Nonocclusive Mesenteric Ischemia Patients Research Articles

Association between Postoperative Adjuvant Vasodilator Therapy and In-Hospital Mortality for Non-Occlusive Mesenteric Ischemia: A Nationwide Observational Study.

Although several clinical guidelines recommend vasodilator therapy for non-occlusive mesenteric ischemia (NOMI) and immediate surgery when bowel necrosis is suspected, these recommendations are based on limited evidence. In this retrospective nationwide observational study, we used information from the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2018 to identify patients with NOMI who underwent abdominal surgeries on the day of admission. We compared patients who received postoperative vasodilator therapy (vasodilator group) with those who did not (control group). Vasodilator therapy was defined as venous and/or arterial administration of papaverine and/or prostaglandin E1 within 2 days of admission. The primary outcome was in-hospital mortality. Secondary outcomes included the prevalence of additional abdominal surgery performed ≥3 days after admission and short bowel syndrome. We identified 928 eligible patients (149 in the vasodilator group and 779 in the control group). One-to-four propensity score matching yielded 149 and 596 patients for the vasodilator and control groups, respectively. There was no significant difference in in-hospital mortality between the groups (control vs. vasodilator, 27.5% vs. 30.9%; risk difference, 3.4%; 95% confidence interval, -4.9 to 11.6; p=0.42) and no significant difference in the prevalences of abdominal surgery, bowel resection ≥3 days after admission, and short bowel syndrome. Postoperative vasodilator use was not significantly associated with a reduction in in-hospital mortality or additional abdominal surgery performed ≥3 days after admission in surgically treated NOMI patients.

MDCT-findings in patients with non-occlusive mesenteric ischemia (NOMI): influence of vasoconstrictor agents

ObjectivesTo evaluate the influence of vasoconstrictor agents (VCAs) on signs of vasoconstriction and bowel ischemia on MDCT detected in patients with non-occlusive mesenteric ischemia (NOMI).MethodsThis 8-year single-center retrospective study consecutively included all patients with histopathologically proven NOMI who underwent MDCT ≤ 48 h prior to surgical bowel resection. Two blinded radiologists jointly reviewed each examination for signs of bowel ischemia, abdominal organ infarct, mesenteric vessel size and regularity, and ancillary vascular findings. VCA administration (length and dosage), clinical and biochemical data, risk factors, and outcomes were retrieved from patients’ medical records. Subgroup comparisons were performed.ResultsNinety patients were included (59 males, mean age 65 years); 40 (44.4%) had received VCAs before MDCT. Overall mortality was 32% (n = 29), with no significant difference between the two groups. In patients treated with VCAs, the calibre of the superior mesenteric artery (SMA) was smaller (p = 0.032), and vasoconstriction of its branches tended to be more important (p = 0.096) than in patients not treated with VCAs. The presence and extent of bowel ischemia did not significantly correlate with VCA administration, but abdominal organ infarcts tended to be more frequent (p = 0.005) and involved more organs (p = 0.088). The VCA group had lower mean arterial pressure (p = 0.006) and lower hemoglobin levels (p < 0.001). Several biomarkers of organ failure and inflammation, differed significantly with VCA use, proving worse clinical condition.ConclusionsMDCT demonstrates more severe SMA vasoconstriction and tends to show increased abdominal organ infarcts after VCA administration in NOMI patients compared to NOMI patients not treated with VCAs.Key Points• In critically ill patients with NOMI, MDCT demonstrates VCA support via increased vasoconstriction of the main SMA and its branches.• VCA administration in NOMI patients tends to contribute to the development of organ infarcts, as shown on MDCT.• An important degree of vasoconstriction in NOMI patients may indicate insufficient resuscitation and, thus, help clinicians in further patient management.

Management of Nonocclusive Mesenteric Ischemia in Patients with Cardiac Failure.

