Reperfusion injury on computed tomography following endovascular revascularization of acute mesenteric ischemia: prevalence, risk factors, and patient outcome

Abstract

Background Data about reperfusion injury (RI) following acute arterial mesenteric ischemia (AAMI) in humans are scarce. We aimed to assess the prevalence and risk factors of RI following endovascular revascularization of AMI and evaluate its impact on patient outcomes. Methods Patients with AAMI who underwent endovascular revascularization (2016–2021) were included in this retrospective cohort. CT performed < 7 days after treatment was reviewed to identify features of RI (bowel wall hypoattenuation, mucosal hyperenhancement). Clinical, laboratory, imaging, and treatments were compared between RI and non-RI patients to identify factors associated with RI. Resection rate and survival were also compared. Results Fifty patients (23 men, median 72-yrs [IQR 60–77]) were included, and 22 were diagnosed with RI (44%) after a median 28 h (22–48). Bowel wall hypoattenuation and mucosal hyperenhancement were found in 95% and 91% of patients with post-interventional RI, respectively. Patients with RI had a greater increase of CRP levels after endovascular treatment (p = 0.01). On multivariate analysis, a decreased bowel wall enhancement on baseline CT (HR = 8.2), an embolic cause (HR = 7.4), complete SMA occlusion (HR = 7.0), and higher serum lactate levels (HR = 1.4) were associated with RI. The three-month survival rate was 78%, with no difference between subgroups (p = 0.99). However, the resection rate was higher in patients with RI (32% versus 7%; p = 0.03). Conclusion RI is frequent after endovascular revascularization of AAMI, especially in patients who present with decreased bowel wall enhancement on pre-treatment CT, an embolic cause, and a complete occlusion of the SMA. However, its occurrence does not seem to negatively impact short-term survival.

Diagnostic Role of MDCT in Acute Mesenteric Ischemia

“…This bull's-eye appearance is similar to venous ischemic bowel wall changes, and similarly, also fat stranding and peritoneal fluid can be observed [14]. Reperfusion phenomena are not necessarily associated with patients' worsening and can also occur after a successful revascularization [17,65].…”

Acute Mesenteric Ischemia: Imaging Findings and Mimics

“…14 Recent research has shown that the 3-month survival after reperfusion between those showing reperfusion injury did not differ from those without findings of reperfusion injury. 16 Imaging findings that can be seen with reperfusion injury include hyperenhancing bowel, bowel wall thickening, ascites, and mesenteric fat stranding.…”

“…Reperfusion injury can lead to shock, disseminated intravascular dissemination, or multiorgan failure, but is associated with an overall better prognosis and decreased mortality than inadequately reperfused bowel 14. Recent research has shown that the 3-month survival after reperfusion between those showing reperfusion injury did not differ from those without findings of reperfusion injury 16…”

Advancements in Revascularization Strategies for Acute Mesenteric Ischemia: A Comprehensive Review

“…A study by Garzelli et al in 2022 demonstrated that reperfusion injury could be a frequent complication of endovascular revascularization of AMI, especially in those who present with decreased bowel wall enhancement on pretreatment CT, anabolic cause, and complete occlusion of the superior mesenteric artery [33]. However, it does not seem to impact short-term survival negatively [33].…”