Coral reef aorta (CRA) is a rare atherosclerotic disease characterized by heavily calcified exophytic plaques that grow into the lumen of the suprarenal and juxtarenal aorta. The etiology and pathogenesis of this entity remains unclear. Malperfusion of the intestinal, renal, and lower limbs arteries can occur as a consequence of significant stenosis, which may lead to intermittent claudication, renovascular hypertension, abdominal angina or renal insufficiency. The optimal treatment for CRA has not yet been established. Conventional open surgery has traditionally been performed, but it can be more invasive and have higher perioperative complications and mortality. More recently, there are an increasing number of patients with CRA treated by percutaneous procedures. Endovascular treatment seems effective and is minimally invasive, but it can be complex and have a risk of dissection and perforation.
We performed a thorough electronic search of the literature using PubMed and Embase databases. We used the following combination of key words in our search strategy ((coral reef) AND (aorta) AND (vascular surgery* OR treatment*). After duplicates removal, titles and abstracts' screening and fully reading the remaining articles, we end up with 23 studies to compose our review, with a total of 49 patients. Articles not in English were excluded. We only included articles published in the last 20 years. Information about patients' characteristics, symptoms and type of treatment were extracted. The primary outcomes were improvement of signs and symptoms and postoperative complications.
We studied 49 cases of patients with CRA, 27 (55%) females and 22 (45%) males, with a mean age of 59 years [37-84]. The main signs and symptoms encountered were intermittent claudication in 30 (61%) patients, refractory hypertension in 30 (61%) patients, intestinal angina in 15 (31%) patients, renal insufficiency in 13 (27%) patients, heart failure/acute pulmonary edema/peripheral edema in 6 (12%) patients, pain at rest in the lower limbs in 6 (12%) patients, weight loss in 3 (6%) patients, and trophic lesions in the lower limbs in 2 (4%) patients. Of all the 49 patients in the study, 38 (78%) were treated with open surgery (aortic endarterectomy, extra-anatomic bypass graft or both), 8 (16%) with endovascular treatment (balloon angioplasty, stent graft, intravascular lithotripsy, or a combination of these techniques) and 3 (6%) by laparoscopy with aortic endarterectomy and aortobifemoral bypass. The mean follow-up time was 41 months [0-180] after open surgery, 6 months [4-6] after endovascular treatment, and 23 months [1-38] after laparoscopic surgery. Postoperatively most patients experienced a great relief or resolution of the symptoms, control of hypertension and/or improvement in renal function. Of the patients treated by open surgery, 4 needed reinterventions, 2 for revascularization and 2 for bleeding. Other complications included occlusion of aortic branches, splenic rupture, and brain and myocardial infarction. In the group of patients treated with endovascular procedures or laparoscopic surgery, no postoperative complications were described.
CRA is a rare condition, but we should be aware of this diagnosis in patients with intermittent claudication, refractory hypertension, renal impairment, or intestinal angina. From what we gathered, both open surgery and endovascular treatment could be a valid therapeutic option. Open surgery seems to be associated with more postoperative complications and need for reintervention. However, there are less studies for the endovascular treatment and they have a significantly shorter mean follow-up. Treatment strategy should be made by a multidisciplinary team and be specific for each individual patient. More studies with long-term follow-up results are warranted to confirm these findings and help the medical community to make an evidence-based treatment decision.