10 : 1-7, % IMA 11/13 10 : 1-7, 2001 IMA AAA. prospective study retrospective study IMA IMA. Tel: ,3

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1 10 : 1-7, IMA IMA IIA % IMA IIA % IMA % % 1 2.1% % 1 0.6% 3 6.4% % % IMA 6 2.8% 77.4% 41/ % 11/13 IMA 10 : 1-7, Ernst 1 AAA Tel: IMA 2,3 prospective study retrospective study IMA 4~8 IMA 1

2 10 1 Table 1 The management of IMA and pelvic circulation in RAAA and NAAA surgery Table 2 The outcomes of RAAA and NAAA surgery according to pelvic circulation AAA % % AAA IMA IIA interrupted group IMA IIA preserved group S CF Student-t test Fisher's exact test p < 0.05 IMA % % % 2

3 Table 3 List of 6 death cases with colon ischemia or infarction, and 1 referential case with normal sigmoid colon % IMA IIA Table 1 13 IIA 1 IIA 5 2 CIA 1 3 RAAA CIA 1 4 IIA 5 5 IIA IIA 1 4 Table % Table cm AAA IMA IIA Ao-biCIA Y graft 2 38' 350 cc 2 3 GOT U/l GPT 4810 U/l LDH U/l CPK 4840 U/l S S 5 AMI 2 75 BP 40 mmhg Hb 7.2 g/dl 9.5 cm RAAA IMA IIA Ao-biCIA Y graft 1 59' 700 cc 18 S S 3

4 MOF BP 70 mmhg 7 cm RAAA IMA IIA Ao- Ao I graft 1 32' 1600 cc 12 S MOF cm RAAA IMA IIA Ao-Ao I graft 2 08' 3150 cc 2 60 mmhg 14 S 42 MOF cm RAAAIMA IIA Ao-biEIA Y graft 3 55' 6300 cc DIC 12 OMI cm RAAA IMA IIA Ao-rtEIA / ltcia Y graft 2 35' 2451 cc MNMS 1 5 VT 8 AMI SMA 73 UN 58 Cr 4.0CT 5 cm RAAA IMA IIA Ao-Ao I graft cc 3 DIC S 10 1 AAA % 2% retrospective study CF prospective study 6% 60% 9, % 8,10~12 90% 10 1 IMA 2 IMA IIA 3 RAAA SMA 8 9 6,7,10 Ernst 1 52 AAA IMA CF IMA mmhg mmhg IMA IMA Poitrowski IMA Pittaluga AAA IMA 11.5% colon 1.2% IMA Hassen-Khadja AAA IMA %non-fatal 2 0.4% non-fatal 1 0.2% fatal 3 0.6% IIA IMA Killen AAA historical control test group 196 concomitant control prospective study test group IMA 50 mmhg 13 IMA his- 4

5 torical control concomitant control 1 historical control 2 0.7% test group 2 1.0% IMA % test group 2 3.4% Meissner l/min vs 3.8 l/min p = % vs 40% p = 0.03 α-adrenergic drug 52% vs 8% p = % IMA AAA IMA 0.4 IMA SMA 3 2.8% IMA S S IIA IMA IIA SMA S S 7 SMA AMI DIC % IMA 6 2.8% 11/ % 77.4% 41/ % 11/13 13 IMA Johnston 13 IMA IMA IMA AAA % AAA % IMA % IMA 155 AMI S 1 0.6% 47 4 S % MOF 13 2 DIC 11 S IMA ) Ernst, C. B., Hagihara, P. F., Daugherty, M. E. et al.: Inferior mesenteric artery stump pressure: A reliable index for safe IMA ligation during abdominal aortic aneurysmectomy. Ann. Surg., 187: , ), :., 5: ,

