontory were measured for each branch. RESULTS: There were two manifestations of the sigmoidea ima artery, irrespective of the branching pattern of the inferior mesenteric artery. It originated below the promontory in 25 cases (83.3%) and above it in three (10%). It did not derive from the superior rectal artery in two cases (6.7%). In these 16.7%, the marginal artery was absent near the rectosigmoid junction. CONCLUSIONS: We suggest the terms "arteria sigmoidea ima pelvina" and "arteria sigmoidea ima abdominalis" for the two variants. The terms "arteria marginalis pelvina" and "arteria marginalis abdominalis" could be applied in clinical practice. An abdominal marginal artery could be considered a risk factor for colonic ischemia in colorectal resections and abdominal aortic aneurysm repair. Both variants should be considered when pre- and intra-operative perfusion measurements are interpreted.

Inferior mesenteric artery replantation does not decrease the risk of ischemic colitis after open infrarenal abdominal aortic aneurysm repair.

BACKGROUND: Ischemic colitis after an open abdominal aortic aneurysm (AAA) repair remains a serious complication with a nationally reported rate of 1% to 6% in elective cases and up to 60% after an aneurysmal rupture. To prevent this serious complication, inferior mesenteric artery (IMA) replantation is performed at the discretion of the surgeon based on his or her intraoperative findings, despite the lack of clear evidence to support this practice. The purpose of this study was to determine whether replantation of the IMA reduces the risk of ischemic colitis and improves the overall outcome of AAA repair. METHODS: Patients who underwent open infrarenal AAA repair were identified in the multicenter American College of Surgeons National Surgical Quality Improvement Program Targeted AAA Database from 2012 to 2015. Emergency cases, patients with chronically occluded IMAs, ruptured aneurysms with evidence of hypotension, and patients requiring visceral revascularization were excluded. The remaining elective cases were divided into two groups: those with IMA replantation (IMA-R) and those with IMA ligation. We measured the 30-day outcomes including mortality, morbidity, and perioperative outcomes. A multivariable logistic regression model was used for data analysis, adjusting for clinically relevant covariates. RESULTS: We identified 2397 patients who underwent AAA repair between 2012 and 2015, of which 135 patients (5.6%) had ischemic colitis. After applying the appropriate exclusion criteria, there were 672 patients who were included in our study. This cohort was divided into two groups: 35 patients with IMA-R and 637 patients with IMA ligation. There were no major differences in preoperative comorbidities between the two groups. IMA-R was associated with increased mean operative time (319.7 ± 117.8 minutes vs 242.4 ± 109.3 minutes; P < .001). Examination of 30-day outcomes revealed patients with IMA-R had a higher rate of return to the operating room (20.0% vs 7.2%; P = .006), a higher rate of wound complications (17.1% vs 3.0%; P = .001), and a higher incidence of ischemic colitis (8.6% vs 2.4%; P = .027). There were no significant differences in mortality, pulmonary complications, or renal complications between the two groups. In multivariable analysis, IMA-R was a significant predictor of ischemic colitis and wound complications. CONCLUSIONS: These data suggest that IMA-R is not associated with protection from ischemic colitis after open AAA repair. The role of IMA-R remains to be identified.

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

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 12-36%) in these patients. The PPV for transmural CI of "moderate to severe CI" on sigmoidoscopy was 73% (8/11; 95% CI 43-90%). The PPV of "mild CI" on sigmoidoscopy was 11% (2/19; 95% CI 2.9-31%). The NPV of "no ischaemia" on sigmoidoscopy was 100% (95% CI 78-100%). Cardiac comorbidity (OR 3.1, 95% CI 1.19-7.97), low first haemoglobin (OR 0.6, 95% CI 0.47-0.87), and high vasopressor administration (OR 9.4, 95% CI 1.99-44.46) 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.

Atypical cause of intractable diarrhea in a hemodialysis patient, masked by Clostridium difficile-associated diarrhea and ischemic colitis: a case report.

BACKGROUND: Patients with end-stage kidney disease (ESKD) most commonly complain of gastrointestinal symptoms, such as diarrhea. Diarrhea negatively affects patient quality of life and has miscellaneous etiologies, such as Clostridium difficile-associated diarrhea (CDAD) and ischemic colitis. However, it is sometimes extremely difficult to determine the true etiology given the comorbidities and complications the patients have. A rare cause of diarrhea is ulcerative colitis (UC), which commonly affects the rectum and proximal colon in a continuous fashion. UC with rectal sparing or segmental distribution, although atypical, sometimes leads to misdiagnosis. Herein, we present a case of UC in a patient on hemodialysis with intractable diarrhea; we initially considered that the diarrhea was caused by CDAD and ischemic colitis. CASE PRESENTATION: A 69-year-old man with a history of hypertension, bilateral thalamic hemorrhage, and decreased kidney function was admitted to our hospital because of congestive heart failure. Volume control was impossible due to renal dysfunction and he was started on hemodialysis. Thereafter, he received various antibiotics for bacterial infections. Simultaneously, he experienced continuous watery, and sometimes bloody, diarrhea, which was diagnosed as CDAD owing to a positive stool test for Clostridium difficile toxins. Antibiotic treatment for CDAD did not result in symptom relief. Subsequently, we performed colon biopsy via colonoscopy, and the pathology showed virtually no inflammation with rectal sparing and segmental distributions. These findings favored the presence of ischemic colitis due to arteriosclerosis and ESKD rather than infections. He died of cardiac arrest before the diarrhea was alleviated. Finally, UC was revealed on autopsy as the main cause of the uncontrollable diarrhea. CONCLUSIONS: Patients with ESKD have a greater risk of developing CDAD and ischemic colitis, which have clinical features that sometimes overlap with those of UC, as in the present case. This case emphasizes the importance of correctly diagnosing the etiology of intractable diarrhea and the fact that other diarrhea etiologies can obscure the existence of inflammatory bowel disease, which should be considered and treated properly when patients on hemodialysis present with intractable diarrhea.

