Simultaneous Open Surgical Treatment of Aortic Coral Reef and Leriche Syndrome: Case Report and Literature Review

Extra-anatomic bypass procedures for severe aortoiliac occlusive disease-A cohort study

OBJECTIVES

Extra-anatomic bypass (ExAB) grafting has been questioned due its inferior durability compared to anatomic bypass for aortoiliac occlusive disease (AIOD). This study aims to present early and late outcomes of patients treated with ExAB as well as to evaluate potential prognostic factors.

METHODS

This is a retrospective cohort study presenting a series of patients treated with ExAB for AIOD. All patients were treated between 2005 and 2022 within the Vascular Surgery Unit of a University Surgery Clinic. Both early (30-day) and late outcomes were evaluated. Univariate and multivariate analyses were conducted for potential predictors. Kaplan-Meier curve was produced for long-term patency.

RESULTS

A total of 41 patients were treated (85.3% males; mean age: 76.3 ± 4.2 years). Indication for treatment included severe claudication or critical limb ischemia (Rutherford stages III-VI). The following procedures were recorded: Femorofemoral bypass (FFB; n = 21) and axillofemoral bypass (AxFB; n = 20). All procedures were conducted using synthetic grafts with external rings. Early outcomes included no death, no myocardial infarction, no major bleeding, no graft infection, and no major amputation. Regarding late outcomes, 14.6% patients were lost after the first month. For the rest of patients (n = 35), five-year primary patency was 88.6%, primary-assisted patency was 94.3%, and secondary patency was also 94.3%. Limb salvage was 100% within follow-up. Endarterectomy at the distal anastomosis was the only independent predictor associated with worse patency in the long-term (OR = 5.356; 95% CI (1.012-185.562); p = .041).

CONCLUSIONS

FFB and AxFB is a safe and durable strategy for treating patients with severe AIOD where no other option is feasible. Regarding predictors, only endarterectomy at the distal anastomosis site was associated with an increased risk for graft failure.

Coral Reef Aorta: Literature Review and Analysis of the Published Cases in the Last 20 Years

BACKGROUND

Coral reef aorta (CRA) is defined by the presence of heavily calcified exophytic plaques that protrude into the aortic lumen. However, the exact causes and development of this condition are still not fully understood. When the aortic branches are affected, it can result in various symptoms. Despite ongoing research, there is currently no established consensus on the best treatment for CRA. This review aims to examine the latest findings regarding the clinical presentation and approach to treating patients with CRA.

METHODS

We conducted a systematic electronic search of the literature using the PubMed and Embase databases. Throughout the search, we adhered to the guidelines outlined in the PRISMA framework. From the identified publications, we extracted information pertaining to patients' characteristics, symptoms, and types of treatment from a total of 124 cases reported over the past 20 years. The primary focus of our analysis was to assess the improvement of signs and symptoms, as well as to evaluate any postoperative complications. To achieve this, we performed both descriptive and inferential analyses on the collected data. Additionally, we conducted subgroup analyses based on treatment types and symptoms observed at presentation, presenting the findings in the form of odds ratios (ORs).

RESULTS

After removing duplicate articles, we carefully screened the titles of 67 retrieved articles and excluded those that did not align with the purpose of our study. Subsequently, we thoroughly analyzed the remaining 41 articles along with their references, ultimately including 29 studies that were deemed most relevant for our systematic review. We examined a total of 124 cases of patients diagnosed with CRA, comprising 77 (62.1%) females and 48 (38.7%) males, with a mean age of 59 years (range: 37-84). The predominant signs and symptoms observed were intermittent claudication, reported in 57 (46.0%) patients, followed by refractory hypertension in 45 (36.3%) patients, intestinal angina in 28 (22.6%) patients, and renal insufficiency in 15 (12.1%) patients. Among the treated patients, 110 (88.7%) underwent open surgery repair (OSR), 11 (8.9%) received endovascular treatment, and 3 (2.4%) underwent laparoscopy. Postoperatively, a significant number of patients experienced substantial relief or complete resolution of their symptoms, as well as improved control of hypertension and renal function. In the group of patients treated with OSR, the inhospital stay mortality rate was 10.9%, the morbidity rate was 28.2%, and the reintervention rate was 15.5%. The high mortality rate during hospital stays in this group may be associated with such invasive procedures performed on patients who have substantial cardiovascular burden and multiple comorbidities. Conversely, no postoperative complications were reported in the group of patients treated with endovascular procedures or laparoscopic surgery.

