Non-occlusive mesenteric ischemia (NOMI): evaluation of 2D-perfusion angiography (2D-PA) for early treatment response assessment

Abstract

Purpose To evaluate the feasibility of 2D-perfusion angiography (2D-PA) for the analysis of intra-procedural treatment response after intra-arterial prostaglandin E1 therapy in patients with non-occlusive mesenteric ischemia (NOMI). Methods Overall, 20 procedures in 18 NOMI patients were included in this retrospective case-control study. To evaluate intra-procedural splanchnic circulation changes, post-processing of digital subtraction angiography (DSA) series was performed. Regions of interest (ROIs) were placed in the superior mesenteric artery (SMA; reference), the portal vein (PV; ROI PV), as well as the aorta next to the origin of the SMA (ROI Aorta). Peak density (PD), time to peak (TTP), and area under the curve (AUC) were assessed, and parametric ratios 'target ROI PD, TTP, AUC /reference ROI' were computed and compared within treatment and control group. Additionally, a NOMI score was assessed pre-and post-treatment compared to 2D-PA. Results Vasodilator therapy leads to a significant decrease of the 2D-PA-derived values PD Aorta (p = 0.04) and AUC Aorta (p = 0.03). These findings correlated with changes of the simplified NOMI score, both for overall (4 to 1, p < 0.0001) and for each category. Prostaglandin application caused a significant increase of the AUC PV (p = 0.04) and TTP PV was accelerated without reaching statistical significance (p = 0.13). When compared to a control group, all 2D-PA values in the NOMI group (pre-and post-intervention) differed significantly (p < 0.05) with longer TTP Aorta/PV and lower AUC Aorta/PV and PD Aorta/PV. Conclusion 2D-PA offers an objective approach to analyze immediate flow and perfusion changes following vasodilatory therapies of NOMI patients and may be a valuable tool for assessing treatment response.

2D-Perfusion Angiography Using Carbon Dioxide (CO2): A Feasible Tool to Monitor Immediate Treatment Response to Endovascular Therapy of Peripheral Arterial Disease?

“…2D-PA assigns density values to each area within an ROI and calculates mean values in each frame. These density values over time have been used to retrieve knowledge about flow rates, flow time and maximum values [2,[13][14][15][16][17]. In our study, we retrospectively assessed pre-and post-interventional blood flow through stenotic vessels using 2D-PA, evaluating it for possible assistance in CO2-based angiographies.…”

“…As previously described, PD characterizes the maximum mean density within the ROI. The AUC is calculated from each density value at each time point using integration of successive values [2,[13][14][15][16][17]. The significant increases in PD OUTFLOW / PD INFLOW and AUC OUTFLOW /AUC INFLOW following EVT imply an intra-individually increased perfusion of the treated artery.…”

“…Numeric density values for the time to peak (TTP), peak density value (PD) and area under the time-density curve (AUC) were computed [2,[13][14][15][16][17][18]. The following ratios were calculated pre-and post-intervention: TTP OUTFLOW / TTP INFLOW , PD OUTFLOW /PD INFLOW and AUC OUTFLOW / AUC INFLOW .…”

“…This technique relies on dedicated post-processing of standard digital subtraction angiography (DSA) images and computes time-density curves, which represent the flow of contrast agent within a region of interest (ROI) throughout the entire DSA run [2,[18][19][20][21][22]. Thus, it allows us to assess the perfusion distal to occluded vessels [2,[13][14][15][16][17] before, during and after endovascular revascularization. This might offer an opportunity to predict and evaluate clinical outcomes.…”

Surgical Abdomen

“…Patients with nonocclusive mesenteric ischemia should be managed initially with fluid resuscitation, optimization of cardiac output, correct the underlying cause whenever possible, and withdrawal of vasopressors (Bela et al 2017). Additional treatment options are selective intraarterial vasodilator therapy (e.g., Prostaglandin E1, papaverine) (Becker et al 2020). Anticoagulant therapy with heparin is successful in most patients (up to 93%) with mesenteric venous thrombosis (Lim et al 2019).…”