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 radiological 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 9,301 cardiac surgery patients during years 2016–2024. Ten cases were excluded for aortic dissection (n=9) and transplantation surgery (n=1). The remaining 43 cases were compared with 86 matched controls. Minimal luminal cross-sectional areas of the coeliac trunk, superior and inferior mesenteric, and internal iliac arteries were measured on CT-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 cases compared with controls (median 59 versus 92 mm²/m², p<0.001). TECSA in the lowest quartile (≤61.5 mm²/m²) was independently associated with high odds of intestinal ischemia (adjusted OR 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 OR 6.13, 95% CI 1.29–29.21). Coeliac trunk stenosis showed a weak association among complete cases only.

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