Coral Reef Aorta Research Articles

Thoraco-abdominal Aortic Bypass in a Patient with Coral Reef Aorta

Thoraco-abdominal Aortic Bypass in a Patient with Coral Reef Aorta

Coral reef aorta: a rare form of obstruction of the ascending aorta in adolescent with aortopathy- case report

BackgroundSupra aortic obstruction in children is uncommon and is seen in certain unique conditions. While intraluminal obstruction due to heavy calcification is seen in older populations, it is not described in pediatric populations. The coral reef aorta is a rare and distinct calcifying disease causing luminal obstruction of the suprarenal aorta in adults. The definition of this diagnosis relies entirely on the unique aspects and consistency of the lesions, which are rock-hard, irregular, gritty plaques with a white luminal surface resembling a coral reef. However, no such case has been described in children.Case presentationWe present an adolescent boy who presented with a heavily calcified ascending aortic lesion associated with aortopathy and hypertension, 12 years after an aortic coarctation repair. The investigations included echocardiography, magnetic resonance and computer-tomographic imaging. A 3-D model was printed in order to visualize and plan surgical steps in advance for safe placement of clamps and defining the extent of resection. In addition, it provided an idea about tissue quality, thickness, spatial relationship, and orientation in relation to surrounding structures. Successful resection and replacement of the diseased segment of the aorta were achieved on cardiopulmonary bypass support. Post-operative recovery was uneventful, and at 6-month follow-up, the patient is doing well. In this report, various aspects of such lesions have been discussed, including clinical presentations, complications, planning and conduct of a safe cardiopulmonary bypass, and precautions during surgery for a successful outcome.ConclusionComplicated obstructive aortic lesions in children require careful assessment, appropriate advanced imaging, and the use of 3-D printing technology in order to plan and perform safe and effective surgical management. The etiology of severe calcified aorta in children may be related to metabolic factors, previous surgery, use of a homograft, or an inflammatory process. However, it has yet to be proven.

Trapdoor endarterectomy for coral reef plaque of the paravisceral aorta in the modern era

Coral reef atherosclerosis of the paravisceral aorta is a rare disease whose description is confined to before contemporary vascular surgical techniques. This study aims to describe the characteristics and outcomes of patients with coral reef aorta treated with trapdoor endarterectomy at a single high-volume quaternary referral center since 2010. From 2010 to 2022, 14 patients with coral reef aorta were treated with trapdoor endarterectomy. The patient data were obtained via a retrospective medical record review. The patients were predominantly women (79%) with a median age of 65 years (interquartile range [IQR], 60-70 years). The patients universally had a tobacco smoking history and hypertension. More than 85% had previously diagnosed carotid stenosis. Two patients (14%) had undergone prior aortofemoral reconstruction, and one patient (7%) had undergone prior axillobifemoral bypass. The most common presenting symptoms were claudication (71%), chronic mesenteric ischemia (50%), and renovascular hypertension (43%). Of the 14 patients, 8 (57%) underwent isolated endarterectomy and 6 (43%) underwent concomitant aortobifemoral bypass. In addition, 13 patients (93%) required a supraceliac aortic clamp position with a median clamp time of 23 minutes (IQR, 20-30 minutes). The median estimated blood loss was 1650 mL (IQR, 1025-3000 mL). A cell saver was used in 13 procedures (93%), with a median transfusion of 563 mL (IQR, 231-900 mL). The median operative time was 341 minutes (IQR, 315-416 minutes). Eight patients (57%) experienced acute kidney injury in the postoperative period with a peak creatinine of 1.96 mg/dL (IQR, 1.50-2.84 mg/dL). The median length of stay was 11 days (IQR, 6-16 days), with an intensive care unit stay of 4 days (IQR, 2-7 days). One patient (7%) required reoperation in the immediate perioperative period for a retroperitoneal hematoma. The postoperative ankle brachial index increased from a median of 0.58 (right) and 0.57 (left) bilaterally in the preoperative period to 1.09 (right) and 1.10 (left) postoperatively. Eight patients (57%) had follow-up data available for >2 years postoperatively, with five patients (36%) having follow-up data available for >3 years. Two major adverse cardiac events were reported at the last follow-up. One patient reported mild recurrent symptoms of chronic mesenteric ischemia during 3 years of postoperatively, with no concurrent imaging findings or loss of patency found on computed tomography angiography. Symptomatic coral reef atherosclerosis of the paravisceral aorta is a complex disease rarely encountered even at high-volume referral centers. These patients can be expected to experience short-term postoperative morbidity and require intensive care. Despite these challenges, trapdoor endarterectomy is a safe and effective procedure for coral reef aorta, and most patients achieve dramatic symptomatic improvement with durable results.

