Trapdoor Endarterectomy for Coral Reef Plaque of the Paravisceral Aorta in the Modern Era

Abstract

Coral reef atherosclerosis (CRA) of the paravisceral aorta is a rare disease whose description is largely confined prior to contemporary vascular surgical techniques. This study aims to describe the characteristics and outcomes of patients with CRA treated with trapdoor endarterectomy (TEA) at a single high-volume quaternary referral center since 2010. From 2010 to 2022, 14 patients were identified who underwent TEA for symptomatic CRA. Data on patient demographics, operative details, hospital course, and outpatient follow-up were obtained via retrospective chart review. Patients were predominantly female (71%) with a median age of 65 years (interquartile range [IQR], 63-70) and had traditional vascular risk factors. Over 85% had previously diagnosed carotid stenosis; two patients (14%) had prior aortofemoral reconstruction, and one (7%) had prior axillobifemoral bypass. The most common presenting symptoms were claudication (64%), chronic mesenteric ischemia (50%), and renovascular hypertension (43%). Eight patients (57%) received isolated TEA and six (43%) received concomitant aortobifemoral bypass (Table I). Thirteen patients (93%) required a supraceliac aortic clamp position with a median clamp time of 26 minutes (IQR, 20-30 minutes). Median estimated blood loss was 1650 mL (IQR, 1025-3750 mL). Cell saver was used in 13 procedures (93%) with median transfusion of 563 mL (IQR, 231-900 mL). Median operative time was 341 minutes (IQR, 315-316 minutes). Eight patients (57%) had acute kidney injury in the postoperative period with peak creatinine of 2.02 (IQR, 1.58-2.95) (Table II). Length of stay was 13 days (IQR, 7-16 days) with an intensive care unit stay of 4 days (IQR, 2-7 days). Two patients (14%) required reoperations in the immediate perioperative period, one for retroperitoneal hematoma and one for target vessel (superior mesenteric artery) occlusion. Postoperative ankle-brachial indices were increased from a median of 0.52 bilaterally in the preoperative period to >1 postoperatively. Eight patients (57%) had follow-up over 2 years after TEA, with five patients (36%) having follow-up over 3 years. Three major adverse cardiac events were reported at last follow-up. Just one patient reported persistent symptoms of chronic mesenteric ischemia at 11 years after TEA. Symptomatic CRA of the paravisceral aorta is a complex disease rarely encountered even at a high-volume quaternary referral center. These patients can be expected to experience short-term postoperative complications and require intensive care. Despite these challenges, trapdoor transaortic endarterectomy is a safe, effective procedure for CRA and most patients achieve dramatic symptomatic improvement with durable results.Table IGeneral operative characteristics (n = 14)VariablesMedian [IQR] or No. (%)Procedure types Trapdoor endarterectomy8 (57) Trapdoor endarterectomy with aortobifemoral bypass6 (43)Starting clamp position Supraceliac13 (93) Supramesenteric1 (7)Subsequent clamp position Infrarenal10 (71) None4 (29)Aortic closure Primary closure12 (86) Bovine patch angioplasty1 (7) Dacron patch angioplasty1 (7)Revascularized vessels Celiac3 (21)Eversion endarterectomy3 (100) Superior mesenteric artery5 (36)Eversion endarterectomy4 (80)Catheter embolectomy1 (20) Left renal5 (36)Eversion endarterectomy4 (80)Bypass graft1 (20) Right renal3 (21)Eversion endarterectomy3 (100) Bilateral renals3 (21)Eversion endarterectomy3 (100) IMA1 (7)Eversion endarterectomy1 (100)Cold renal perfusion8 (57)Estimated blood loss, mL1650 [1025-3750]Intraoperative transfusion, units2 [1-4]Cell saver13 (93) Volume transfused, mL563 [231-900]Suprarenal clamp time, minutes (n = 13)26 [20-30]Operative time, minutes341 [315-416]IQR, Interquartile range. Open table in a new tab Table IIPostoperative course, (n = 14)VariableMedian [IQR] or No. (%)Inpatient complications Anemia14 (100) Acute kidney injury8 (57)Creatinine (peak)2.02 [1.58-2.95]Dialysis1 (7) Cardiopulmonary complications5 (36) Reoperation2 (14)Retroperitoneal hematoma1 (7)Secondary intervention1 (7) Ileus2 (14) Colitis2 (14) Deep vein thrombosis1 (7) Myocardial infarction1 (7) Infection1 (7) Death1 (7)Intensive care unit admission14 (100) Length of stay, days4 [2-7]Total length of stay, days13 [7-16]Laboratory tests Blood urea nitrogen (preoperative)14 [10-16] Creatinine (preoperative)1.01 [0.91-1.31] Creatinine (discharge)1.06 [0.70-1.35]Hemodynamics Right ABI (preoperative), n = 100.52 [0.34-0.90] Left ABI (preoperative), n = 100.52 [0.38-0.81] Right ABI (postoperative op), n = 91.12 [1.06-1.16] Left ABI (postoperative), n = 91.10 [1.09-1.15]Readmission within 30 days3 (21)Duration of follow-up, years2 [0.5-3.0]Outpatient complications, time postoperative3 (21) Ureteral stricture, 2 months1 (7) Loss of primary patency, 18 months1 (7) New chronic mesenteric ischemia, 8 years1 (7)Amputation0 (0)Persistent symptomatology at last follow-up (n = 13)1 (7) Claudication or rest pain0 (0) Mesenteric angina1 (7)Major adverse cardiac events at last follow-up3 (21) Death2 (14) Myocardial infarction1 (7)IQR, Interquartile range. 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