CONCLUSIONS

While coral reef aorta (CRA) is considered a rare condition, it is crucial for the medical community to remain vigilant about its diagnosis, particularly in patients presenting with symptoms such as intermittent claudication, refractory hypertension, renal impairment, or intestinal angina. Based on the findings of this review, both OSR and endovascular treatment have shown promise as viable therapeutic options. Although endovascular therapies may not always be feasible or may have reduced durability in these calcified bulky lesions, they should be considered in patients with multiple comorbidities, due to the high postoperative mortality rates associated with more invasive approaches. Additionally, these endoluminal procedures have demonstrated good patency rates during the 18-month follow-up period. It is essential to emphasize that the treatment strategy should be determined on a case-by-case basis, involving a multidisciplinary team to tailor it to the specific needs of each individual patient.

Balloon angioplasty for uncontrollable hypertension caused by coral reef aorta: A case report

Coral reef aorta is a stenosis of the aorta due to severe calcification. We report the case of a 74-year-old woman with coral reef aorta whose hemodynamics were physiologically similar to those found in patients with renovascular hypertension. The patient had resistant hypertension, refractory edema, and renal dysfunction. Bilateral renal artery stenosis and infrarenal aortic stenosis were suspected after a Doppler ultrasound examination. Evaluation by intravascular ultrasound and pressure wire revealed that the high blood flow caused by infrarenal aortic stenosis derived from the high-flow velocity in a renal artery without stenosis. Angioplasty with balloon improved the stenosis, and the patient was relieved from a spiral of uncontrollable hypertension, edema, and renal dysfunction. This rare case was a patient with coral reef aorta who was diagnosed with uncontrollable hypertension and angioplasty was performed effectively and minimally invasively. <Learning objective: Coral reef aorta should be considered as a diagnosis for patients suspected to have renovascular hypertension. Furthermore, angioplasty with balloon is an effective treatment approach.>.

Refractory heart failure and intermittent claudication secondary to supra-renal coral reef aorta

Coral reef aorta (CRA), a rare disease, is characterized by severe calcification of the juxta-renal and suprarenal aorta that grows into the lumen and leads to severe stenosis. A 70-year-old woman with refractory hypertension and lower limb claudication presented with hypertension and congestive heart failure. Treatment with vasodilators and diuresis led to oliguria and exacerbated kidney function, while her congestion remained. Abdominal computerized tomography showed a bulky, irregular localized supra-renal aortic calcification with stenosis. A peripheral artery ultrasound and angiography showed no occlusive lesions in the distal run-off vessels. Based on her medical history and the unique aspects of the localized calcified lesion, CRA was diagnosed. We suspected that the congestive heart failure, refractory hypertension, and renal failure resulted from the supra-renal aortic stenosis. Because she developed oliguria with diuretics and vasodilators, we performed an open graft replacement with a thoracoabdominal approach. The reddish-brown calcified mass came off easily and was very fragile. The postoperative course was uneventful, and her heart and renal failure were completely resolved. This is the first report showing the fragility of CRA. Considering its fragility, catheter treatment may need to be avoided to prevent distal embolism. <Learning objective: When we encounter a calcified lesion localized at the level of the juxta and supra-renal aorta with extensive growth into the lumen, coral reef aorta (CRA) should be suspected. Considering that CRA lesion can be very fragile in contrast to the usual atherosclerotic lesion, as shown in our case, CRA might possibly increase the risk of distal embolization. Therefore, open graft replacement could be safer than endovascular stent-graft placement.>.

Concomitant Revascularization Using Ascending Aortic Rerouting in Coral Reef Aortic Syndrome

Coral reef Aortic Syndrome can result in significant visceral and lower limb ischemia. We present a 72-year-old male with postprandial abdominal pain and intermittent claudication. Computed tomography demonstrated a calcified plaque occluding the thoracoabdominal aorta. Additionally, the celiac axis was stenotic, and the superior mesenteric artery was completely occluded. The origin of the inferior mesenteric artery was aneurysmal. Aortic rerouting from the ascending to the infrarenal aorta was performed. The superior mesenteric artery was reconstructed with a saphenous vein, and the inferior mesenteric artery was divided and anastomosed directly to the aortic bypass. The procedure resulted in complete relief from the ischemic symptoms.

Extra-Anatomic Revascularization of Extensive Coral Reef Aorta

BACKGROUND

Coral reef aorta (CRA) is a rare, potential lethal disease of the visceral aorta as it can cause visceral and renal infarction. Various surgical approaches have been proposed for the CRA treatment. The purpose of this article is to report different extensive extra-anatomic CRA treatment modalities tailored on the patients' clinical and anatomic presentation.

METHODS

From April 2006 to October 2012, 4 symptomatic patients with extensive CRA were treated at our department. Extra-anatomic aortic revascularization with selective visceral vessels clamping was performed in all cases.

RESULTS

Technical success was 100%. No perioperative death was registered. All patients remained asymptomatic during the follow-up period (62, 49, 25, and 94 months, respectively), with bypasses and target vessels patency.

CONCLUSIONS

The extra-anatomic bypass with selective visceral vessels clamping reduces the aortic occlusion time and the risk of organ ischemia. All approaches available should be considered on a case-by-case basis and in high-volume centers.