This study aimed to evaluate the surgical procedures, outcomes, and prognostic factors in patients with ischemic heart disease who were operated on due to nonocclusive mesenteric ischemia (NOMI). This research contains all patients diagnosed with congestive heart failure and NOMI between January 2011 to January 2020. The patients who had angiography or CT that showed occlusion of more than 50% in any of the main branches of the mesenteric artery or patients who presented with symptoms in correlation with a total occlusion were excluded from the study. Patients who underwent coronary heart surgery but were not diagnosed with congestive heart failure and those with atrial fibrillation also were excluded from the study. Patients divided into two groups, according to a medical database. A significant difference was found between the surviving and non-survivor groups in minutes, in terms of median time to segmenter intestinal resection (P = 0.042). An early diagnosis and surgical segmental intestinal resection before peritonitis worsens can be the key to better prognosis for NOMI patients.

Planned Versus On-Demand Relaparotomy Strategy in Initial Surgery for Non-occlusive Mesenteric Ischemia

BackgroundThere has been insufficient evidence regarding a treatment strategy for patients with non-occlusive mesenteric ischemia (NOMI) due to the lack of large-scale studies. We aimed to evaluate the clinical benefit of strategic planned relaparotomy in patients with NOMI using detailed perioperative information. MethodsWe conducted a multicenter retrospective cohort study that included NOMI patients who underwent laparotomy. In-hospital mortality, 28-day mortality, incidence of total adverse events, ventilator-free days, and intensive care unit (ICU)–free days were compared between groups experiencing the planned and on-demand relaparotomy strategies. Analyses were performed using a multivariate mixed effects model and a propensity score matching model after adjusting for pre-operative, intra-operative, and hospital-related confounders. ResultsA total of 181 patients from 17 hospitals were included, of whom 107 (59.1%) were treated using the planned relaparotomy strategy. The multivariate mixed effects regression model indicated no significant differences for in-hospital mortality (61 patients [57.0%] in the planned relaparotomy group vs. 28 patients [37.8%] in the on-demand relaparotomy group; adjusted odds ratio [95% confidence interval] = 1.94 [0.78–4.80]), as well as in 28-day mortality, adverse events, and ICU-free days. Significant reduction in ventilator-free days was observed in the planned relaparotomy group. Propensity score matching analysis of 61 matched pairs with comparable patient severity did not show superiority of the planned relaparotomy strategy. ConclusionsThe planned relaparotomy strategy, compared with on-demand relaparotomy strategy, did not show clinical benefits after the initial surgery of patients with NOMI. Further studies estimating potential subpopulations who may benefit from this strategy are required.

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

PurposeTo 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).MethodsOverall, 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; ROIPV), as well as the aorta next to the origin of the SMA (ROIAorta). Peak density (PD), time to peak (TTP), and area under the curve (AUC) were assessed, and parametric ratios ‘target ROIPD, 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.ResultsVasodilator therapy leads to a significant decrease of the 2D-PA-derived values PDAorta (p = 0.04) and AUCAorta (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 AUCPV (p = 0.04) and TTPPV 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 TTPAorta/PV and lower AUCAorta/PV and PD Aorta/PV.Conclusion2D-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.

Abstract No. 416 Two-dimensional perfusion angiography and its suitability in diagnosing and documenting early treatment response in patients with non-occlusive mesenteric ischemia: a retrospective analysis