6 3),, :., 28: , ) Pittaluga, P., Batt, M., Hassen-Khodja, R. et al.: Revascularization of internal iliac arteries during aortoiliac surgery: A multicenter study. Ann. Vasc. Surg., 12: , ) Killen, D. A., Reed, W. A., Gorton, M. E. et al.: Is routine postaneurysmectomy hemodynamic assesment of the inferior mesenteric artery circulation helpful? Ann. Vasc. Surg., 13: , ) Brewster, D. C., Franklin, D. P., Cambria, R. P. et al.: Intestinal ischemia complicating abdominal aortic surgery. Surgery, 109: , ) Hassen-Khadja, R., Pittaluga, P., Le Bas, P. et al.: Role of direct revascularization of the internal iliac artery during aortoiliac surgery. Ann. Vasc. Surg., 12: , ) Piotrowski, J. J., Ripepe, A. J., Yuhas, J. P. et al.: Colonic ischemia: The Achilles heel of ruptured aor tic aneurysm repair. Am. Surg., 62: , ) Ernst, C. B., Hagiwara, P. F., Daugherty, M. E. et al.: Ischemic colitis incidence following abdominal aortic reconstruction: A prospective study. Surgery, 80: , ) Ernst, C. B.: Prevention of intestinal ischemia following abdominal aortic reconstruction. Surgery, 93: , ) Levison, J. A., Halpern, V. J., Kline, R. G. et al.: Perioperative predictors of colonic ischemia after ruptured abdominal aortic aneurysm. J. Vasc. Surg., 29: 40-47, ) Meissner, M. H. and Johansen, K. H.: Colon infarction after ruptured abdominal aortic aneurysm. Arch. Surg., 127: , ) Johnston, K. W. and Scobie, T. K.: Multicenter prospective study of nonruptured abdominal aortic aneurysms. I. Population and operative management. J. Vasc. Surg., 7: 69-81,

7 Is Inferior Mesenteric Artery Reconstruction Necessary in Abdominal Aortic Aneurysmectomy? A Study of Ruptured and Non-Ruptured Abdominal Aortic Aneurysm with Regard to Pelvic Circulation Takatoshi Furuya, Nobutaka Tanaka, Masakazu Nobori, Tatsu Nakazawa, Motoki Nagai, Yuujirou Tanaka, Takuya Hashimoto, Yoshihiro Kazama, Hiroki Sakata and Chihiro Takahashi Department of Surgery, Asahi General Hospital Key words: Inferior mesenteric artery, Abdominal aortic aneurysm, Ruptured abdominal aortic aneurysm, Ischemic colitis, Bowel infarction We studied 215 consecutive abdominal aortic aneurysmectomies without inferior mesenteric artery (IMA) reconstruction performed during the past 8 years to determine the incidence of ischemic colitis according to the pelvic circulation and presence of rupture. The 53 (24.7%) ruptured and 162 (75.3%) non-ruptured abdominal aortic aneurysms (AAA) in this series were classified into four groups: non-ruptured AAA with preserved pelvic circulation (NAAA/P-group, 155 cases), non-ruptured AAA with totally interrupted pelvic circulation (NAAA/Igroup, 7 cases), ruptured AAA with preserved pelvic circulation (RAAA/P-group, 47 cases), and ruptured AAA with totally interrupted pelvic circulation (RAAA/I-group, 6 cases). The IMA was ligated in all the ruptured and non-ruptured AAA cases (203, 94.4%) except for 4 ruptured and 8 non-ruptured AAA cases with preserved IMA (5.6%). No IMA reconstruction was performed in this series. Thirteen cases (6.0%, 6 RAAA and 7 NAAA) had no pelvic flow, and the other 202 cases (94.0%, 47 RAAA and 155 NAAA) had either IMA or at least unilateral internal iliac arterial flow. There were no significant differences in average age, aneurysmal size, estimated blood loss, urine output, incidence of ischemic colitis and bowel infarction between the NAAA/P-group and the NAAA/I-group and between the RAAA/P-group and the RAAA/I-group. There was no significant difference in the mean length of stay among the 4 groups. A total of 194 cases (90.2%) were discharged alive on an average of 11.6 days after operation without major complications. We ligated IMA in 94.4% of all abdominal aortic aneurysmectomies including ruptured cases, but bowel ischemia was observed in only 6 cases (2.8%), which were invariably related to severe shock conditions, such as rupture or acute myocardial infarction. With 77.4% of ruptured and 84.6% of obstructed pelvic circulation cases surviving without fatal colonic ischemia, this complication depends more on perioperative profound shock or systemic severe hypoperfusion, rather than the surgical treatment of IMA. (Jpn. J. Vasc. Surg., 10 : 1-7, 2001) 7