Acute Mesenteric Ischemia with Air Embolism in the Superior Mesenteric Artery: A Rare Case and a Literature Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Good case and it described in great detail. The comparison with other case reports with the etiology and site is a great addition. The use of radiologic including angiographic images as well as other illustrations enhances the quality of the paper.

Author Response

Good case and it described in great detail. The comparison with other case reports with the etiology and site is a great addition. The use of radiologic including angiographic images as well as other illustrations enhances the quality of the paper.

Response: We would like to express our sincere gratitude for your dedicated time and effort in reviewing our manuscript. 
We sincerely thank you for your positive feedback. 

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript presents a well-documented and rare case of acute mesenteric ischemia (AMI) with air embolism in the superior mesenteric artery, complemented by a comprehensive literature review.

 

Several minor changes should be done.

1. Line 67” After treatment, the patient is admitted to the Coronary Care Unit (CCU),”  it should be was admitted to (…)
2. The bibliography ‑review methods are not reproducible. The authors write that they “made an extensive review of the literature … using the PUBMED database”  please indicate the exact search terms with the Boolean operators,
3. Some times the authors use ischemia and other the use ischaemia. The terminology should be always the same.
4. In table I there is a typo  “tipe A” it should be type A. (Lambert L. et al.[12])
5. The patient underwent endovascular thrombectomy only. Please explain why surgery was not used in this case and discuss whether earlier laparotomy could have avoided death.
6. Figure 1 has a single arrow, but the legend lists four arteries; they should be identified. Please remember that anyone, not just experts, can read the paper.
7. The discussion says that it was  “probably iatrogenic.”   Include objective arguments (catheter position, timing, flush technique, etc.) supporting this iatrogenic entry.
8.  Also, explain how alternative mechanisms were ruled out.
9. Figure 2 is difficult to interpret because it mixes 2 reconstruction techniques: a standard coronal lung‑window image and an axial minimum‑intensity projection (MinIP)) without labelling them clearly.

This leaves readers unsure which panel shows gas in the main SMA trunk and which shows the distal branches.

Rewrite with a  clearer caption for example:

Figure 2. Venous‑phase contrast‑enhanced CT. (a) Coronal lung‑window image with 10 mm MinIP inset (white arrow) highlights air in the caudal segment of the superior mesenteric artery. (b) Axial 10 mm MinIP image (black arrowhead) demonstrates air in the distal SMA branches.

Author Response

The manuscript presents a well-documented and rare case of acute mesenteric ischemia (AMI) with air embolism in the superior mesenteric artery, complemented by a comprehensive literature review.

 

Several minor changes should be done.

- Line 67” After treatment, the patient is admitted to the Coronary Care Unit (CCU),”  it should be was admitted to (…)

Response 1: We thank the reviewer for the suggestion. We replaced “is” with “was”.

- The bibliography ‑review methods are not reproducible. The authors write that they “made an extensive review of the literature … using the PUBMED database”  please indicate the exact search terms with the Boolean operators,
Response 2: We thank the reviewer for the comment. We wrote the exact search terms with the Boolean operators.

- Some times the authors use ischemia and other the use ischaemia. The terminology should be always the same.

Response 3: We would like to express my sincere gratitude for the feedback you provided us.
We replaced the words “ischaemia” with “ischemia”.

- In table I there is a typo  “tipe A” it should be type A. (Lambert L. et al.[12])

Response 4: We corrected the typo, we replaced “tipe A” with “type A”.

- The patient underwent endovascular thrombectomy only. Please explain why surgery was not used in this case and discuss whether earlier laparotomy could have avoided death.

Response 5: We would like to thank you for this valuable comment.
As clarified in the revised manuscript, surgery was not performed in accordance with the patient’s and relatives’ wishes, given the severe clinical condition. While laparotomy might have been life-saving, it also carried a high risk of short bowel syndrome, which would have significantly compromised the patient's quality of life and long-term prognosis.

- Figure 1 has a single arrow, but the legend lists four arteries; they should be identified. Please remember that anyone, not just experts, can read the paper.

Response 6: We sincerely thank you for your thoughtful feedback, which we have carefully considered. To preserve the clarity of the image, we chose not to modify it, but we have revised the figure legend to ensure accuracy, omitting the names of the other three arteries to avoid potential confusion.

- The discussion says that it was  “probably iatrogenic.”   Include objective arguments (catheter position, timing, flush technique, etc.) supporting this iatrogenic entry.

Response 7: We would like to thank you for the feedback you provided on our manuscript. We have replaced the term 'probably iatrogenic' with 'potentially iatrogenic,' as—based on the patient’s clinical history—the iatrogenic origin cannot be ruled out, although it is not definitively more likely than other possible etiologies.

- Also, explain how alternative mechanisms were ruled out.

Response 8: We would like to thank you for the feedback you provided. In line with the changes made in the previous point, we believe that none of the proposed theories can be definitively ruled out.

- Figure 2 is difficult to interpret because it mixes 2 reconstruction techniques: a standard coronal lung‑window image and an axial minimum‑intensity projection (MinIP)) without labelling them clearly.
This leaves readers unsure which panel shows gas in the main SMA trunk and which shows the distal branches.
Rewrite with a  clearer caption for example:
Figure 2. Venous‑phase contrast‑enhanced CT. (a) Coronal lung‑window image with 10 mm MinIP inset (white arrow) highlights air in the caudal segment of the superior mesenteric artery. (b) Axial 10 mm MinIP image (black arrowhead) demonstrates air in the distal SMA branches.

Response 9: We would like to thank you for the feedback you provided on our manuscript. We have made the necessary revisions accordingly and have rewritten the caption of Figure 2 to improve its clarity and comprehensibility.

Reviewer 3 Report

Comments and Suggestions for Authors

The authors' case report is very fascinating. It deals with a very difficult subject with no unambiguous guidelines on the interventionist side. The gold standard of diagnosis has been performed and the mysterious presence of air in the artery compartment is difficult to diagnose. As the literature cited has evidenced, many more failures than successes, and it is appropriate for the authors to integrate the discussion of fulminant dysbiosis associated with the presented condition. Unfortunately, difficult-to-manage sepsis often sets in due to a lack of vascularisation of the abdominal compartment, demonstrating that microbiota is also linked to the health of the gastrointestinal epithelium.

For the rest the work is well structured.

Author Response

Commenti: The authors' case report is very fascinating. It deals with a very difficult subject with no unambiguous guidelines on the interventionist side. The gold standard of diagnosis has been performed and the mysterious presence of air in the artery compartment is difficult to diagnose. As the literature cited has evidenced, many more failures than successes, and it is appropriate for the authors to integrate the discussion of fulminant dysbiosis associated with the presented condition. Unfortunately, difficult-to-manage sepsis often sets in due to a lack of vascularisation of the abdominal compartment, demonstrating that microbiota is also linked to the health of the gastrointestinal epithelium.

For the rest the work is well structured.

 

Response: We would like to express our sincere gratitude for the time and effort you dedicated to reviewing our manuscript. We have carefully considered the feedback provided and made the necessary revisions accordingly. In particular, we have supplemented the discussion with the causes and processes, according to the literature, leading to the establishment of sepsis.