Evaluation of the feasibility of 2D-perfusion angiography (2D-PA) in assessing the intraprocedural treatment response of the splanchnic vessel territory after vasodilatory therapies in patients suffering from non-occlusive mesenteric ischemia (NOMI). 19 procedures in 17 NOMI patients (mean age, 60.9 ± 11 years) were included in this retrospective study. We performed postprocessing of the acquired digital subtraction angiography (DSA) series to evaluate flow and perfusion changes after vasodilatory prostaglandin therapy. We placed target regions of interest (ROIs) in the portal vein, the aorta, and a reference ROI in the superior mesenteric artery (SMA). The peak density (PD), time to peak (TTP) and area under the curve (AUC) were then assessed and the following ratios ‘target ROI (TTP, AUC)/ reference ROI’ computed. Furthermore, the simplified NOMI score was assessed pre- and post-NOMI therapy. Significant changes could be recorded in the individual categories as well as in the overall simplified NOMI score following interventional NOMI therapy (4 to 1, P <0.0001). Both PD and AUC values in the aorta decreased significantly pre- to postinterventionally (PD: P = 0.04; AUC: P = 0.03), while the AUC in the portal vein (PV) was significantly increased (P = 0.04) after prostaglandin application. Though without statistical significance, TTP measured in the PV demonstrated an increase after vasodilator therapy as well (P = 0.13). Our findings are in concordance with the simplified NOMI score. 2D-PA is a suitable method for the analysis of immediate perfusion changes following vasodilatory therapies of NOMI patients and may be a valuable addition to previously published angiographic scoring systems, such as the subjective simplified NOMI score.

What affects the prognosis of NOMI patients? Analysis of clinical data and CT findings.

Non-occlusive mesenteric ischemia (NOMI) is a mesenteric ischemic disease with considerably high mortality rate, although little has been known about what factors affect the patients' prognosis. The purpose of this study was to investigate prognostic factors of clinical data and computed tomography (CT) findings in patients with NOMI. This was a single institutional, retrospective study, reviewing 21 consecutive patients diagnosed with NOMI on angiography. Patients were divided into either ''survivor'' group or ''non-survivor'' group based on their clinical courses 1month after diagnosis. Clinical information such as laboratory data, Charlson Comorbidity Index, and time from CT to injecting vasodilator was obtained from patients' medical records. Contrast-enhanced CT images were assessed in following items: defect of mural enhancement, pneumatosis intestinalis, hepatic portal venous gas, paralytic bowel dilatation, bowel wall thinning, and diameters of the relevant vessels. Eight patients belonged to ''survivor'' group, whereas eleven were allocated to ''non-survivor'' group. None of CT findings showed significant difference between survivor group and non-survivor group [defect of mural enhancement: 75% and 100% (p = 0.16), pneumatosis intestinalis: 50% and 45.5% (p = 1.00), hepatic portal venous gas: 37.5% and 45.5% (p = 1.00), paralytic bowel dilatation: 12.5% and 63.6% (p = 0.06), and bowel wall thinning: 50% and 45.5% (p = 1.00)]. The diameters of the relevant vessels did not have significant difference either. Time from CT to injecting vasodilator was revealed to be significantly shorter in survivor group [187.5 (122.5-294) min and 310 (187-925.5)] (p = 0.048). None of the other clinical information had significant difference between each group. Prompt angiography may be a key to improve the prognosis of NOMI patients.

Establishment of Predictive Models for Nonocclusive Mesenteric Ischemia Comparing 8,296 Control with 452 Study Patients

The aim of this study was to develop clinical preoperative, intraoperative, and postoperative scores for early identification of patients who are at risk of nonocclusive mesenteric ischemia (NOMI). A retrospective analysis. Single center. From January 2008 to December 2014, all patients from the Department of Thoracic and Cardiovascular Surgery were included on the basis of the hospital database. All mesenteric angiographically identified NOMI patients were compared with non-NOMI patients. The study population of 8,748 patients was randomized into a cohort for developing the scores (non-NOMI 4,214 and NOMI 235) and a cohort for control (non-NOMI 4,082 and NOMI 217). Risk factors were identified using forward and backward Wald test and were included in the predictive scores for the occurrence of NOMI. C statistic showed that the scores had a high discrimination for the prediction of NOMI preoperatively (C statistic 0.79; p < 0.001), intraoperatively (C statistic 0.68; p < 0.001), and postoperatively (C statistic 0.85; p < 0.001). A combination of the preoperative, intraoperative, and postoperative risk scores demonstrated the highest discrimination (C statistic 0.87; p < 0.001). The combined score included the following risk factors: renal insufficiency (preoperative); use of cardiopulmonary bypass and intra-aortic balloon pump support (intraoperative); and reexploration for bleeding, renal replacement therapy, and packed red blood cells ≥ 4 units (postoperative). The results were similar in the control group. These scores could be useful to identify patients at risk for NOMI and promote a rapid diagnosis and therapy.

