Successful endovascular management of coral reef aortic occlusion

Abstract

Transaortic thromboendarterectomy and bypass have been the conventional treatment for coral reef aortic occlusions but are associated with significant mortality, morbidity and reintervention rate since these patients often present with heart failure, uncontrolled hypertension and renal dysfunction. Endovascular treatment has not become popular because of fear of aortic rupture and visceral ischemia. We present our experience with endovascular management of 10 patients with coral reef aorta. Uncontrolled hypertension, chronic renal disease, disabling claudication, and critical limb ischemia with tissue loss were the presenting symptoms. Seven patients had infrarenal aortic occlusion, and 3 had occlusion at renal and suprarenal aorta. Eight had involvement of the visceral vessels and 3 had renal artery stenosis. Common iliac, femoral and subclavian were the other arteries involved. All procedures were done under local anaesthesia. Aortic stenting was done in 7 and aortoiliac stent in 3. Two had covered stents and the rest had bare metal stents. Two had renal artery stenting. In 2 patients with suprarenal aortic occlusion, intravascular lithotripsy was used prior to aortic stenting. We achieved technical success in all patients with control of blood pressure and increase in Ankle Brachial Index (ABI). One patient died due to acute coronary event 2 months later.

Keywords: Aortic calcification; Aortic stenting; Coral reef aorta; Visceral protection, intravascular lithotripsy.

Fig. 1

a Extensive calcification seen in the abdominal aorta and iliac arteries. b Plain computerised tomography (CT) abdomen showing dense calcification filling the entire lumen of aorta

Fig. 2

Computerised tomography aortogram (CTA) showing coral reef calcium causing total occlusion of suprarenal aorta and superior mesenteric artery. Infrarenal aorta and left renal artery are reformed. Left renal ostium shows calcific plaque causing critical stenosis. Right kidney is not visualised and is non functional

Fig. 3

a Coral reef aorta (CRA) causing total occlusion of infrarenal aorta distal to inferior mesenteric artery. Left distal common iliac totally blocked by coral reef calcium and right common iliac bifurcation showed critical narrowing. Digital subtraction angiography (DSA) was done by simultaneously injecting contrast both from femoral sheath and from proximal aortic sheath. b Completion angiogram showing balloon expandable kissing stents at bifurcation and two separate balloon expandable stents at common iliac bifurcation

Fig. 4

a Calcium was cracked using 7-mm intravascular lithotripsy (IVL) balloon and another 6-mm balloon in the same patient as in Fig. 2. Left renal artery was protected by using an embolic filter and balloon occlusion of the ostium. b Completion aortogram showing aortic stent and renal artery stent. Complete dilatation of the aorta was not attempted. The aortic stent was smaller than the diameter of the aorta

Fig. 5

a, b Aortogram done 4 years later showing patent stent with no reduction in lumen size