Factors associated with acute intestinal ischemia after cardiac surgery: A propensity score-matched study

Acute intestinal ischemia from cardiac surgery is rare but highly lethal. Conventional risk models lack preoperative markers reflecting splanchnic arterial capacity. We hypothesized that subclinical abdominal atherosclerosis predisposes to perioperative intestinal ischemia and introduced a novel radiologic measurement-the total enteric cross-sectional artery-area (TECSA)-to quantify anatomical obstruction of intestinal flow capacity.

In this retrospective, propensity score-matched study, we identified 53 cases of acute intestinal ischemia among 9301 patients who underwent cardiac surgery during years 2016-2024. Ten cases were excluded for aortic dissection (n = 9) and transplantation surgery (n = 1). The remaining 43 case patients were compared with 86 matched control patients. Minimal luminal cross-sectional areas of the celiac trunk, superior and inferior mesenteric, and internal iliac arteries were measured on computed tomography angiograms and indexed to body surface area to derive TECSA. Abdominal aortic and splanchnic calcium scores and stenoses were also assessed. Associations were analyzed using multivariable logistic regression with multiple imputations.

TECSA was lower in case patients compared with control patients (median 59 vs 92 mm²/m², P < .001). TECSA in the lowest quartile (≤61.5 mm²/m²) was independently associated with high odds of intestinal ischemia (adjusted odds ratio, 8.10; 95% CI, 1.58-41.41). High abdominal aortic calcium score was associated with intestinal ischemia in a sensitivity analysis (≥10,559; adjusted odds ratio, 6.13; 95% CI. 1.29-29.21). Celiac trunk stenosis showed a weak association among complete cases only.

Low TECSA and high abdominal aortic calcium score can be used to identify patients at risk of acute intestinal ischemia. TECSA represents a novel, physiologically grounded, and reproducible radiological measurement for risk stratification in cardiac surgery.