Prevention and management of sigmoid and pelvic ischemia associated with aortic surgery.

Ischemia of the colon, rectum, and pelvis continues to be a significant source of morbidity and mortality after aortic reconstruction. Complications associated with colonic and pelvic ischemia are severe and include impotency, buttock claudication, colonic and rectal infarction, buttock and perineal necrosis, and spinal cord or lumbar plexus injury. To prevent these complications the vascular surgeon must make every attempt to guarantee the adequacy of colonic and pelvic blood supply after aortic reconstructive procedures. During open surgical repair of aneurysms or aortoiliac arterial occlusive disease, patent inferior mesenteric arteries must either be routinely reimplanted or selectively ligated on the basis of object intraoperative assessment of colonic perfusion. In addition, when possible, antegrade perfusion should be maintained in patent internal iliac arteries, and femoral reconstructions should include reconstruction of the deep femoral artery to assure adequate perfusion of potential pelvic collaterals. The rate of colonic and pelvic ischemia after endovascular aneurysm repair appears lower than after open repair, but all of the complications of colonic and pelvic ischemic seen after open repairs have been reported after endoluminal aneurysm repair. Thus, during stent-graft repair of abdominal aortic aneurysms, all attempts also should be made to preserve pelvic perfusion by maintaining antegrade flow to a least one patent internal iliac artery. The principle to remember in the management of complications of pelvic ischemia associated with aortic reconstruction is prevention because when complications of pelvic ischemia occur, the damage often is irreversible.