Extraanatomic Bypass and Coronary Artery Grafting for Coral Reef Aorta
Takaki Sugimoto, MD,
Noriko Omura, MD,
Takashi Kitade, MD
Department of Surgery, Hyogo Prefectural Awaji Hospital, Sumoto, Japan
Takaki Sugimoto, MD, Tel: +81 799 22 1200; Fax: +81 799 24 5704, Email: sugimoto{at}awaji-hosp.sumoto.hyogo.jp, 1-6-6 Shimokamo, Sumoto, 656-0013, Japan
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ABSTRACT
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A 63-year-old man complained of abdominal angina and intermittent claudication. Multidimensional angiography showed focal calcified obstruction of the suprarenal aorta, occlusion of the right external iliac artery, and instent restenosis in the right coronary artery. Extraanatomic bypass was performed from the ascending aorta to the left external iliac and right femoral arteries, using an 8-mm bifurcated graft, with concomitant off-pump coronary artery grafting. The patient’s digestive symptoms and leg claudication disappeared.
Key Words: Aorta • Artherosclerosis • Blood Vessel Prosthesis Implantation • Coronary Artery Bypass
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INTRODUCTION
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Endoaortic calcified proliferation, also known as coral reef aorta, is a rare form of atherosclerosis characterized by significant obstruction of the suprarenal aorta.1–3 Surgical treatment is recommended because of the unfavorable natural history of symptomatic lesions which threaten digestive, renal, and lower extremity perfusion.1–4
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CASE REPORT
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A 63-year-old man underwent an emergency right hemicolectomy for acute intestinal infarction. Three months later, he was readmitted with continuing abdominal angina and intermittent claudication. He had undergone a percutaneous coronary intervention on the right coronary artery and pacemaker implantation for sick sinus syndrome 3 years previously, and was taking medication for hypertension, diabetes mellitus, and hypothyroidism. He was of medium height and build, with a pacemaker rhythm of 70 beats·min–1. His blood pressure was 30 mm Hg lower in the right arm than the left. There was an audible abdominal bruit, and femoral arterial pulses were diminished in both legs (ankle-brachial index: 0.56 on right side, 0.66 on left). Multidimensional angiography showed dense calcification of all except the ascending segment of the aorta (Figure 1A
), and total occlusion of the right external iliac artery (Figure 1B). There was focal calcified obstruction of the suprarenal aorta, which was more distinct in the lateral view (Figure 1C) or transverse plane (Figure 1D). The cervical arteries showed severe calcification, with significant stenosis producing a pressure gradient in the brachiocephalic artery. Coronary angiography revealed a long 99% stenosis of the right coronary artery where a stent had been placed. Myocardial scintigraphy demonstrated ischemic changes in the inferior wall, with residual viability. An extraanatomic bypass was employed because of the history and various atherosclerotic lesions. The bilateral axillary arteries were inappropriate because of the brachiocephalic artery lesion and pacemaker implantation in the left subclavian region. The ascending aorta with little calcification was chosen for the inflow, and bypassed retroperitoneally the left external iliac artery and then the right superficial femoral artery subcutaneously, with an 8-mm bifurcated woven Dacron graft (Figure 2). Off-pump coronary artery bypass grafting was performed concomitantly between the graft and the posterior descending artery, using reversed saphenous vein. Postoperatively, multidimensional angiography showed all grafts were patent (Figure 3). After an uneventful postoperative course, the patient was discharged on the 15th postoperative day. One year later, his hypertension, digestive symptoms, and leg claudication had been relieved.
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Figure 1. Multi-dimensional angiography showing (A) dense calcification of the aorta and (B) total occlusion of the right external iliac artery. (C) There was localized obstruction at the level of the celiac artery in longitudinal lateral view and (D) calcification almost occluding the aortic lumen in the transverse plane.
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Figure 2. Schematic drawing of the operative procedures. Extraanatomic bypass from the ascending aorta to the left external iliac and right femoral arteries was performed with a bifurcated graft, along with off-pump coronary artery grafting.
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DISCUSSION
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A unique manifestation of atherosclerosis with focal calcified obstruction, coral reef aorta is predominantly located in the suprarenal abdominal aorta, and rarely in the infrarenal aorta.1–4 It is estimated to account for <1% of operable aortic disease.1 The lesion is only a few centimeters in length and consists of a heavily calcified intraaortic mass that is rock-hard, irregular, and gritty, with a white luminal surface, and it reduces the aortic lumen, producing a pressure gradient. The lesion is usually associated with other manifestations of atherosclerosis. In this case, the iliac, coronary, carotid and iliofemoral arteries showed obstructive atherosclerotic lesions. Renal and visceral artery insufficiency may coexist and cause hypertension and visceral ischemia (abdominal angina, renal dysfunction).
Atherectomy with or without endarterectomy is the surgical treatment of choice.1–4 It necessitates an extensive surgical approach, such as a thoracoabdominal incision for suprarenal lesions, although totally laparoscopic removal has been reported.5 In this case, extraanatomic bypass was preferred because of the previous colectomy for intestinal infarction with purulent peritonitis and associated diseases including atherosclerotic obstructive lesions. The ascending aorta, which showed only a little calcification, was chosen as the inflow source in view of the concomitant coronary artery bypass grafting. Consequently, the bypass to the left external iliac artery provided retrograde flow to the visceral artery, and the bypass to the right superficial femoral artery improved forward flow to the right lower extremity. Long-term follow-up is mandatory in such cases because of the possibility of further progression of the calcified lesions.1
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REFERENCES
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- Qvarfordt PG, Reilly LM, Sedwitz MM, Ehrenfeld WK, Stoney RJ. "Coral reef" atherosclerosis of the suprarenal aorta: a unique clinical entity. J Vasc Surg 1984;1:903–9.[Medline]
- Peillon C, Morlet C, Laissy JP, Watelet J, Testart J. Endoaortic calcific proliferation of the upper abdominal aorta. Ann Vasc Surg 1989;3:181–6.[Medline]
- Schulte KM, Reiher L, Grabitz L, Sandmann W. Coral reef aorta: a long-term study of 21 patients. Ann Vasc Surg 2000; 14:626–33.[Medline]
- Rosenberg GD, Killewich LA. Blue toe syndrome from a "coral reef" aorta. Ann Vasc Surg 1995;9:561–4.[Medline]
- Di Centa I, Coggia M, Javerliat I, Alfonsi P, Maury JM, Kitzis M, et al. Total laparoscopic suprarenal aortic coral reef removal. J Vasc Surg 2006;44:194–7.[Medline]
Asian Cardiovasc Thorac Ann 2009;
17:183-185
© 2009 by SAGE Publications
DOI: 10.1177/0218492309103310
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ABSTRACT
INTRODUCTION
