Blue toe syndrome from a "coral reef" aorta

Supersized Atheroma Causing Acquired Coarctation of Aorta Leading to Heart Failure

Calcified atheromatous aortic lesion causing significant narrowing of the aorta is an uncommon clinical entity. This calcified atheroma leads to obstruction of the lumen of the aorta simulating acquired coarctation of aorta causing impaired perfusion of lower limbs, visceral ischemia, and hypertension. We report a case of 58-year-old patient who presented with dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, 25-lb weight gain, lower extremity edema, and chest pain. Extensive workup including computed tomography and magnetic resonance imaging revealed a large calcific mass in the aortic arch causing his presenting symptoms. After surgical correction his symptoms resolved. Any patient presenting with heart failure symptoms in the setting of uncontrolled renovascular hypertension, intermittent claudication symptoms, or visceral ischemia with normal ejection fraction but moderate to severe left ventricular hypertrophy should be in high suspicion for acquired coarctation of aorta. The routine thorough examination of pulses in bilateral upper and lower extremities in all hypertensive patients is a very simple and useful clinical tool to diagnose acquired aortic coarctation.

The Coral Reef Aorta: Diagnosis and Treatment Following CT

The Coral Reef Aorta is a rare phenomenon of extreme calcification in the juxtarenal and suprarenal aorta. The calcifications are often similar in appearance to growths of hyperplastic bone, though abnormalities in serum calcium are not found. [1] In contrast to the typical appearance of atherosclerosis of the great vessels, which follows the curve of the vessel wall, the calcifications of Coral Reef Aorta jut irregularly into the lumen. Consequences may include severe downstream ischemic and embolic events involving the viscera and the lower extremities, as well as endovascular operative complications. In this report we present a case of Coral Reef Aorta in a 73 year old man who experienced renal ischemia and surgical difficulties during attempted stent placement. We propose that preoperative review of vascular imaging with explicit attention to the presence of Coral Reef-like plaques can prevent intraoperative and postoperative morbidity. Furthermore, heightened awareness of the existence of these plaques on routine reads of abdominal CT or vascular imaging may prompt clinicians to enact early prophylaxis against later ischemic events.

Treatment of symptomatic coral reef aorta with an uncovered stent graft

Coral reef aorta is a rare condition characterised by extreme calcific growths affecting the juxta and suprarenal aorta. It can cause symptoms due to visceral ischaemia, lower limb hypoperfusion, and distal embolisation. We present a case of a 61-year-old man with unresponsive hypertension, who was found to have an occluded right renal artery, and an extensive coral reef aorta with a marked pressure gradient across the lesion. Renal hypoperfusion secondary to aortic coral reef aorta was thought to be the cause for his hypertension. Endovascular placement of a balloon expandable uncovered stent resolved his hypertension within one month, with no adverse effects noted at subsequent follow-up. Endovascular treatment of coral reef aorta is technically possible and avoids a major vascular procedure.

Coral reef aorta, emergency surgical: case report and literature review

Coral reef aorta is described as an uncommon entity characterized by the presence of coarse calcifications, which are developed in the visceral aorta. These calcifications grow toward the lumen of the artery and can result in significant stenosis, so that causing malperfusion of the lower limbs, visceral ischemia or hypertension secondary to renal involvement. We report here a case of a 54-year-old patient with coral reef aorta and symptomatic. The clinical presentation of the patient required the surgical approach. A review of literature in major databases was conducted to compare health-related aspects of the disease presentation and management. Coral reef aorta should be considered as the diagnosis for patients with visceral and limbs ischemia. The approach in our case was consistent with other studies previously published in the literature.

Coral reef aorta: case report and review of the literature

Coral reef aorta (CRA) is a rare form of atherosclerosis that affects the paravisceral and pararenal aorta and its branches. Patients typically present with arterial insufficiency of the bowels, kidneys and lower extremities. The current mainstay of treatment is operative, typically involving transaortic endarterectomy. Herein, we describe a 54-year-old woman with incapacitating lower extremity claudication secondary to a paravisceral coral reef atheroma treated successfully with transaortic endarterectomy via a left retroperitoneal approach. In addition, we present a complete review of modern English literature on CRA.