Temporary diaphragm pacing for patients at risk of prolonged mechanical ventilation after extensive aortic repair

ObjectiveProlonged mechanical ventilation (MV) after extensive aortic reconstructive surgery is common. Studies have demonstrated that diaphragm pacing (DP) improves lung function in patients with unilateral diaphragm paralysis. The goal of this study is to determine whether this technology can be applied to complex aortic repair to reduce prolonged MV and other respiratory sequelae. MethodsA retrospective review was performed of patients who underwent temporary DP after extensive aortic reconstructive surgery between 2019 and 2022. The primary end point was prolonged MV incidence. Other measured end points included diaphragm electromyography improvement, length of hospitalization, duration of intensive care unit stay, and reintubation rates. ResultsFourteen patients deemed at high risk of prolonged MV based on their smoking and respiratory history underwent DP after extensive aortic repair. The mean age was 70.2 years. The indications for aortic repair were a thoracoabdominal aortic aneurysm (n = 8, including 2 ruptured, 2 symptomatic, and 1 mycotic), a perivisceral aneurysm (n = 4), and a perivisceral coral reef aorta (n = 2). All patients had a significant smoking history (active or former) or other risk factors for ventilator-induced diaphragmatic dysfunction and prolonged MV. The mean total duration of MV postoperatively was 31.9 hours (range, 8.1-76.5 hours). The total average pacing duration was 4.4 days. Two patients required prolonged MV, with an average of 75.4 hours. Two patients required reintubation. No complications related to DP wire placement or removal occurred. ConclusionsDP is safe and feasible for patients at high risk of pulmonary insufficiency after extensive aortic reconstructive surgery.

Unconventional treatment in a Rare Case of Complex Coral Reef Aorta

Unconventional treatment in a Rare Case of Complex Coral Reef Aorta

Abstract No. 78 Coral reef aorta: an increasingly recognized atherosclerotic manifestation with varied symptomatology

Abstract No. 78 Coral reef aorta: an increasingly recognized atherosclerotic manifestation with varied symptomatology

An Analysis of Clinical Treatment Outcomes, Symptomatology, and Extent of Aortic Stenosis in Coral Reef Aorta

A coral reef aorta (CRA) is an increasingly recognized form of visceral aortic calcification. Retrospective case series have reported the risk factors and most common symptoms but considered only patients who had undergone operative treatment. Furthermore, the anatomy of a CRA with regard to particular symptoms is only beginning to be explored.

Acquired coarctation of aorta: Coral reef aorta

Acquired coarctation of aorta: Coral reef aorta

The Use of a Commercially Available Endovascular Filter Catheter (Capturex®) for Thoracic Endovascular Aortic Repair (TEVAR) in a Patient with a Coral Reef Aorta

Due to the risk of mobilizing plaque fragments, transfemoral TEVAR is a potentially dangerous procedure in patients with a coral reef aorta. We describe a practical method for transfemoral TEVAR in a patient with a degenerative thoracic aneurysm and a coral reef aorta. After placing a filter catheter in the abdominal aorta via a contralateral percutaneous femoral access, a working channel through the distal thoracic aorta was created with a balloon-expandable stent graft in the coral reef segment. Thereafter, transfemoral TEVAR could be performed successfully, without any complications. The additional use of a percutaneously placed filter catheter potentially allows reduction of peripheral embolism and hence may prevent patients from more invasive treatment.

A case of a common iliac-mesenteric bypass for chronic mesenteric ischemia with coral reef aorta after common iliac endarterectomy.

Chronic mesenteric ischemia is a clinical diagnosis characterized by weight loss, food fear, and postprandial pain.1 Although retrograde mesenteric bypass is a commonly described technique in the literature, an end-to-end anastomosis directly from the common iliac artery (CIA) concurrent with iliac endarterectomy has not been frequently performed. Combined endarterectomy and bypass approaches have been proved to be durable in regard to patency rates and freedom from restenosis.2 We have described the case of a 75-year-old woman who had presented with a 15-lb weight loss, postprandial abdominal pain, and food fear.

Endovascular Treatment of Acquired Atheromatous Postsubclavian Aortic Coarctation

Coral reef aorta is a rare calcifying obstructive disease that involves the thoracoabdominal aorta. Similar presentations in the postsubclavian aorta may result in acquired atheromatous aortic coarctation leading to systemic hypertension and heart failure. The associated calcification makes surgical anatomic or extraanatomic bypass and thromboendarterectomy challenging. Extensive circumferential calcification often precludes endovascular intervention. We present the case of a 25-year-old man with an acquired atheromatous coarctation of the postsubclavian aorta who underwent successful endovascular treatment with use of a balloon-expandable covered stent.