Ischemic colitis following left antegrade sclerotherapy for idiopathic varicocele.

The Tauber procedure, i.e., antegrade sclerotherapy for varicocele, can lead to ischemic colitis. The pathogenesis can involve an atypical systemic-portal communication, which could represent an infrequently reported (rare) anatomical variant. The aim of this study is to review clinical cases from the literature to highlight the anatomical bases of such complications. A computer-aided and hand-checked review of the literature was used to identify relevant publications. Also, the computed tomography (CT) examination of a clinical case with medico-legal implications due to severe vascular complication following Tauber's procedure was reviewed. Although specific references to this complication have appeared since the 19th century, reports in the contemporary literature include only a few clinical cases of ischemic colitis following Tauber's procedure. The CT scan images of a filed lawsuit revealed traces suggesting a significant communication between the testicular and left colic veins, forming part of the systemic-portal anastomoses. An anatomical variation consisting of a communication between the testicular and left colic veins has been described from the clinical point of view, corresponding to a significant anatomical finding identified in the past that has been under-reported and its clinical importance subsequently underestimated. For the first time we have demonstrated its pathophysiological significance in a real clinical scenario, linking the anatomical variation to the clinical complication. This demonstrates the importance of raising scientific awareness on this issue to prevent possibly devastating complications in daily clinical practice. Clin. Anat. 31:774-781, 2018. © 2018 Wiley Periodicals, Inc.

A Surgical Case of Inferior Mesenteric Arteriovenous Malformation.

The treatment option for inferior mesenteric arteriovenous malformations is under debate because of the number of cases. We, herein, report about a 35-year-old man with congenital inferior mesenteric artery malformation (AVM) presenting with mucous stool and severe abdominal pain. The radical operation, after building the diverting stoma, minimized the extent of the resection. This is the first reported case where surgical management was used to control severe symptoms induced by inferior mesenteric AVM.

[A Case of Ischemic Colitis Four Months after Laparoscopic Left Hemicolectomy Preserving Superior Rectal Artery].

The case was for a male at the age of 80. We performed laparoscopic left hemicolectomy and D3 lymph node dissection for descending colon cancer. He had a good postoperative prognosis and was discharged on the 14th day after the operation. Later, he was receiving the treatment on an outpatient basis without postoperative adjuvant chemotherapy during the followup period. He visited the hospital for sudden abdominal pain and melena as chief complaint approximately 4 months after the operation. We found prominent edematous wall thickening and increased surrounding fat concentration in the anal side of colon from the anastomosis site with plain abdominal CT scan. We also found that the anal side of colon from the anastomosis site an edematous change broadly in the lower gastrointestinal endoscopy. We conducted conservative treatment with the diagnosis of ischemic colitis at the anal side of colon from the anastomosis site. He was discharged on the 11th day after the hospitalization. Later, we conducted a follow-up examination for him on an outpatient basis. We recognized the symptom improvement approximately 2 months after the onset of the ischemic colitis.

Implications of concomitant hypogastric artery embolization with endovascular repair of infrarenal abdominal aortic aneurysms.

OBJECTIVE: Hypogastric artery embolization (HAE) is associated with significant risk of ischemic complications. We assessed the impact of HAE on 30-day outcomes of endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysms. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2014 to identify and to compare clinical features, operative details, and 30-day outcomes of EVAR with those of concomitant HAE with EVAR (HAE + EVAR). Multivariate analysis was performed to determine preoperative and intraoperative factors associated with development of significant complications observed in patients with HAE + EVAR. RESULTS: In a cohort of 5881 patients, 387 (6.6%) underwent HAE + EVAR. Compared with EVAR, a higher incidence of ischemic colitis (2.6% vs 0.9%; P = .002), renal failure requiring dialysis (2.8% vs 1%; P = .001), pneumonia (2.6% vs 1.3%; P = .039), and perioperative blood transfusion (17% vs 13%; P = .024) was noted after HAE + EVAR. Thirty-day thromboembolic events, strokes, myocardial infarction, lower extremity ischemia, reoperation, and readmission rates were not significantly different (P > .05). Mortality at 30 days in HAE + EVAR patients was 4.1% compared with 2.5% with EVAR (P = .044). HAE was independently associated with increased risk of colonic ischemia (adjusted odds ratio, 2.98; 95% confidence interval, 1.44-6.14; P = .003) and renal failure requiring dialysis (adjusted odds ratio, 2.22; 95% confidence interval, 1.09-4.53; P = .029). However, HAE was not an independent predictor of mortality. Average length of hospital stay was 4 ± 8.5 days after HAE + EVAR vs 3.3 ± 5.9 days after EVAR (P = .001). CONCLUSIONS: Concomitant HAE with EVAR is associated with longer and more complicated hospital stays. Ischemic colitis is a rare complication of EVAR. HAE increases the risk of ischemic colitis and renal failure requiring dialysis. This study highlights the importance of hypogastric artery preservation during EVAR.