The coral reef aorta - a single centre experience in 70 patients

Coral reef aorta (CRA) is described as rock-hard calcifications in the visceral part of the aorta. These heavily calcified plaques grow into the lumen and can cause significant stenoses, which may lead to malperfusion of the lower limbs, visceral ischemia or hypertension due to renal ischemia. From January 1984 to February 2007, 70 patients (24 men, 46 women, mean age 59.5 years, range 14 to 81 years) underwent treatment in the Department of Vascular Surgery and Renal Transplantation, University Hospital, Heinrich-Heine-University (Düsseldorf, Germany) for CRA. The present study is based on a review of patients' records and the prospective follow-up in the outpatient clinic. The most frequent finding was renovascular arterial hypertension (44.3%) causing headache, vertigo and visual symptoms. Intermittent claudication due to peripheral arterial occlusive disease was found in 28 patients (40.0%). Seventeen patients (24.3%) presented with chronic visceral ischemia causing diarrhea, weight loss and abdominal pain. Sixty-nine of the 70 patients (98.6%) underwent surgery; in 57 patients, aortic reconstruction was achieved with thromboendarterectomy, performed on an isolated suprarenal segment in six cases (8.7%), an infrarenal segment in 15 cases (21.7%), and the supra- and infrarenal aorta in 43 cases (62.3%). Eight patients (11.6%) died during or soon after surgery. Postoperative complications requiring corrective surgery occurred in 11 patients (15.9%). Almost one-third of the patients (n=19, 27.5%) returned for follow-up after a mean of 52.6 months (range six to 215 months). Of the 19 patients, there was significant clinical and diagnostic improvement in 16 patients (84.2%) and three patients (15.8%) were unchanged. Impairment was not observed. Despite the existing and improving surgical techniques for the treatment of CRA, its pathophysiological basis and genesis is not yet understood.

Retroperitoneal trapdoor endarterectomy for paravisceral "coral-reef" aortic plaque

A 67-year-old woman presented to the emergency room with progressive claudication, chest pain, and flash-pulmonary edema. Her past medical history was significant for poorly controlled hypertension requiring multiple antihypertensive medications, renal insufficiency, and tobacco abuse. Diagnostic evaluation revealed an extensive exophytic plaque localized to the paravisceral aorta resulting in high-grade stenoses of the proximal aorta as well as the celiac, superior mesenteric, and left renal arteries. She underwent surgical revascularization through a retroperitoneal aortic exposure and trapdoor aortic endarterectomy, the technical conduct of which is described in this manuscript. The patient recovered uneventfully and experienced resolution of her claudication and pulmonary symptoms, improved blood pressure control, and normalization of her creatinine. Review of the medical literature pertaining to management of proximal occlusive disease of the abdominal aorta is discussed.

Extraanatomic bypass and coronary artery grafting for coral reef aorta

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.

Total laparoscopic suprarenal aortic coral reef removal

Symptomatic suprarenal coral reef aortic lesions have a poor natural history and threaten visceral and lower extremity perfusion. We report our experience with total laparoscopic suprarenal aortic coral reef removal in three patients, aged 46, 48, and 52 years. Coral reef lesions were associated with aortoiliac occlusive lesions in two cases. One patient had an associated thoracic coral reef lesion. Patients underwent total laparoscopic coral reef removal combined with laparoscopic aortobifemoral bypass in two cases and open thoracic coral reef removal in one case. Postoperative courses were uneventful. All patients were alive with patent revascularization after a mean follow-up of 38 months, 29 months, and 1 month.

Do we really need to pay attention to the less common crystals?

In addition to monosodium urate, calcium pyrophosphate dihydrate, and apatite crystals, a wide variety of less common crystals, artifacts, and, occasionally, some unidentified birefringent materials may be seen in synovial fluids in association with acute or chronic arthritis. These unusual crystals and their associated musculoskeletal manifestations may be confused with the more common crystals and their manifestations and sometimes may provide the clue for systemic disease because they may present with a pseudovasculitis syndrome. Important advances in understanding the molecular aspect and management of primary hyperoxalurias as well as nephropathic cystinosis provide important general information to be applied in research and in the search for a more effective management of other common crystal-induced arthritis.