Occurrence and severity of non-occlusive mesenteric ischemia (NOMI) after cardiovascular surgery correlate with preoperatively assessed FGF-23 levels.

PurposeTo evaluate the value of preoperatively assessed fibroblast growth factor 23 (FGF-23) levels and to correlate FGF-23 with angiographic findings in non-occlusive mesenteric (NOMI) ischemia using a standardized scoring system.Materials and methodsBetween 2/2011 and 3/2012 a total of 865 patients (median age: 67 years) underwent cardiovascular surgery during this ethics committee approved, prospective study. 65 of these patients had clinical suspicion of NOMI and consequently underwent catheter angiography of the superior mesenteric artery. Images were assessed using a standardized reporting system (Homburg-NOMI-Score). These data were correlated to following preoperative parameters of kidney function: cystatin C, creatinine, FGF-23 and estimated glomerular filtration rate (eGFR), and outcome data (death, acute renal failure) using linear and logistic regressions, as well as nonparametric tests.ResultsSignificant correlations were found between FGF-23 and the angiographic appearance of NOMI (p = 0.03). Linear regression analysis showed no significant correlation to the severity of NOMI with creatinine (p = 0.273), cystatin C (p = 0.484), cystatin C eGFR (p = 0.914) and creatinine eGFR (p = 0.380). Logistic regression revealed a significant correlation between death and the Homburg-NOMI-Score (p<0.001), but not between development of NOMI and acute renal failure (p = 0.122). The ROC Analysis yielded an area under the curve of 0.695 (95% CI: 0.627–0.763) with a sensitivity of 0.672 and specificity of 0.658.ConclusionsFGF-23 significantly correlates with the severity of NOMI, which is in contrast to other renal function parameters. The applied scoring system allows to predict mortality in NOMI patients.

Clinical Outcomes and Prognostic Factors After Surgery for Non-Occlusive Mesenteric Ischemia: a Multicenter Study

BackgroundTo date, no large-scale study has been undertaken to understand the clinical features of non-occlusive mesenteric ischemia (NOMI) after surgery. We thus performed a multicenter investigation to clarify the clinical outcomes and prognostic factors of NOMI. Patients and MethodsClinical databases from 22 Japanese facilities were reviewed for evaluation of patients who received surgery for NOMI between 2004 and 2012. NOMI patients (n = 51) were divided into two groups: group I (n = 28) consisted of patients who survived, and group II (n = 23) consisted of patients who did not survived. Prognostic factors were compared between the two groups. ResultsNOMI surgery represented 0.04 % of the total number of operations performed in this time period. The overall mortality rate for NOMI surgery was 45 %. Hemodialysis was a significant negative prognostic factor (p = 0.027). Preoperative elevation of transaminases, potassium, and white blood cell count, as well as metabolic acidosis and colon ischemia was poor prognostic factors. The mean Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) score of group I versus group II was 54.5±3.6 and 85.2 ± 4.1, respectively (p < 0.001). ConclusionsCurrently, NOMI surgery has a 45 % mortality rate. POSSUM scores can be used to predict the clinical outcome of patients who receive NOMI surgery.

