## 1 Introduction  
Colonic ischemia (CI) following major abdominal vascular surgery is one of the rarest but most lethal and often unrecognized complications. This condition arises from a temporary or permanent reduction in blood flow to the colon, resulting in tissue hypoperfusion and subsequent necrosis of the intestinal wall. The incidence of ischemic colitis remains significant in patients undergoing isolated aortic surgery or associated with peripheral revascularization for Peripheral Chronic Obliterative Arteriopathy, also known as Peripheral Artery Disease, and its pathogenesis is multifactorial [1]. The onset of CI is associated with longer hospital stays, increased complexity of care, and reduced long-term survival after aortic surgery [2]. The mortality rate is high, and so the early identification of this condition is crucial. It can be achieved by recognizing signs and symptoms and using appropriate instrumental diagnostics.  
The incidence of colonic ischemia (CI) following major aortic surgery has remained relatively stable over the years, yet it continues to be a matter of debate, due to the heterogeneity in sample sizes and patient characteristics among different studies. The most notable recent finding is the significantly lower incidence of CI following endovascular aortic repair (EVAR) compared to open surgical repair (OSR). Conversely, [PERSON] et al. reported an incidence of approximately 0.6% after EVAR, versus 3.7% following OSR (_p_ < 0.001), due to the absence of aortic cross-clamping and reduced intraoperative blood loss, minimizing the likelihood of hypoperfusion and subsequent ischemia-reperfusion damage [3].  
Moreover, the majority of the current literature focuses exclusively on either elective or urgent settings. This narrative review aims to synthesize the current body of evidence regarding this complication, including both urgent and elective settings, and focus on the understanding of risk factors, strategies for early diagnosis, and the development of tailored therapeutic approaches to optimize management.  
The prognosis for these patients can be improved by optimizing risk factors, implementing perioperative and intraoperative strategies, and ensuring early diagnosis, with a consequent reduction in mortality rate.  
A comprehensive literature search was conducted using PubMed to identify studies reporting on colonic ischemia (CI) in the context of major aortic surgery. The search included articles published from 2000 to 2025 and used the following MeSH search terms: \"[colonic ischemia]\"; \"[bowel ischemia]\", \"[vascular surgery procedure]\", \"[rupted abdominal aortic aneurysm]\", \"[abdominal surgery]\", and \"[postoperative complications]\".  
Only studies published in English were considered. Additional relevant articles published prior to this timeframe were included when identified through the reference lists of selected papers, based on their relevance to the topic.  
Studies were screened based on their titles and abstracts, and full texts were reviewed for inclusion based on relevance to colon ischemia as a postoperative complication of elective or urgent aortic surgery, including both endovascular aortic repair (EVAR) and open surgical repair (OSR).