Use of Intravascular Lithotripsy for Coral Reef in the Visceral Aorta to Treat Severe Lower Limb Claudication

Abstract

Introduction:

Coral reef aorta (CRA) is a rare condition described as severe hard-rock calcifications in the aortic lumen. It may present as renal hypertension, lower limb claudication, or even visceral ischemia in some cases. Management is usually by open surgical repair, by aortic endarterectomy, or surgical bypass. Recently, severe arterial calcifications have been treated with intravascular lithotripsy (IVL) with promising results. We aim to present our experience in using IVL in the treatment of CRA.

Methods:

This is a retrospective case series of a cohort of patients treated for visceral aorta CRA with IVL. Patients’ demographics, symptomatology, perioperative data, and follow-up are described.

Results:

Four patients (1 man, 3 women) with a mean age of 71 years were treated by IVL for CRA between January 2023 and June 2024. All patients (n=4, 100%) presented with severe lower limb claudication (Rutherford grade III). Upon investigations, CRA was diagnosed by CT angiogram, with no associated significant iliac or infra-inguinal lesions. Involvement of the renal and mesenteric arteries was inconstant and always asymptomatic. Patients were deemed high risk for open aortic repair and thus underwent IVL. Aortic angioplasty was performed in a kissing position (normal angioplasty balloon + IVL balloon). None of the patients required aortic stenting or mesenteric and renal stenting post-IVL. Preoperative aortography showed an absence of complications in the digestive and renal arteries, and no aortic rupture. Mean operative time was 90.2 minutes with a scopy time of 19.7 minutes. Mean hospital stay was 2.5 days. After a mean of 11 months of follow-up, patients presented with significant clinical improvement, granting reduction to Rutherford grade II.

Conclusion:

This series describes the technical feasibility and perioperative safety in treating visceral aorta CRA by IVL. It could be used as an alternative treatment for coral reefs in a highly selected cohort of patients. Larger studies are needed, however, to demonstrate efficacy in the long term and for well-selecting candidates for IVL for CRA.

Clinical impact

Taking advantages of innovations in vascular surgery, we describe the use of Intravascular lithotrispsy (IVL) in treating heavily calcified aortic lesions in the visceral aorta. The use of IVL in the aorta is still Off-Label, however, from this case series, the use of intravascular lithotripsy seems safe and feasible, and could be used as an alternative treatment for coral reef in highly selected patients.