A Scoring-System for Angiographic Findings in Nonocclusive Mesenteric Ischemia (NOMI): Correlation with Clinical Risk Factors and its Predictive Value

This study was designed to evaluate the clinical value of a standardized angiographic scoring system in patients with nonocclusive mesenteric ischemia (NOMI). Sixty-three consecutive patients (mean age: 73 ± 8 years) with suspect of NOMI after cardiac or major thoracic vessel surgery underwent catheter angiography of the superior mesenteric artery. Images were assessed by two experienced radiologists on consensus basis using a scoring system consisting of five categories, namely vessel morphology, reflux of contrast medium into the aorta, contrasting and distension of the intestine, as well as the time to portal vein filling. These were correlated to previously published risk factors of NOMI and outcome data. The most significant correlation was found between the vessel morphology and death (p < 0.001) as well as reflux of contrast medium into the aorta and death (p = 0.005). Significant correlation was found between delayed portal vein filling and preoperative statin administration (p = 0.011), previous stroke (p = 0.033), and renal insufficiency (p = 0.043). Reflux of contrast medium correlated significantly with serum lactate >10 mmol/L (p = 0.046). The overall angiographic score correlated with death (p = 0.017) and renal insufficiency (p = 0.02). The ROC-analysis revealed that a score of ≥3.5 allows for identifying patients with increased perioperative mortality with a sensitivity of 85.7 % and a specificity of 49 %. With the use of a simplified score (vessel morphology, reflux of contrast medium into the aorta, and time to portal vein filling), specificity was increased to 71.4 %. The applied scoring system allows standardized interpretation of angiographic findings in NOMI patients. Beyond that the score seems to correlate well with risk factors of NOMI and outcome.

Non-occlusive mesenteric ischemia (NOMI): utility of measuring the diameters of the superior mesenteric artery and superior mesenteric vein at multidetector CT.

To investigate the diagnostic capability of multidetector computed tomography for detecting non-occlusive mesenteric ischemia (NOMI). We studied 11 NOMI patients and 44 controls. Radiologists evaluated the CT images for the presence of bowel ischemia and measured the diameters of the superior mesenteric artery and the superior mesenteric vein (D SMA and D SMV). We also performed linear discriminant analysis (LDA) using D SMA and D SMV. All NOMI patients presented with more than 2 CT findings of bowel ischemia. D SMA and D SMV were significantly smaller in NOMI patients than in the controls (p<0.01). At the optimal cut-off values for D SMA (6.5mm), D SMV (9.0mm), and the Z value in LDA (0.93), sensitivity and specificity were 81.8 and 81.8; 81.8 and 88.6; and 81.8 and 97.7%, respectively. D SMA and D SMV were significantly smaller in NOMI patients than in the controls and D SMV is a more significant parameter than D SMA.

Risk factors for nonocclusive mesenteric ischemia after elective cardiac surgery

Nonocclusive mesenteric ischemia (NOMI) may occur after cardiopulmonary bypass. It is crucial to early identify patients who are at risk of developing this complication. The aim of this prospective study was to evaluate perioperative risk factors in a large cohort of patients undergoing elective cardiac surgery. From January 1, 2010, to March 31, 2011, all patients scheduled for elective cardiac surgery were screened for participation in this trial. If NOMI was suspected, arterial angiography was performed. NOMI and non-NOMI patients were compared with respect to all variables assessed in this study. Additionally, odds ratios were calculated. Linear discriminant analyses as well as logistic regression analyses were performed to develop a model that identifies patients at risk for developing NOMI. Eight hundred sixty-five patients were included in the study, of whom 78 developed NOMI. Among preoperative parameters, renal insufficiency, diuretic therapy, and age >70 years showed the highest odds ratios for postoperative NOMI. The highest odds ratios for development of NOMI were observed with postoperative variables. In particular, the need for intra-aortic balloon pump support and serum lactate concentrations >5 mmol/L proved to be serious risk factors. Using a linear discriminant analysis with 7 variables, 92.3% of patients were correctly classified (sensitivity 76.9%, specificity 93.8%). A high index of suspicion for NOMI in patients with the above-mentioned risk factors may decrease the diagnostic and therapeutic delay. To identify at-risk patients the developed risk equation is a useful tool with a high specificity.