Treatment of Coral Reef Aorta by Endovascular VIABAHN VBX Balloon-Expandable Stent-Graft Placement.

Coral reef aorta (CRA) has been described as a rare disease characterized by the presence of dense calcifications of the aorta. In this study, we report on two patients with CRA caused by intermittent claudication (IC) who underwent endovascular VIABAHN VBX balloon-expandable stent-graft (VVBX) placement. Both patients underwent successful endovascular VVBX placement via transfemoral artery approach, and hemostasis was achieved via vascular closure device. Their symptoms were observed to disappear completely after treatment, and they were discharged without serious adverse events. No symptoms were noted at 1.5-year and 1-year follow-up.

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.>

Chimney Technique to Preserve Visceral Flow in a Coral Reef Aorta

The coral reef aorta (CRA) is a rare phenomenon of extreme calcification in the juxtarenal and suprarenal aorta. Open revascularization has an overall in-hospital mortality rate of 13%. We present a patient with a suprarenal CRA with colon ischemia. She has an extensive past medical history of percutaneous transluminal angioplasty and stenting of the celiac trunk (CT) and superior mesenteric artery (SMA). The computed tomography angiography showed a CRA of the suprarenal aorta with occlusion of the CT stent and near occlusion of the SMA stent. Our case illustrates that the CRA in the suprarenal part of the aorta can be treated well by chimney graft procedure, although owing to lack of long-term follow-up, it might be reserved for high-risk candidates for (thoraco)abdominal aortic surgery.

Calcific Plug Obstructing the Thoracic Aorta.

We describe a case of a 57-year-old woman with occlusion of the thoracic aorta due to a calcific plug as an unusual cause of refractory hypertension. Middle aortic syndrome, also known as “ coral reef aorta ,” defined as a clinical condition caused by thoracic and/or abdominal aortic stenosis, requires peculiar treatment strategies representing a complex surgical challenge.

Successful Surgery for Coral Reef Aorta Owing to Takayasu’s Arteritis Complicated by Infected Aortic Aneurysms

A 61-year-old woman presented with coral reef aorta (CRA) owing to Takayasu’s arteritis (TA) complicating infective aortic aneurysms. Though antibiotic therapy was continued, infective aortic aneurysms were growing, so urgent surgical treatment was required. First, we performed thoracic endovascular aortic repair (TEVAR) using trans-subclavian access, followed by open repair. TEVAR access and landing zone are limited in CRA cases. Moreover, the risk of persistent infection may be important in the situation where sepsis is ongoing. Few reports describe CRA complicated by infected aortic aneurysms. We describe a method of surgical treatment for this condition.

Endovascular approach in the treatment of steno-occlusive pathology of the infrarenal aorta: a case report of coral reef aorta

Endovascular approach in the treatment of steno-occlusive pathology of the infrarenal aorta: a case report of coral reef aorta

Medical image of the week: coral reef aorta

Medical image of the week: coral reef aorta

Visceral Ischemia Caused by Extra-Anatomical Bypass for Coral Reef Aorta

A 72-year-old woman was presented with intermittent claudication of bilateral lower extremities, refractory hypertension, and mild renal impairment. Computed tomographic angiography showed severe aortic stenosis caused by calcifications protruding into the aortic lumen proximal and distal to the visceral and renal branches, so-called coral reef aorta. An axillo-iliac bypass was performed. Postoperatively, the patient developed ileus and acute renal failure, presumably caused by a steal phenomenon to the lower extremities. Endovascular stenting of the aorta increased forward blood flow and dramatically improved the patient’s condition. This case study illustrates potential hemodynamic complications after extra-anatomical axillo-iliac bypass for coral reef aorta.

Calcified obstructive disease of the aortic arch

Coral reef aorta is described as rock-hard calcifications usually localized in the visceral part of the aorta. Rare cases of acquired coarctation of the descending aorta due to coral reefs have been mentioned in the literature. A more uncommon entity is the coral reef of the aortic arch. We are presenting a rare case of a 55-year old woman referred to our vascular department for bilateral lower limb claudication associated with resistant hypertension and anisotension. A thoracoabdominal computed tomography scan was subsequently performed and showed a preocclusive calcified lesion located at the termination of the aortic arch, involving the ostia of the left subclavian artery. An open surgical approach was decided upon and an aortic endarterectomy by transversal aortotomy was successfully performed. Although uncommon, acquired coarctation should be considered in all hypertensive patients presenting with bilateral lower limb claudication and blood pressure differences between the upper and lower extremities.