Ann Thorac Surg 2008;85:1817-1819. doi:10.1016/j.athoracsur.2007.11.053
© 2008 The Society of Thoracic Surgeons
How To Do It
Treatment of Symptomatic Coral Reef Aorta by Endovascular Stent-Graft Placement
Johannes Holfeld, MSa,
Roman Gottardi, MDa,
Daniel Zimpfer, MDa,
Marion Dorfmeister, MDa,
Julia Dumfarth, MSa,
Martin Funovics, MDb,
Maria Schoder, MDb,
Ernst Weigang, MDa,
Johannes Lammer, MDb,
Ernst Wolner, MDa,
Martin Czerny, MDa,*,
Michael Grimm, MDa
a Department of Cardiothoracic Surgery, Medical University of Vienna, Vienna, Austria
b Department of Interventional Radiology, Medical University of Vienna, Vienna, Austria
Accepted for publication November 15, 2007.
* Address correspondence to Dr Czerny, Waehringer Guertel 18-20, Vienna, A-1090, Austria (Email: martin.czerny{at}meduniwien.ac.at).
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Abstract
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We report 2 patients who were referred for treatment of hemodynamically significant symptomatic stenosis of the aorta at the thoracoabdominal transition (coral reef aorta) that was causing abdominal angina and intermittent claudication. Both patients underwent successful transfemoral endovascular stent-graft placement and are free of symptoms, with regular findings at 6-month follow-up completion computed tomography scan.
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Introduction
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Hemodynamically significant symptomatic stenosis of the aorta—in particular at the thoracoabdominal transition—is rare [1]. In symptomatic patients, treatment options include conventional surgical repair and extraanatomic revascularization with or without opening of the thorax and the abdomen [2]. Endovascular stent-graft placement is the treatment modality of first choice in various acute and chronic thoracic and abdominal aortic pathologies [3, 4]. The procedure points out its merits especially in elderly patients and in patients with multiple comorbidities, who are generally more frail and have a diminished physiologic reserve compared with their younger counterparts [5].
We report 2 patients who were referred to the Medical University of Vienna for treatment of hemodynamically significant symptomatic stenosis of the aorta at the thoracoabdominal transition (coral reef aorta), which had caused abdominal angina and intermittent claudication. Both patients underwent successful transfemoral endovascular stent-graft placement.
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Technique
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Patient 1
In March 2007, a 76-year-old man was admitted with a symptomatic coral reef aorta (Fig 1). The patient had undergone coronary artery bypass grafting in 2001 due to ischemic cardiomyopathy and multivessel coronary artery disease. Because of abdominal angina, a weight loss of 15 kg body weight could be observed within 3 months. His walking capacity was limited to 50 m.
A thoracoabdominal computed tomography (CT) scan revealed a hemodynamically significant stenosis of the aorta at the thoracoabdominal transition as the underlying pathology. Because of his general condition and a high the European System for Cardiac Operative Risk Evaluation (EuroSCORE; numeric, 16; logistic, 66), he was not deemed suitable for conventional surgical repair. Outcome after axillobifemoral bypass grafting is not that satisfying, so an alternative approach was chosen.
The patient underwent transfemoral endovascular stent-graft placement with a Gore TAG 34/150 mm prosthesis (W. L. Gore & Associates, Flagstaff, AZ). In order not to enhance embolization of atherosclerotic debris into downstream vascular beds, supportive alignment with a balloon dilatation was not performed.
The patient experienced an uneventful clinical course and showed immediate relief of symptoms after the procedure. Completion CT scan before discharge revealed the stent-graft in place, restored antegrade distal perfusion, as well as already advanced expansion of the stent-graft (Fig 2). The patient was discharged 5 days after stent-graft placement and is free of symptoms, with regular findings at the 6-month follow-up completion CT scan.
Patient 2
In April 2007, shortly after the first case, an 84-year-old man was admitted with a symptomatic coral reef aorta (Fig 3). The patient had no prior cardiovascular interventions. A complete workup, however, revealed several other signs of systemic obliterative atherosclerosis such as asymptomatic borderline internal carotid artery stenosis, hemodynamically nonsignificant multivessel coronary artery disease, and chronic occlusion of the celiac trunk.