Usefulness of multidetector-row CT (MDCT) for the diagnosis of non-occlusive mesenteric ischemia (NOMI): Assessment of morphology and diameter of the superior mesenteric artery (SMA) on multi-planar reconstructed (MPR) images

Objective The purpose of this study was to assess the efficacy of multidetector-row CT (MDCT) for the diagnosis of non-occlusive mesenteric ischemia (NOMI) by analyzing morphology and diameter of superior mesenteric artery (SMA). We assessed whether MDCT was as useful as angiography for the diagnosis of NOMI. Materials and methods Four patients who were diagnosed with NOMI were retrospectively analyzed. All patients had 8-row MDCT followed by laparotomy. Two of them underwent angiography after MDCT. The morphology and diameter of SMA of these cases was analyzed on multi-planar reconstructed (MPR) images. The mean diameter of SMA of NOMI cases was compared to that of 13 control cases. Results MPR images of all NOMI cases showed irregular narrowing of the SMA, spasm of the arcades of SMA, and poor demonstration of intramural vessels. MPR images of two patients who had angiography were concordant with their angiograms. The mean diameter of SMA of NOMI patients was 3.4 ± 1.1 mm, which was statistically smaller than that of 13 control patients, 6.0 ± 1.5 mm ( P < 0.05, Wilcoxon rank sum tests). Conclusion Angiography has been recognized essential for the diagnosis of NOMI. This study shows the possibility of MDCT to be an equivalently useful modality compared to angiography for the diagnosis of NOMI by interpreting morphologic appearance and diameter of SMA. Introduction of MDCT in the decision tree of NOMI treatment may bring the benefit of prompt diagnosis and subsequent early and efficient initiation of therapy, which may improve the mortality.

Survival of Three Nonocclusive Mesenteric Ischemia Patients following Early Diagnosis by Multidetector Row Computed Tomography and Prostaglandin E1 Treatment

Nonocclusive mesenteric ischemia (NOMI) is an acute mesenteric circulatory disorder which is characterized by spasm and narrowing of the arterial branches. In contrast to occlusive disease, early diagnosis of NOMI is difficult because of its mild symptoms, thus resulting in a high mortality rate. In this study, we report three cases who survived NOMI because of early diagnosis by multidetector row computed tomography and immediate treatment with prostaglandin E1, which is known to improve blood flow by relaxing vascular smooth muscle. We conclude that early diagnosis and treatment of NOMI with prostaglandin E1 considerably improves the prognosis of this disease.

Nonocclusive mesenteric infarction in hemodialysis patients

Background: Dialysis patients develop nonocclusive mesenteric ischemia (NOMI) at an increased rate. Previous studies have associated atherosclerosis and hemodialysis-induced hypotension as inciting factors for NOMI development. A retrospective review of 29 of 1,370 longterm hemodialysis patients who developed NOMI from January 1992 to December 1997 was performed. The NOMI patients were compared with a similar profile of hemodialysis patients to identify risk factors for the development of NOMI and for outcomes assessment.Study Design: All NOMI patients had hypotensive episodes during hemodialysis the week before the development of abdominal symptoms, and additional risk factors of hypertension (83%), diabetes (55%), and atherosclerosis (38%). The majority of patients (83%) experienced abdominal pain more than 24 hours before admission. Sixty-six percent of patients had leukocytosis on admission laboratory data.Results: Sixteen patients (55%) had ischemia of the small bowel, all underwent laparotomy, and nine (56%) died. Thirteen patients (45%) had ischemia of the colon and were managed nonoperatively; four (31%) of them died. Overall mortality rate for NOMI was 45%.Conclusions: NOMI occurs at an increased rate in hemodialysis patients. Identification of patients at high risk for NOMI and close monitoring of filtration rates may impact on the high mortality of this disease.