Preoperative Planning for Superior Mesenteric Artery Aneurysm
Round 1
Reviewer 1 Report
Dear authors
The process of preoperative planning, which consists in performing the procedure in a virtual environment, has been known for nearly 20 years. The pioneers in creating tools for the use of CT (MRI) to introduce human tissues into a virtual environment for the purpose of separating individual tissues were Materialise and its MIMISC® tool developed so far. The standard virtual treatment procedure consists of:
- diagnosing the size and location of the defect (change),
- selection of a replacement system and determination of its size and common features, e.g. contact surface (coverage),
- proposing a method of treatment, in many cases two alternative methods to remove the dysfunction,
- comparison of treatment effects by carrying out numerical tests, e.g. assessing the state of stresses and deformations of tissues and the replacement system or testing the flow inside a healthy vessel and comparing it with the flow inside the proposed replacement system.
- selection of the optimal treatment method and diagnostics of the applied solution, including numerical tests of a personalized solution applied to a specific patient,
- etc.
The work presented by the authors is very correctly written. The adopted methodology is correct, but it does not bring anything new in terms of preoperative planning. The publications available in international databases contain dozens of publications on the use of various configurations of virtual and diagnostic tools for personalizing procedures, i.e. varicose veins (aneurysms), heart valves, reconstruction of bone defects, including skull bones and human joints, etc. In many publications, preoperative planning allows for the selection of alternative reconstruction techniques and allows for the optimization of the treatment result by visualizing the flows in the reconstructed vessel or assessing the stress state of the implant-tissue system and determining critical contact areas.
From the detailed comments, it is necessary to point out the poor quality of the drawings and the poor literature review, of which only 4 out of 15 publications refer to publications from the last 5 years. In such a dynamically developing field of knowledge and the more and more common use of numerical tools in medicine in recent years, it is advisable to thoroughly prepare a literature review and indicate that the method proposed by the authors is innovative and has been previously described in detail in other publications.
Author Response
In this article, the authors describe that a software platform, CardioCTNav, can help planning the operation of a mesenteric artery aneurysm. It is a well-written paper; however, there are some significant concerns about this article.
- There are no statements of primary outcomes and secondary outcomes in this article.
Would you please state at the end of the introductions?
We propose a preoperative planning protocol, which consists in four steps, namely high-quality 3D rendering, virtual navigation (angiography) through the arteries, automatic and semi-automatic (point and click) measurements, 3D stent simulations. These steps are exemplified and implemented in our own (in-house) software application, CardioCTNav. The main advantages of our solutions are the quality of implementation (it is a fast, stable, and bugs free application), the price – a binary package can be provided free of charge on request, easy of use – no sophisticated and difficult segmentations are required to perform the suggested planning protocol, the time necessary to perform the planning – it can be done in less than 10 minutes, and it has virtually no training curve – intuitive user interface and simple gestures that can be learned in only a few minutes.
2. In addition, there are not enough comparisons (CardioCTNav and other methods) and no discussions in this article. The authors should reconstruct the article.
Image processing software and virtual planning methods are already of great importance in medical practice. It could be made a long list of either free of charge medical imaging software platforms, e.g.MITK, 3D slicer, semi-commercial, e.g. Osirix, or commercial ones. Characteristics used for the evaluation of such platforms could be: the functionalities it offers (3D rendering, segmentation, measurements, virtual simulations, etc.), the price (from free of charge to very expensive), training curve, hardware requirements, etc.
- If Figure 10 is not original, the authors should state permission for diversion in the article.
The figure was replaced with an original figure drawn by Dr Vergil Pop.
Reviewer 2 Report
The authors propose a step-by-step Standard operation protocol (SOP) for preoperatory planning for superior mesenteric artery aneurysm, including: 3D reconstruction and visualization of arteries, Virtual angiography (endonavigation), Automatic measurements of the artery diameter in the necessary ROIs, Stent placement simulation and 3D visualization.
The SOP was carried out in a real, single case.
There is a feeling that authors would like to discuss about a new software platform; in such a case it is necessary to perform a comparison with other similar software platforms, evaluating cons and pros evaluation in detail, emphasising the strongest points of the new platform.