The clinical symptoms in this patient were fully comparable to the symptoms of patient 1, including weight loss. Owing to his age and to the high EuroSCORE (numeric, 13; logistic, 45) conventional surgical repair was not deemed suitable. The distal end of the lesion extended down to the origin of the celiac trunk. Conveniently, the celiac trunk was chronically occluded; therefore, a sufficient distal landing zone became available. This patient also underwent transfemoral endovascular stent-graft placement with a Gore TAG 28/100 mm prosthesis.
Completion CT scan before discharge revealed the stent-graft in place, restored antegrade distal perfusion, and already advanced expansion of the stent-graft (Fig 4). The patient was discharged 6 days after stent-graft placement and is free of symptoms, with regular findings at the 6-month follow-up completion CT scan.
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Comment
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Hemodynamically significant symptomatic stenosis of the aorta at the thoracoabdominal transition is a rare finding [1, 2]. Similar to other varieties of aortic pathologies such as perforating ulcers, this so-called coral reef aorta represents an advanced stage of a severe chronic obliterative atherosclerotic systemic process. The general condition of these patients at the time of referral is usually weak, thereby potentially prohibiting conventional surgical repair consisting of multilevel invasive surgical exposure of the target vessels [6].
As a consequence, less invasive approaches such as axillobifemoral bypass grafting have been applied [7]. This approach, however, is associated with an increased risk of early and late graft failure that can potentially lead to acute malperfusion of all downstream vascular beds. Furthermore, extensive anticoagulation is required when using this approach, thus increasing the risk of coagulation-related adverse events.
Endovascular stent-graft placement is the treatment modality of first choice in various acute and chronic thoracic and abdominal aortic pathologies [3, 4]; however, few experiences on the treatment of a coral reef aorta are available in the literature. Stent-graft placement may be limited by the lack of self-expanding capacity of the graft itself thereby not enabling sufficient restoration of antegrade perfusion. Detachment of atherosclerotic debris may also cause deleterious consequences by distal embolization irrespective of the affected region. In addition, owing to the location of the lesion at the thoracoabdominal transition and the anatomic proximity to vessels supplying the spinal cord, paraplegia may occur after stent-graft placement. Cerebrospinal fluid drainage in advance may therefore serve as a protective measure against this dreadful complication. Without doubt, this remains an issue with the need to be aware of.
Finally, another potential concern is that the severely calcified aorta may induce accelerated fracture of the stent-graft. Nevertheless, even if a lesion within the fabric occurs, it might remain without clinical consequence, as the aim of the therapy, namely restoration of regular antegrade perfusion, has already been achieved. None of these potential adverse events have been observed in these 2 patients; nevertheless, a careful and critical case-by-case evaluation remains mandatory.
In summary, endovascular stent-graft placement may turn out to serve as the treatment modality of first choice in hemodynamically significant symptomatic stenosis of the aorta at the thoracoabdominal transition by minimizing morbidity and by maximizing effectiveness and durability.
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References
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- Qvarford PG, Reilly LM, Sedwitz MM, Ehrenfeld WK, Stoney RJ. "Coral reef" atherosclerosis of the suprarenal aorta: a unique clinical entity J Vasc Surg 1984;1:903-908.[Medline]
- Di Centa I, Coggia M, Javerliat I, et al. Total laparoscopic suprarenal aortic coral reef removal J Vasc Surg 2006;44:194-197.[Medline]
- Eggebrecht H, Nienaber CA, Neuhauser M, et al. Endovascular stent-graft placement in aortic dissection: a meta-analysis Eur Heart J 2006;27:489-498.[Abstract/Free Full Text]
- Blum U, Voshage G, Lammer J, et al. Endoluminal stent-grafts for infrarenal abdominal aortic aneurysms N Engl J Med 1997;336:13-20.[Abstract/Free Full Text]
- Czerny M, Fleck T, Zimpfer D, et al. Risk factors of mortality and permanent neurologic injury in patients undergoing ascending aortic and arch repair J Thorac Cardiovasc Surg 2003;126:1296-1301.[Abstract/Free Full Text]
- Schulte KM, Reiher L, Grabitz K, Sandmann W. Coral reef aorta: a long-term study of 21 patients Ann Vasc Surg 2000;14:626-633.[Medline]
- Agrifoglio G, Agus GB, Castelli P, Costantini A. Bypass procedures in the management of juxtarenal aortic occlusion J Cardiovasc Surg (Torino) 1984;25:43-46.[Medline]
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Abstract
Introduction
