Discussion
The ICG-FA technology serves as a trans-operative tool for real-time
perfusion evaluation in multiple procedures, providing visual feedback
for the improvement of clinical decision-making, especially in high
morbidity and mortality cases. Acute MI continues to be a
life-threatening condition with mortality rates comparable to CS
[1,5]. Owing to the
nature of these, evaluation of bowel vitality and cardiac stability is
critical for successful outcomes when performing a surgical approach.
The clinical decision-making based on surgeons’ clinical judgment has
low sensitivity and specificity for all kinds of anastomosis
[6]. Adequate surgical
navigation is a culprit for successful surgical intervention in the
presence of MI, and so is the ability to diagnose accompanying
conditions that may preclude operative outcomes.
This case conveys multiple conditions that further extend the
mortality risk of the patient. However, the resolution of the patient’s
PE, subsequent RV failure and MI, and ensuing CS, shifted priorities.
While pulmonary embolectomy, RV failure and CS have been described as a
cascade of cardiac complications, this case stands out due to the ELS
provided to address NCSPs. In a recent study examining NCSPs in patients
on ECMO, after logistic regression analysis, the requirement of NCSPs
was not associated with mortality (odds ratio [OR]: 0.91, 95%
confidence interval [CI]: 0.68–1.23, p = 0.17)
[7].
This case report challenges the paradigm of no-intervention in
the setting of ELS. After multidisciplinary discussions, abdominal
surgery was performed despite VA-ECMO support. The benefits overweighed
the risks because of the ultimate objective to correctly preserve tissue
with the potential to recover. As it is well known, perfusion at the
site of resection/anastomosis is challenging to evaluate. While models
of prediction of intestinal viability using subjective clinical criteria
have been reported, 57% accuracy is underwhelming
[8]. Conversely,
trans-operative perfusion assessment techniques via ICG-FA have reported
multiple satisfactory outcomes, including the detection of necrotic
intestinal segments otherwise non-discernable by the naked eye, and the
improved outcomes of acute MI cases when implementing ICG-FA as part of
protocol intervention. A larger study determined the applicability of
ICG-FA to reduce extended bowel resections in acute MI by leading to
major changes in operative strategy and better clinical outcomes
[9]. Parallelly, ICG-FA
has assessed bowel perfusion during laparoscopic colorectal resection,
eliminating the presence of postoperative leaks and reducing mortality
rates [10].
While the dosing, approach, indications, presence of
comorbidities vary, a standardized clinical guideline has yet to be
placed in order to serve as a navigational course when considering
ICG-FA. While our patient ultimately succumbed, the NCSPs performed
safely with outstanding preservation of viable gastrointestinal segments
and cardiac stability. It is important to highlight that the patient
presented with a superimposed high mortality risk (primary PE,
irreversible RV, acute MI, and CS). The main purpose of this case report
is to propose the consideration of performing NCSPs even in critical
cardiac condition patients.
This case report’s strength holds sound in the pioneering
venture of safely performing NCSPs under ELS. The weaknesses are
directed towards the relative novelty of the application of this
technique and its lack of standardized societal clinical guidelines. Our
experience with ICG-FA is based on time to peak intensity and dose
dependent, regardless of ELS. Thus, although visual aid was achieved, a
level of subjectivity accompanies the clinical decision-making of the
resection/anastomotic approach. Whether these variables have a true
effect on the adequacy of the perfusion evaluation, its preservation and
absence of leak was still achieved. More so, ICG-FA models have yet to
determine the precise and optimal blood flow rate needed to ensure
tissue salvage/preservation. Previous efforts to assess blood supply
have yet to define the optimal blood flow needed to avoid anastomotic
leakage [10]. Finally,
ICG has limits to take into account: Limited penetrance of 10 mm in
target tissues, short vascular clearance of 3-4 minutes, and a relative
dependency on albumin bonds
[4]. These become
relevant, especially in the presence of multiorgan failure from a
secondary CS, consequent of a primary PE, further complicated by acute
MI.