Unique solution for a rare disease: IVL to manage coral reef aorta-EHJ case report

The coral reef aorta (CRA) is a rare disease of extreme calcification in the juxtarenal aorta. Surgery or percutaneous intervention with stenting carries a high risk of complications and mortality. Chag et al report first-ever use of intravascular lithotripsy (IVL) to treat CRA in the latest edition of European Heart Journal.

Coral reef aorta (CRA) is a rare disease of extreme calcification of supra, juxta, or infrarenal aorta where these heavily calcified exophytic plaques grow into the lumen and can cause significant stenosis of the abdominal aorta, which may lead to visceral ischaemia, renovascular hypertension, and claudication. Surgery for this condition has very high complication rate and percutaneous intervention with or without a stent of a heavily calcified aorta carries a high risk of dissection and perforation. The stent-graft will need measures to protect visceral and renal branches which will increase the complexity and the cost.

IVL is a novel technique in which multiple lithotripsy emitters deliver a small electrical discharge which vaporizes the fluid and creates a rapidly expanding bubble within the balloon. This bubble generates a series of sonic pressure waves at nearly 50-atmosphere pressure that travel through the fluid-filled balloon and pass through soft vascular tissue, selectively cracking the hardened intimal and medial calcified plaque. These microfractures in calcified plaques make the vessel more compliant to yield to simple balloon dilatation.

A 67-year-old female had presented with severe hypertension and exercise limiting claudication for 18 months. On evaluation, she was found to have severe bilateral renal artery stenoses with juxtarenal CRA causing subtotal occlusion. Both renal arteries were stented.

For CRA, authors used intravascular lithotripsy (IVL) assisted plain balloon angioplasty to minimize possibilities of major dissection and perforation and avoided chimney stent-grafts required to protect visceral and renal arteries. They used a double-balloon technique using a 6 × 60 mm IVL Shockwave M5 catheter and a 9 × 30 mm simple peripheral balloon catheter, inflated simultaneously at the site of CRA as parallel, hugging balloons to have an effective delivery of IVL. Shockwaves were given in juxta/infrarenal aorta to have satisfactory dilatation without any complication. The gradient across aortic narrowing reduced from 80 to 4 mmHg. (Figure) She had an uneventful recovery and has remained asymptomatic at 6-month follow-up.

When CRA is juxtarenal with no safe landing zones for stent-grafts, IVL may be a safe, less complex and effective alternative to the use of juxtarenal aortic stent-graft with multiple chimney or snorkel stent-grafts.

Source: European Heart Journal - Case Reports, Volume 5, Issue 4, April 2021, ytab102, https://doi.org/10.1093/ehjcr/ytab102