Line 133 - the manufacturer of the software is not indicated.
Line 178-179 - the meaning and purpose of this statement is not clear.
Author Response
The process of preoperative planning, which consists in performing the procedure in a virtual environment, has been known for nearly 20 years. The pioneers in creating tools for the use of CT (MRI) to introduce human tissues into a virtual environment for the purpose of separating individual tissues were Materialise and its MIMISC® tool developed so far. The standard virtual treatment procedure consists of:
- diagnosing the size and location of the defect (change),
- selection of a replacement system and determination of its size and common features, e.g. contact surface (coverage),
- proposing a method of treatment, in many cases two alternative methods to remove the dysfunction,
- comparison of treatment effects by carrying out numerical tests, e.g. assessing the state of stresses and deformations of tissues and the replacement system or testing the flow inside a healthy vessel and comparing it with the flow inside the proposed replacement system.
- selection of the optimal treatment method and diagnostics of the applied solution, including numerical tests of a personalized solution applied to a specific patient,
- etc.
The work presented by the authors is very correctly written. The adopted methodology is correct, but it does not bring anything new in terms of preoperative planning. The publications available in international databases contain dozens of publications on the use of various configurations of virtual and diagnostic tools for personalizing procedures, i.e. varicose veins (aneurysms), heart valves, reconstruction of bone defects, including skull bones and human joints, etc. In many publications, preoperative planning allows for the selection of alternative reconstruction techniques and allows for the optimization of the treatment result by visualizing the flows in the reconstructed vessel or assessing the stress state of the implant-tissue system and determining critical contact areas.
From the detailed comments, it is necessary to point out the poor quality of the drawings and the poor literature review, of which only 4 out of 15 publications refer to publications from the last 5 years. In such a dynamically developing field of knowledge and the more and more common use of numerical tools in medicine in recent years, it is advisable to thoroughly prepare a literature review and indicate that the method proposed by the authors is innovative and has been previously described in detail in other publications.
As far as we know this is the first attempt to perform surgery planning on an superior mesenteric aneurysm. We did our best to include the most research articles we were able to find. We improved the References section with several new entries to better cover the domain.
Our proposed method is innovative and was never described the same way in other publications.
Reviewer 3 Report
In this article, the authors describe that a software platform, CardioCTNav, can help planning the operation of a mesenteric artery aneurysm. It is a well-written paper; however, there are some significant concerns about this article.
- There are no statements of primary outcomes and secondary outcomes in this article.
Would you please state at the end of the introductions?
- In addition, there are not enough comparisons (CardioCTNav and other methods) and no discussions in this article. The authors should reconstruct the article.
- If Figure 10 is not original, the authors should state permission for diversion in the article.
Author Response
The authors propose a step-by-step Standard operation protocol (SOP) for preoperatory planning for superior mesenteric artery aneurysm, including: 3D reconstruction and visualization of arteries, Virtual angiography (endonavigation), Automatic measurements of the artery diameter in the necessary ROIs, Stent placement simulation and 3D visualization.
The SOP was carried out in a real, single case.
There is a feeling that authors would like to discuss about a new software platform; in such a case it is necessary to perform a comparison with other similar software platforms, evaluating cons and pros evaluation in detail, emphasising the strongest points of the new platform.
Line 133 - the manufacturer of the software is not indicated.
We used a in-house custom made platform named CardioCTNav in order to investigate all the anatomical details and to perform surgery planning.
Line 178-179 - the meaning and purpose of this statement is not clear.
We added a better explanation and purpose for that statement
Round 2
Reviewer 1 Report
The introduced amendments emphasize the scientific part of the work. Before going for publication, I suggest that you conduct a thorough literature review and refer the authors' research to the available publications directly related to preoperative planning (2018-2021). This will make it possible to clearly demonstrate the authors' own contribution to such an important area from the point of view of personalized medicine.
Author Response
We added two new paragraphs that briefly present two new directions in preoperative planning:VR and 3D printing from 2021
Author Response File: 
Author Response.docx
Reviewer 3 Report
It is well revised. some minor English polishing is required.
Author Response
We revised the language and performed small corrections, hopefully for the better.
Author Response File: Author Response.docx
